Respiratory Flashcards
What is the primary concern for upper airway fractures?
Ensure patent airway!! Nursing priority to promote oxygenation**
What structures involve upper airway?
nose, sinuses, oropharynx, larynx, trachea–> they all provide entrance for air which is necessary for oxygenation and tissue perfusion
Nasal fracture: what Tx is needed if bone or cartilage is NOT displaced?
May not need Tx; serious complications usually do not result.
Nasal fracture: what Tx is needed if bone or cartilage IS displaced or deformity exists?
Closed reduction: manipulation of bones by palpation
Rhinoplasty: surgical reconstruction
Nasoseptoplasty: removal of cartilage to straighten nasal septum
How would you document an assessment of nasal fracture?
- If bone or cartilage is displaced
- Where there is blood or clear fluid (CSF)
- Note presence of yellow hallow from nasal secretions as CSF (yellow is glucose on dried edges of fluid)
- Change in nasal breathing
- Note crepitus, bruising and pain
What interventions are necessary after rhinoplasty?
- Observe for bleeding and edema
- VS q4h
- Pt should sit in semi-fowlers, MOVE SLOWLY
- Limit valsalva maneuvers
- Don’t take ASA or NSAIDs to prevent risk of bleeding
- Assess how often pt is swallowing
What assessment is priority after nasal surgery, like rhinoplasty?
How often the pt swallows. Doing so repeatedly may indicate posterior nasal bleeding which is an EMERGENCY! (b/c it can’t be easily reached & pt may lose blood quick)
What are chronic symptoms of a deviated septum?
“stuffy nose”, snoring, sinusitis
What can cause epistaxis?
Nosebleeds can occur as a result of:
- trauma,
- HTN,
- Inflammation
- decreased humidity
- nose blowing
- nose picking
- NG suctioning
- blood dyscrasia (e.g. leukemia),
- tumor
- cocaine use
Tx for anterior epistaxis?
oPosition the patient upright and leaning forward to prevent blood from entering the stomach and possible aspiration
oReassure pt and attempt to keep pt quiet to reduce anxiety and BP
oApply direct lateral pressure for 10 mins and
oApply ice or cool compress to the nose and face
oPrevent rebleeding: don’t blow the nose for 24 hrs after bleeding stops
Use nasal saline sprays and humidification
Avoid blowing nose and use of ASA and NSAIDs
Tx for posterior epistaxis? What should you assess for? Administer?
- posterior packing (gauze above throat and string thread thru the nose)
- epistaxis catheters (nasal pressure tubes) or
- gel tampons (which expand on contact w/ blood to compress vessels)
•Assess for respiratory distress and for tolerance of packing or tubes
**Administer:
humidification,
oxygen,
bed rest,
antibiotics (esp. w/ tubes)
pain medications PRN (esp. w/ tubes)
What can be done if a nosebleed does not respond to emergency care?
Affected Capillaries are cauterized with silver nitrate or electrocautery
Nosebleed is packed
What should the nurse watch for in pt with nasal polyps?
o possible obstruction of nasal breathing, usually bilateral
o change character of nasal discharge (infection)
o change in speech quality (obstruction)
How are nasal polyps treated?
• Benign polyps managed w/ inhaled steroids then surgical removal
o Surgery – treatment of choice is polypectomy
o Watch for bleeding after surgery
o Nostrils are packed w/ gauze for 24h
o Polyps often recur after treatment
What are the LaForte levels?
o LeForte I – Nasoethmoid complex fracture
o LeForte II – Maxillary and nasoethmoid complex fracture
o LeForte III – Combination of I and II plus an orbital-zygoma fracture or a craniofacial disjunction (The most serious of the LeForte fractures)
Upon arrival of a pt with facial trauma, what care should be given?
AIRWAY, control hemorrhage, and assess extent of injury
o Anticipate need for emergency intubation (these pt will need!)
Tracheotomy surgical incision into the trachea to create an airway
Cricothyroidotomy creation of a temporary airway or making a small opening in the throat between the thyroid cartilage and the cricoid cartilage
Why do you need to stabilize a jaw fracture? What is the procedure?
allows teeth to heal in proper alignment
Tx:
Fixed occlusion wiring the jaws together in the mouth closed position (6-10 wks)
• Given antibiotics b/c of wound contamination
Debridement removal of dead tissue may be needed if there is mandibular bone infection
• Caused by treatment delay, tooth infection or poor oral care
What is the primary concern w/ facial fractures?
AIRWAY!
Always assess the patients need for an airway FIRST (whether it be his own or artificial)
What manifestations present with airway obstruction?
Decreased oxygen saturation Stridor (block in larynx, heard on inhale) Dypsnea/ SOB/ air hunger Anxiety/ Restlessness Hypoxia (not enough oxygen to tissues) Hypercarbia (↑CO2 in the blood) Cyanosis Loss of consciousness
What is definition of OSA?
