Respiratory Flashcards
Position for a thoracentesis?
Can’t do what during it?
What if they can’t sit up?
Good lung where?
Where is the fluid/blood/exudate being removed from and allowing what?
Sit up, leaning over or backwards on a chair
NO coughing of deep breathing
Lie on unaffected sided with HOB up 45 degrees
*Good lung DOWN
Removed from pleural space, allowing the lung to expand
Thoracentesis at risk for what?
Post op do what?
Fluid volume deficit: check vitals!
CXR
Reason for chest tube?
Where are they placed to remove air vs fluid?
Can they have both?
Collapsed lung
Air: 2nd IC space
Fluid: 8-9th IC space
YES - Y connected
May be midaxillary for air and drainage***: have to cut through pectoral muscles and have longer healing
What kind of dressing is over a chest tube?
What does the CDU do?
Air-tight
CDU: Restore normal vacuum pressure in the pleural space through a 1-way system
Purpose of water seal?
How much water is in it?
Prevent back flow of air by a 1-way flow
2cm water
Where does air vs drainage go in the CDU?
Drainage: 1st chamber
Air: Goes through water seal and vented out of suction chamber
Suction chamber
What kind of where is place how high?
What does this do?
Turn up the wall suction until when?
Sterile water to 20 cm line
This prevents too much negative pressure in the pleural space
Until you have slow, gentle, continuous suctioning
Report pulse ox when?
How often to report drainage?
Want this patient to do what to help reexpand the lungs?
When should you report to the physician?
Below 90%
First 24 hours, then every 8
Cough, deeb breathe, IS (prevent pneumonia/atelectasis)
*Assess BOTH lungs
REPORT IF there is over 100ml in the first hour, or if there is a change in color to bright red
S/S infection of chest tube
Fever, WBC, drainage
What to watch daily in chest tube patient?
CXR for lung re-expansion
What happens if the chest tube is not below the chest?
No gravity drainage and fluid will go back in
What does tidaling mean?
What does it mean when they stop?
There are no kinks or disruption in the tubing - tape all connections
The lung has re-expanded (usually)
May also stop if there is a kink/clot in the tubing, of if there is a defendant loop
What do you do if the chest tube tubing becomes disconnected?
Have another sterile connector at the bed side and reconnect is ASAP
What do you do if the CDU falls over and water leaks out or goes into the drainage department?
What happens if there isn’t water in the water seal chamber?
Have the patient do what?
Do WHATEVER to re-establish that water seal! Because we NEED water in that water seal to 2 cm! You can even stick the water seal tubing end in a glass of water
Air can cause LUNG COLLAPSE!
Have patient deep and cough in case any air went into the pleural space
What if the chest tube gets pulled out?
No gauze?
Sterile gauze 3 sided tape
Put your hand there and YELL
If nothing: every time they breathe, they will pull air into the pleural space
BUBBLING NORMALS
Suction chamber
Water seal
Suction Chamber: gentle continuous bubbling
Water Seal: intermittent in pneumo pt that is coughing, sneezing, or taking a deep breath
Continuous water seal: air leak
- MD may want you to clamp the tube
As long as the intermittent bubbling is there, air is still leaking out and the chest tube needs to remain
Never do what to a chest tube without an order? Why?
Clamp!! Could lead to a tension pneuma
NEED AN ORDER!!!!!
How to remove a chest tube
Have patient take a deep breath and hold
Place occlusive petroleum dressing over the site
S/S of hemo/pneumothorax
Lungs? Pain? Vitals? Movement? XR results show what?
SOB, cough Tachycardia Diminished lung and less movement on affected side Chest pain SC emphysema`in neck/face/chest
XR: Air or fluid/blood
RULE about a penetrating object
What about eye injury?
NEVER pull it out!!
Cover both eyes
How to treat hemo/pneumo?
Thracentesis, Chest tube, Daily CXR
Causes of a Tension Pneumo
What is happening?
Trauma
PEEP
Clamping a chest tube
Taping all 4 sides of pneumothorax
*Pressure causes collapsed lung, air can’t get out, pressure pushes everything to unaffected side
S/S Tention pneumo
How is this fatal?
