Respiratory Flashcards
Normal Function of the Lung
Oxygen enters our lungs as part of the air that we breathe. It goes to the blood vessels deep in our lungs and then on to all parts of our body. As our body uses oxygen, it makes a waste product called carbon dioxide. We get rid of carbon dioxide when we breathe out.
This provides oxygen for metabolism of the tissues
Removes carbon dioxide, the waste product of metabolism
Secondary functions include sense of smell, producing speech, maintaining acid base balance, maintain water levels and maintain heat balance
Effective gas exchange depends on the distribution of gas and blood in all portions of the lungs.
Tracheal suctioning
Don’t suction before drawing ABG’s- will deplete the O2
Assist client into upright position Hyperoxygente Client Insert cath without suction applied Once inserted, apply suction intermittently while rotating and withdrawing catheter Hyperoxygenate listen to breath sounds Document
Thoracentesis
Pre-procdure:
CXR and baseline vials
Sitting up leaning over bed side table or lying on unaffected side with HOB at 45
Procedure:
VERY STILL, no coughing or deep breaths
Fluid/exudate is removed from pleural space
Lung re expands
Since fluid is being removed, they can go into a fluid volume deficit. Check BP and pulse.
Post procedure
CXR
D- Dimer
A blood test that measures clot formation and lysis that results from the degradation of fibrin
Helps diagnosis DVT, PE, or stroke. Also assists in diagnosing DIC and monitor effectiveness of treatment
Chest Tube Location implications
If the chest tube is placed in the upper anterior chest, it is to remove air
If the chest tube is placed laterally in the lower chest, then it is for exudate/fluid
A client is able to have both that are Y connected and attaached to a closed chest drainage unit (CDU)
Chest Tube Insertion and Purpose of the CDU
A chest tube is sutured to the chest wall and an air tight dressing is applied around the chest tube exit site and then connected to the CDU.
The CDU is to restore the normal vacumn pressure in the pleural space. It does this by removing all air and fluid in a closed one way system until the problem is corrected.
CDU drainage collection chamber
The Chest tube connects to a 6 foot connection tube that leads to the drainage collection chamber. when it is full, REPLACE.
CDU water seal chamber
The purpose of the water seal is to promote one way flow out of the pleural space which will prevent air from moving back up the system and into the chest.
The drainage chamber and water seal chamber are connected by a strawlike
CDU water seal chamber
The purpose of the water seal is to promote one way flow out of the pleural space which will prevent air from moving back up the system and into the chest.
The drainage chamber and water seal chamber are connected by a 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 contains 2cm of water which acts as a valve preventing oneway flow.
You may see bubbling when the client coughs, sneezes or exhales and a slight rise when they breath. Tidaling is normal and when it has stopped it means the lung has re-expanded. The Air exits the water seal chamber and enters the suction control.
CDU Suction control Chamber
If the client needs suction to remove air and fluid, this chamber control the amount of pressure applied.
Sterile water is placed in this chamber up to the 20 cm line. Turn on wall vacuum until you have slow gentle continuous bubbling
Management of CDU
Assessment:
Assess Dressing - Must be kept tight and clean
Listen to lungs bilaterally
Monitor pulse ox and report below 90%
Record Drainage every hour for 24 hours and then every 8
NOtify PHC of 100ml of drainage or greater in one hour or if there is a change of color to bright red.
Deep breath, cough and use incentive spirometer
Watch for fever, WBC up and drainage = infection
Daily CXR
Maintaing CDU
Keep below the chest
if too high, Drainage will shwoop back in. promote gravity drip.
Keep tubing straight and free of kinks and dependent loops
Tape connections. MuST BE A CLOSED ASS SYSTEM
Monitor water levels
Wanna see tidaling with resps
Trouble shooting
Keep another sterile connector at bed side if disconnected - reconnect as fast as u can
If it falls over
Do what you can to protect the water seal
HAve the client cough and deep breath to prevent air from pleural space
no water = collapse lung
If it is pulled out Occlusive dressing taped down 3 sides
Chest Tube Removal
Have client take a deep breath and bear down and place an occlusive petroleum dressing over the site
When is bubbling normal?
