Respiratory Flashcards
Pre procedure thoracentesis
CXR, baseline vitals
Position: sitting up leaning over table, sit in a chair backwards, propped up over the back of the chair, if they can’t sit up: lie on unaffected side with HOB at 45 degrees
Thoracentesis procedure
Client must be very still, no coughing or deep breaths
The fluid/blood/exudate is being removed from pleural space
As the fluid is removed, the lung should reexpand
Since you’re removing fluid, the client could go into a fluid volume deficit, so check vitals
Post procedure thoracentesis
Another CXR
Chest tubes
If the chest tube is placed in the upper anterior chest (2nd intercostal space) then it’s for what?
Removal of air, because air rises
If the chest tube is placed laterally in the lower chest, (8-9th intercostal space) then it’s for what?
Drainage, because drainage settles
Can the client have both a chest tube for removal of air and drainage?
Yes, they are y-connected together and attached to a closed drainage unit (CDU)
How is the chest tube secured to the client?
Sutured to the chest wall and a Vaseline or air tight dressing is applied around the chest tube exit site. The chest tube is then connected to a closed chest drainage unit
What is the purpose of the CDU?
To restore normal vacuum pressure in the pleural space. The CDU does this by removing all air and fluid in a closed one way system until the problem is corrected
3 chambers of CDU
- Drainage collection chamber
- Water seal chamber
- Suction control chamber
Drainage collection chamber
The chest tube connects to a 6 foot connection tube that leads to the drainage collection chamber.
What do you do do if the drainage chamber fills up?
Get a new CDU
What is the purpose of the water seal chamber?
To promote one way flow out of the pleural space which will prevent air from moving back up the system and into the chest
How are the drainage chamber and water seal chamber connected?
By a straw like channel that allows the drainage to remain in the first chamber and the air to go down into the water of the water seal chamber.
The water seal chamber contains how much water?
2 cm to act as a one way valve. Prevents backflow
When will the water seal chamber bubble?
If the client coughs, sneezes, or exhales
Tidaling
Fluctuation of rise and fall of water in the water seal tube as the client breathes. Normal, if it stops, it usually means the lung has reexpanded, there is a kink/clot in tubing, or a dependent loop is present
What happens when air exits the water seal chamber?
It enters the third chamber called the suction control chamber. This allows any air to be vented out through the air vent found at the top of the suction control chamber
If the chest tube client needs suction to remove air and fluid, what happens?
The suction control chamber controls the amount of pressure applied
What is filled in the suction control chamber?
Sterile water is placed up to the 20 cm line.
How do you set suction for suction control chamber?
Turn on the wall vacuum suction until you have slow gentle continuous bubbling
Dry suction system
Water is not used to regulate the pressure and therefore has no bubbling. A dial is used to set the desired negative pressure. Increasing the vacuum wall suction will not increase the pressure.
Assessment of closed chest drainage systems
Keep dressing tight and intact
Listen to bilateral lung sounds
Report pulse ox
What level should the CDU be at?
Below level of chest
If you lift it too high, fluid goes back in
We want gravity drainage
Tubings of CDU
Keep straight and free of kinks and dependent loops
Connections of CDU
Tape them, it must be a closed system
What do you do if the CDU tubing becomes d/c
Keep another sterile connector at bedside, reconnect as fast as you can
What do you do if the CDU falls over and the water leaks out or shifts to the drainage compartment?
Do whatever you can to reestablish the water seal. Set the CDU upright, check all the chambers, and fill the water seal chamber to 2cm of water
Have client deep breathe and cough in case any air went into pleural space
If there is not water in the water seal chamber then air can collapse the lung
What if the chest tube is accidentally pulled out?
Sterile vaseline gauze taped down on 3 sides. Otherwise, every time they take a breath, they will pull air into pleural space
When is chest tube bubbling normal?
Chest tube connection to suction, gentle continuous bubbling is expected in the suction chamber
If a client with a pneumothorax is coughing, sneezing, or just taking a deep breath and exhaling, you may see intermittent bubbling in the water seal chamber
As long as there is intermittent bubbling, the client needs the chest tube bc air is still leaking out of the pleural space
When is chest tube bubbling a problem?
If there is continuous bubbling in the water seal chamber, then you have an air leak in the system
Never clamp a chest tube without an order. It could lead to a tension pneumothorax
Chest tube removal
Have client take a deep breath and hold (valsalva) and place an occlusive petroleum dressing over the site
Patho of hemo/pneumothorax
Blood or air has accumulated in the pleural space
The lung has collapsed
S/S of hemo/pneumothorax
SOB Increased HR Diminished breath sounds on affected side Less movement on affected side Chest pain Cough Blood or air on CXR Subq emphysema is air trapped in tissue (usually face, neck, chest)
Never do what to a penetrating object?