SC emphysema
Absent breath sounds on affected side
RR distress
Thorax moved
Accumulating pressure compresses vessels, decreasing venous return, thus decreasing CO
How to treat a tension pneumo
Large Bore needle placed at 2nd ICS to allow air to escape
THEN the cause is found and patient gets a chest tube
Open Pneumo (sucking wound)
Treatment
Positioning?
DON’T PULL STUFF OUT
Have patient valsalva to decrease air coming in
3-sided tape
Sit up if they can to expand the lungs
Stay flat if they are a trauma to prevent other injuries
S/S Fib fractures
Hemodynamics
PAIN - splinting
Crepitus (bones grinding)
Shallow RR
Respiratory Acidosis
How to treat rib fractures—
What kind of pain meds?
What will assist with coughing?
How to splint?
What is not recommended to use? Why?
Observe for what?
Non-narcotics
Nerve blocks
Support area with hands
Not recommended to use immobilizers like chest binders and straps because it could lead to shallow breathing, atelectasis, and pneumonia
Observe for Cx like Pneuma/Hemo, flail chest
S/S Flail chest
PAIN See-saw (Paradoxical) SOB Cyanosis Increased pulse
Flail chest - how to assess for symmetry?
Stand at the foot of the bed
How do you treat flail chest?
MV
PEEP
How does PEEP work?
Reasons for use?
Classic reason?
Positive pressure on end expiration to keep alveoli open
Flail chest: Expands and realigns the ribs so they will grow back together
May be used for pulmonary edema or severe hypoxemia
Classic reason: ARDS
Bi-Pap mechanism?
Who uses this?
Different levels of positive pressure support + O2
ARDS, COPD, HF, sleep apnea, coming off vent
C-PAP mechanism?
Used for who?
Continuous positive airway pressure
Used for obstructive sleep apnea
PRIORITY ASSESSMENT when you have a patient on PEEP, CPAP/BiPAP????
LUNG SOUNDS!!! - The pressure could cause a pneumo!!
Causes of PE
What can this lead to that causes HF?
Dehydration Immobile - venous stasis Clotting disorders Arrhythmias (a-fib) Heart problems (DVT 90%) Birth control pills
pulmonary HTN
1?
S/S PE
PaO2?
Vitals?
Pain? Kind?
1 Hypoxemia: 100% can’t perfuse! Ventilation problem!
Restlessness SOB Cough - Hemoptysis Decreased PaO2 Increase P and RR (because hypoxic) Pulmonary HTN - leads to cor pulmonate (Enlarged R side heart) Chest pain (sharp/stabbing)
Diagnostics for PE
D-Dimer +
VQ scan +
Spiral CT / CT angiogram
CXR - atelectasis
What does D-Dimer tell us?
Tells us if there is a clot ANYWHERE in the body… not just in the lungs
Can be positive from things like surgery!
What does a VQ scan show?
What does it use?
Remove what?
Looks at blood flow to the lungs
DYE
Remove jewelry from chest area
Best way to prevent PE
PREVENT!
Ambulate and hydrate
Do isometric exercises to decrease stasis
Treatment of PE
Give what ASAP? Meds? Monitor what? What precautions? Surgery?
OXYGEN! - according to ABG
Anti-coagulants - usually start on Hep and go home on Warfarin (can be on both)
Pain meds
Monitor ABG
Monitor clotting factors
Bleeding precautions
Can do surgery
Position after a PE?
BED REST - worry about dislodging a clot!
Elevate extremities to increased venous return and decrease pooling
What else can be used to increase venous return and decrease pooling?
What if they have a clot?
Size?
How often to remove?
TED hose
NEVER USE ON A CLOT
Need to be fitted
Twice a day
PE what will decrease inflammation?
Warm, moist heat
NEVER put cold on a vein
What do we need to limit when taking Warfarin?
Green leafy veggies
Foods high in K!
No more than 3 times per week
Normal clotting times
aPTT
PT
INR
aPTT: 30-40
PT: 11-13
INR: 2-3
Who can transport a patient with a chest tube?
RN
LPN for STABLE patient
*Ongoing monitoring while they are being transported