Chest tube connected to suction - gentle and slow. with coughing, sneezing deep breathing and exhaling - intermittent
When is bubbling a problem/
IF THERE IS INTENSE BUBBLING IN THE WATER SEAL THEN YOU HAVE AN AIR LEAK
NEVER CLAMP A CHEST TUBE withOUT PRESCRIP. COULD CAUSE A TENSION PNEUMO
Hemothorax/Pneumothorax
Blood or air has accumulated in the pleural space and the lung has collapsed.
SOB Increased HR Diminished breath sounds on the affected side Decreased movement on affected side Chest pain Cough Air or fluid on CFXR SubQ emphysema is air trapped in the tissue
Thoracentesis, chest tubes, daily CXR
We want that intermittent bubbling
Tension Pneuomothroax
Caused by trauma, PEEP, clamping chest tubes or taping an open pneumo on all 4 sides without an air valve can cause a tension pneumo
Pressure has built up in the pleural space and has collapsed the lung - pressure pushes everything to the opposite side (mediastinal shift)
SubQ emphysema (crepitus on palpation), absence of breath sounds on one side, asymmetry of thorax, resp distress, decreased chest expansion, hypotension. Acumulating pressure compresses the vessels which decreases the venous return and decreases cardiac output
PUNCTURE THE LUNG and insert chest tube.
Open Pneumothorax
Gun shots + Stabbings
Opening through the chest that allows air into the pleural space
Have the client inhale or valsalva and hmm
This will increase the intra-thoracic pressure so no more outside air can get into the body
Then place a piece of petro gauze with 3 sides taped
Have client sit up to expand. Trauma client is flat until evaluated for other injuries
Fracture of ribs and sternum
Pain and Tenderness
Crepitis
Shallow breaths
Resp acidosis
Non-narc analgesic
Nerve Block to assist with productive coughing
Support injured area with hands
Don’t immobilize client
Observe for complications such as flail chest, pnemo and hemo
Flail Chest
Occurs with multiple rib fractures and blunt chest trauma.
Paradoxicial chest wall movement (see-saw chest); chest sucks inwardly on expiration and puffs out on inspiration
To assess chest symmetry, always stand at foot of bed to observe how chest is rising and falling. Dyspnea, cyanosis and increased pulse, Hypotension, shallow resps, diminished breath sounds
Stabilize area, intubate and ventilate Positive Pressure Ventilation PEEP BiPAP CPAP Maintain Fowlers position Oxygen Encourage coughing and deep breathing Pain meds Bed rest/limit oxygen demands
PEEP
Client is on the ventilator
On end expiration, the vent exerts PRESSURE down the lungs and keep the alveoli open
Improves Gas exchange and decreases the work of the lungs
It expands and realigns the ribs so they can start growing back together
Can also treat pulmonary edema or severe hypoxia and ARDS
BiPAP
Non-invasive ventilation (masks)
Used for ARDS clients with COPD, HF and sleep apnea, asthma and pulmonary edema
Exerts different levels of positive pressure support along with Oxygen
CPAP
Pressure is delivered continuously during breathing, for both inspiration and expiration
Used for obstructive sleep apnea
Anytime you see PEEP CPAP or BiPAP your priority nursing assessment is to check bilateral lung sounds
Pulmonary Embolism
Dehydration, venous stasis from prolonged immobility or surgery or birth control pills
Clotting disorders or heart arrthymias like Afib
S/S Hypoxemia PaO2 is down SOB, cough, Increased RR INcreased D-Dimer Positive VQ scan ( looks at perfusion in the lungs, dye is not used, remove jewlellery) Positive CT or CT angiography Hemoptysis Increased pulse because hypoxic Sharp stabbing chest pain CXR will show right sided failure Pulmonary HTN
PREVENT - ambulate and hydrate! Oxygen ABG's Decrease Pain Heparin + anticoagulants While on warfarin, limit green leafy veggies/ high in vitamin k Bleeding precautions Surgery
Anti-tuberculin: Isoniazid (INH),
Rifampin (Rifadin)
TUberculosis
PO/IV Rapid Interactions: Acetaminophen, chloramphenicol, cyclosporine, digoxin, diltiazem, antacids
MoA: Prevents the replication of tubercle bacilli by inhibiting DNA dependent polymerase. Bactericidal against the following organisms:
staphylococcus aureus, Haemophilus influenza, Neisseria meningitis, legionella pneumophila
Side Effects: Headache Vertigo Dyspepsia Hepatotoxicity Nausea/vomiting Red-brown discoloration to sweat, urine and sputum
Adverse:
Pseudomembranous colitis
Pancreatitis
Acute renal failure
Intervention: Monitor liver function test every month Monitor renal status Observe for diarrhea, abdominal pain, fever associated with pseudomembranous colitis. Culture before treatment started
Education:
This medication is best taken on an empty stomach with a full
glass of water (8 ounces or 240 milliliters) 1 hour before or 2
hours after meals
Do not take antacids with rifampin since it will lessen the
effectiveness of this drug.