Pull it out
Tx of hemo/pneumothorax
Thoracentesis, chest tubes, daily CXR
If a pneumothorax is present and the client has a chest tube, what type of bubbling would be expected in the water seal chamber?
Intermittent bubbling
Patho of tension pneumothorax
Pressure has built up in the chest/pleural space and has collapsed the lung. Pressure pushes everything to the opposite side. (mediastinal shift)
What can cause a tension pneumothorax?
Trauma, PEEP, clamping chest tube, taping an open pneumothorax on all four sides without an air valve
S/S of tension pneumothorax
Subq emphysema, absence of breath sounds on one side, asymmetry of thorax, respiratory distress
Can be fatal as accumulating pressure compresses vessels and decreases venous return which decreases CO
Tx of tension pneumothorax
Large bore needle is placed into the 2nd intercostal space by doc to allow excess air to escape. Then the cause is found, and the chest tubes are inserted
Open pneumothorax
“Sucking wound”
Opening through chest allows air into pleural space
Tx of open pneumothorax
Have client inhale and hold or valsalva or hummmmm to increase the intra-thoracic pressure so no more outside air can get into the body
Then, place a piece of petroleum gauze over the area. Tape down 3 sides, 4th side acts as air vent/flutter valve
Have client sit up if possible to expand lungs
Trauma clients stay flat until evaluated for other injuries
S/S of ribs and sternum
Pain/tenderness
Crepitus (bones grating together)
Shallow respirations
Respiratory acidosis
Tx of fx ribs/sternum
Non-narcotic analgesic
Nerve block to assist w/ productive coughing
Support injured are with hands
Not recommended to immobilize with chest binder and straps bc it could lead to shallow breathing, atelectasis and pneumonia
Observe for complication such as pneumothorax, hemothorax, and flail chest
Multiple rib fx
Flail chest
S/S of flail chest
Pain Paradoxical chest movement To assess chest symmetry, always stand at food of bed to observe how the chest is rising and falling Dyspnea, cyanosis Increased pulse
Paradoxical chest movement
“See-saw chest”
Chest sucks inwardly on inspiration and puffs out on expiration
Tx of flail chest
Stabilize area, intubate, ventilate
PEEP
PEEP
Client is on vent
On end expiration, the vent exerts pressure down into the lungs to keep alveoli open
Improves gas exchange and decreases the work of breathing
Expands and realigns ribs so they can start growing back together
PEEP can treat what?
Flail chest, pulmonary edema, sever hypoxemia, ARDS
BiPAP
Bi-level Positive Airway Pressure
Used for ARDS in clients with COPD, heart failure, sleep apnea
Exerts different levels of positive pressure support, along with oxygen
CPAP
Continuous Positive Airway Pressure
Pressure is delivered continuously during spontaneous breathing, for both inspiration and expiration
What is CPAP used for?
Obstructive sleep apnea
What is the priority nu assessment with PEEP, CPAP, or Bi-PAP?
Bilateral breath sounds
Causes of pulmonary embolism
If a client becomes dehydrated, has venous stasis from prolonged immobility or sx, birth control pills, clotting disorders or heart arrhythmias like A-Fib
(All these things make blood thick. Clot forms, travels to lungs. Usually comes from legs)
S/S of PE
#1: hypoxemia Decreased PaO2, give 100% O2 SOB, cough, increased RR Increased D-dimer, tells if there is a clot located anywhere in the body, not just lungs Positive VQ scan: most widely used test (ventilation/perfusion scan used to detect an embolus, done in radiology. Looks at blood flow to lungs. Dye is used, remove jewelry from chest area) Positive spiral CT or CT angiography Hemoptysis (coughing up blood) Increase pulse bc hypoxic Chest pain: sharp, stabbing CXR shows atelectasis increased BP in lungs-pulmonary HTN
Tx of PE
Prevent with ambulation and hydration, SCDs, isometric exercises to decrease stasis
Oxygen
ABGs
Decrease pain
Heparin sodium, warfarin, enoxaparin
Bleeding precautions
Sx
Bedrest
Elevate extremities to increase venous blood return, decrease pooling
TED hose to increase venous return and decrease pooling: often used with SCDs, with a known clot: use TEDs or SCDs on the unaffected extremity or not at all
Warm, moist heat to decrease inflammation
Normal aPTT
30-40 seconds
Normal PT
11-12.5 seconds
Therapeutic INR
2-3
Can you be on heparin and warfarin at the same time?
Yes
Why don’t you put cold on a vein with PE
Excessive vasoconstriction
Why don’t you put hot on a vein with PE
Excessive vasodilation
How often do you remove TED hose?
Twice a day/once per shift