Obstructive sleep apnea is disruption of breathing during sleep that lasts at least 10sec and occurs minimum of 5x in 1hr
What is the non-surgical tx of OSA?
For mild apnea:
- change of sleep position,
- weight loss,
Severe apnea:
non-invasive positive-pressure ventilation (BiPAP, APAP, CPAP) (Bi-level, autotitrating, continuous)
What is occurring with OSA to disrupt breathing? Effect on CO2 and pH?
• During sleep the muscles relax and the tongue and neck structures are displaced
o result: upper airway is obstructed but chest movement is unimpaired
o Apnea ↑ blood CO2 levels and ↓ pH
What are the side effects of OSA on the person?
Excessive daytime sleepiness, inability to concentrate, and irritability
What factors contribute to OSA?
o Obesity
o Short neck
o Smoking
o Large uvula
o Enlarged tonsils or adenoids
o Oropharyngeal edema
What is the surgical tx for OSA?
- adenoidectomy,
- uvulectomy or
- uvulo-palato-pharyngo-plasty (remodeling of the entire posterior oropharynx),
**Tracheostomy may be needed for very severe sleep apnea that is not relieved by more moderate interventions
what interventions are immediately required for upper airway obstruction?
- Assessment for cause of the obstruction
- Maintenance of patent airway and ventilation:
Endotracheal intubation: naso- or orotracheal
Tracheostomy
reserved for pt who can’t easily be intubated w/ endotracheal tube
Cricothyroidotomy (last resort, when only option)–> stab wound b/w thyroid cartilage and cricoids cartilage
Signs of partial upper airway obstruction?
o Diaphoresis
o Tachycardia
o Elevated BP
What will you observe in pt with upper airway obstruction?
o Hypoxia and hypercarbia o Restlessness & Increasing anxiety o Sternal retractions (sucked in at sternum) o “seesawing” (chest & abdomen) o Air hunger, feeling of doom
What is the immediate assessment concern for trauma to face and neck?
AIRWAY!! The priority nursing care for a patient with neck trauma is assessing for and maintaining a patent airway–>
Once airway is patent for face and neck trauma, what is next assessment?
• Once airway is patent, assess for BLEEDING or IMPENDING SHOCK!
• Assess for other injuries including cardiovascular, respiratory, intestinal, and neurologic damage.
o Neuro assessment: mental status, sensory level, motor function
o Assess carotid artery (may cause death, stroke or paralysis)
Assess esophagus, injury may occur with neck trauma
Assess for chest pain and tenderness, oral bleeding, and crepitus
o Assess for cervical spine injuries, and prevent excess neck movement.
Cervical spine injury can occur with neck injury
Make little to no neck movement
What is the problem for cystic fibrosis patients?
Error of chloride transport in the cell membranes, More chloride than normal is in the sweat
o Produces mucus that has low water content which makes it thick and very difficult to mobilize – sits in the base of their lungs and can’t cough it out.
What does mucus do to the lungs?
plugs up glands, causing atrophy and organ dysfunction in the lungs, pancreas, liver, salivary glands, and testes.
What is main cause of death with CF?
respiratory failure
How do CF pt manage secretions?
Chest physiotherapy w/ postural drainage– used frequently (DAILY) for mobilization of secretions; decrease of secretion mobilization can be loosened and promoted through this treatment.
• chest percussion and vibration; dependent drainage positions to loosen and help drain
What should you not do for airway mgmt in CF patients?
• Patients with CF want to stay away from mechanical ventilation at all costs. It will be difficult to wean the patient from the ventilator.
What is the primary cause of pulmonary HTN?
• General pulmonary HTN can occur as complication of other lung d/o
• Primary pulmonary arterial HTN occurs in the absence of other lung d/o
CAUSE UNKNOWN
o 50% of ppl w/ it have genetic mutation in the BMPR2 gene—thickens arteries
What is happening with pulmonary HTN?
o PATHOLOGY: blood vessel constriction with increasing vascular resistance in the lung
Pulmonary BP ↑ and blood flow ↓
poor perfusion and hypoxemia (O2 in blood)
Right side of ♥ fails (cor pulmonale) from con’t workload of pumping against the high pulmonary pressures
Without treatment, death occurs within 2 years
Why is lung cancer the leading cause of cancer deaths in the world?
Usually by the time you find lung cancer it has metastasized…. Easily spreads b/c close to lymph system. #1 CAUSE IS SMOKING, 85% of deaths
What is difference b/w hypoxia and hypoxemia?
- Hypoxemia – low O2 in the blood
* Hypoxia – decreased tissue oxygenation
what is the goal of oxygen treatment?
to provide the lowest amount of O2 needed in order to obtain acceptable O2 levels without causing harmful side effects.
When should you provide humidified air?
If oxygen is above 4L!!
What are the 3 chambers of a chest tube drain?
Chamber 1: collects the fluid draining from the patient
Chamber 2: water seal that prevents air from entering the patient’s pleural space
Chamber 3: suction control of the system
What do the bubbles in chamber 2 of chest tube signify?