Keep MD appointments to prevent relapse.
Many tuberculosis medications can cause toxic effects such as hepatotoxicity, nephrotoxicity, neurotoxicity , optic neuritis or ototoxicity. Teach client about the signs of toxicity and inform the client that the HCP needs to be notified if any signs arise.
Bronchodilators – Antileukotriene / Leukotriene Receptor Antagonist : Montelukast
(Singulair),
Zafirlukast (Accolate
Prophylactic treatment of chronic bronchial Asthma
PO
Interactions: Barbiturates decrease montelukast levels; black and green tea increase stimulation. When administered with inhaled glucosteroids, increases risk of upper resp infection.
MoA: Inhibits leukotriene formation which prevents smooth muscle contraction of the bronchial airways, decreased mucus secretion and reduced vascular permeability (which reduces edema).
Advantages: Stops asthma symptoms that are caused
by the immune system at the cellular
level.
Side Effects:
Headache Dizziness
GI upset Insomnia
Drowsiness
Adverse Effects:
Thrombocytopenia
Suicide thoughts
Seizures
Interventions:
Monitor liver enzymes, can be hepatotoxic.
Not indicated for acute episodes, improvement
usually seen after one week of administration.
Monitor CBC and blood chemistry during treatment.
Assess for suicidal thoughts.
Assess respiratory rate, rhythm, depth and auscultate fields bilaterally.
Education:
Avoid hazardous activities dizziness may occur
Teach not to be used for acute attacks
Increase fluid intake.
Bronchodilators – Beta Adrenergic Agonists : Albuterol (Proventil,
Ventolin), Terbutaline
Sulfate (Brethine),
Salmeterol (Serevent),
Common uses: Asthma Bronchitis Emphysema COPD
Contraindications: Hypersensitivity Tachy-arrhythmias Severe cardiac disease or heart block Hyperthyroidism Peptic ulcer disease
PO/aerosol/nebulizer
Interactions: Adrenergic drugs increase action of
albuterol so don’t use together.
B- adrenergic blockers
MoA: These drugs are usually used during the acute phase of an asthma attack to quickly reduce airway constriction and restore airflow
to normal. They are agonist or stimulators of the adrenergic receptors in the sympathetic nervous system. They imitate the effects
of norepinephrine and cause bronchodilation
Side Effects:
Muscle tremor Anxiety
Nervousness Insomnia
Tachycardia
Adverse Effects:
Hypertension
Hallucinations
Dysrhythmias
Interventions:
Assess heart rate and rhythm, assess respiratory function, ABGs, lung
sounds
Watch for evidence of allergic reactions. Notify prescriber if
bronchospasms occur.
EDucation:
Do not use other bronchodilators or OTC medications with Terbutaline, as they may cause additive cardiovascular effects.
Do not break, crush or chew extended release tablets
Give inhaler instructions.
Limit caffeine products such as chocolate, coffee, tea and cola
Mucolytic : Acetylcysteine
Mucomyst
Common uses: Acetaminophen toxicity Bronchitis/ COPD Cystic Fibrosis Atelectasis
Contraindications:
Increased ICP, Status asthmatics
PO/IV/Neb
Interactions: Nitrates: increased effects, Iron, copper, nickel or rubber – Interacts with acetylcysteine
MoA: Decreases the viscosity of secretions in respiratory tract by breaking disulfide links of mucoproteins. Inactivates acetaminophen
toxic metabolites in acetaminophen overdose.