Must always contain 2cm of water to prevent air from returning to pt
Water bubbles when air from pt passes thru the one-way valve (will stop bubbling when there isn’t any more air)
• Bubbling greater with exhalation, cough or sneeze
• Bubbling occurs with blocked or kinked CT
• Air leak causes excessive bubbling
What is difference in wet and dry suction?
WET: fluid level set by HCP (usually 20cm), turn up suction ‘til you see bubbling in chamber
DRY: suction level prescribed by HCP, if connected to wall it is set by manufacturer
How can you tell if there is an air leak in chest tube?
If air leak present, NOTIFY PROVIDER clamp may be applied
• Clamp on tubing close to dressing
o Bubbles stop—leak at chest tube insertion or in chest (NEED DOCTOR!)
o Bubbles DO NOT stop—GOOD! Leak is b/w clamp and drainage system
If chest tube malfunctions, what assessment is needed?
• When managing a chest tube – always make sure CONNECTIONS are sealed, no KINKS in the tubing, to decrease respiratory distress by the patient
o Check hourly for sterility and patency
o Tape tubing junction to prevent accidental disconnections
o Keep an occlusive dressing at the chest tube insertion site
o Position tube to decrease kinks and large loops
o Assess respiratory status, document amount and type of drainage, check for bubbling d/t air leak
How does non-invasive positive pressure tx affect airway mgmt?
o Uses positive pressure to keep alveoli open and improve gas exchange WITHOUT THE NEED FOR AIRWAY INTUBATION (eliminates the risk of ventilator-associated pneumonia)
o Mask must fit tight to have proper seal
o Should only be used on pt with intact mental status and able to protect their airway
What does BiPAP do?
mechanical delivery of set positive inspiratory pressure each time the patient begins to inspire; as the patient begins to exhale, the machine delivers a lower set end-expiratory pressure, together improving tidal volume.
What does CPAP do?
delivers a set positive airway pressure throughout each cycle of inhalation and exhalation;
CPAP the effect is to open collapsed alveoli.
Those who can benefit from this:
1. after atelectasis surgery or
2. cardiac-induced pulmonary edema or
3. Pt w/ COPD.
***Not beneficial for patient with resp failure following extubation
What does APAP do?
o APAP adjust continuously to deliver what the pt needs
What do you do for tracheostomy tube displacement?
If tube falls out:
1. assess patient,
2. provide O2,
3. call md,
4. may use obturator (at patients bedside) directly into stoma
Tube dislodgement in first 72h is an emergency!! Replacement is difficult b/c tracheostomy tract is not mature and tube may end up in subq tissues instead of trachea
Decannulation after 72h, and the nurse can replace the tube. You want to:
• Extend pt neck and open tissues of stoma with curved Kelly clamp to secure airway
• Insert obturator into tube, replace the tube and remove obturator
• Check for airflow thru tube and bilateral breath sounds
Assessment of trach patients?
POST-OP: MAKE SURE AIRWAY IS PATENT ALWAYS!!!!
o Hear bilateral breath sounds!
o Respiratory assessment q2h
Prevention of tissue damage:
Check cuff pressure often (it can cause mucosal ischemia)–> Use minimal leak technique and occlusive technique
Prevent tube friction and movement–> want to fit a finger b/w strap and neck
Prevent and treat
- malnutrition,
- hemodynamic instability, or
- hypoxia
What is pneumonia?
an excess of fluid in the lungs resulting from an inflammatory process triggered by infectious organisms (many) and by inhalation of irritating agents
What are the primary causes of pneumonia?
o Organisms penetrate airway mucosa and multiply in alveoli…
They come from: environment, invasive devices, equipment and supplies, staff/people
Caused by: bacteria, viruses, mycoplasmas, fungi, rickettsiae, protozoa, helminths
Pathophysiology of pneumonia?
o Inflammation occurs in the interstitial spaces, alveoli and bronchioles
WBC migrate there and cause
• Capillary leak, Edema , exudates
• Fluid collects in and around alveoli, and alveolar wall thickens
• Reduces gas exchg and lead to hypoxemia
RBC and fibrin move into alveoli
• Capillary leak spreads infection to other areas of the lung
• If organism moves into blood SEPSIS!
Causes of Resp ACIDOSIS
asthma atelectasis brain trauma bronchitis CNS depressants emphysema hypoventilation penumonia pulmonary edema or emboli
Causes of Resp Alkalosis
fever hyperventilation hypoxia hysteria pain overventilation by mechanical ventilator
Causes of Metabolic Acidosis
DM or DKA Excessive ASA use High-fat diet Malnutrition Renal insufficiency Sever diarrhea
Causes of Metabolic Alkalosis
Diuretics Excessive vomiting Excessive Gastro suctioning Hyperaldosteronism Massive transfusion of whole blood Ingestion of and/or infusion of excess sodium bicarbonate