Side Effects: Stomatitis Fever Nausea/vomiting Rhinorrhea Drowsiness Diaphoresis Chest tightness
Adverse Efects:
Hepatotoxicity
Anaphylaxis
Bronchospasms
Interventions:
Assess cough type, frequency, character including sputum.
Assess character, rate, rhythm of respirations.
Assess liver function test
May be given in nebulizer or instilled intratracheally
If the patient vomits within one hour of administration, repeat the
dose.
Give gum, hard candy, frequent rinsing of mouth for dryness of oral
cavity
EDucation:
Teach patient that unpleasant odor will decrease after
repeated use.
Tell client to avoid alcohol and other CNS depressants as they
will enhance the sedating properties of this product
Classification of Tuberculin Skin test Reaction
5 or >5 is positive in HIV infected, recent contact of TB person, person with fibrotic changes on CXR consistent with prior TB, organ transplants and immunosuppressed peeps
10 or >10= recent immigrants in high prevalence countries, Injection drug users, Residents and employees in high risk congregate settings, mycobacteriology lab personal, persons with clinical conditions that place them at high risk, children <4 years, infants children and adolescents exposed to adults in high risk categories
15 or >15 = any person including persons with no known risk factors for TB
An individual who has received a BCG vaccine will have a positive tuberculin test result and should be evaluated for tuberculosis with a CXR
Tuberculosis
Highly communicable disease. usually upper lobes of lung affected, but can affect brain intestines peritoneum kidney joints and liver.
There is an exudative response causes a nonspecific pneumonitis and development of granulomas in lung tissue
Spread through the air by droplets. Put these patients in a negative pressure and monitored room. ROOM TO REMAIN CLOSED.
Fatigue, Lethargy, Anorexia, Weight loss, Low grade fever, Chills, Night sweats, Persistent cough and the production of mucoid and mucopurulent sputum, which is occasionally streaked with blood, chest tightness and a dull aching chest pain may accompany the cough.
Bronchodilators: Methylxanthines -Theophylline, Aminophylline
Methylxanthine stimulate the CNS and respiratoin, dilate coronary and pulmonary vessels, cause diuresis and relax smooth muscle
Contraindications: Hypersensitivity Tachy-arrhythmias Severe cardiac disease or heart block Hyperthyroidism Peptic ulcer disease
Interactions:
Theophylline increases the risk of digoxin toxicity and decreases the effects of lithium and phenytonin.
If B2 adrenergic agonists are used together, cardiac dysrhthmias can result
beta blockers, cimetidine and erythromycin increase effects.
Barbituates and carbamazepine decrease effects.
Theophylline toxicity is likely to occur when the serum level is 20 mcg/ml or 111 mcmol/L. Early signs of toxicity include restlessness, nervousness, tremors, palpitations and tachycardia
Anticholinergenics: Ipratropium and Tiotropium
Inhaled medications that improve lung function by blocking muscarinic receptors in the bronchi, which results in bronchodilation.
COPD, Allergy induced asthma and excercise induce bronchospasmn
Side effects: Dry mouth and irritation of the pharynx
Adverse: Increased intraoccular pressure, blurred vision, tachycardia, cV events, urinary retention and constipation
If client has a peanut allergy, dont take certain ipratropium products because they contain soy lecthin
Expectorants : Guaifenesin
Loosen bronchial secretions so that they can be eliminated with coughing; they are used for dry unproductive cough and to stimulate bronchial secretions
Antitussives: codeine, Dextromethorphan
Act on the cough control center in the medulla to supress the cough reflex ; used for a cough that is nonproductive and irritating
Obstructive sleep apnea
is the most common type of breathing disorder during sleep and is characterized periods of apnea (>10 seconds) and diminished airflow (hypopnea). A partial or complete obstruction occurs due to upper airway narrowing that results from relaxation of the pharyngeal muscles or from the tongue falling back on the posterior pharynx due to gravity. During periods of apnea, desaturation (hypoxemia) and hypercapnia occur; these stimulate the client to arouse and breathe momentarily to restore airflow. These cycles of apnea and restored airflow can occur several hundred times per night, resulting in restless and fragmented sleep. Partners of clients with OSA witness loud snoring, apnea episodes, and waking with gasping or a choking sensation (Options 5 and 6).
During the day, clients experience morning headaches, irritability, and excessive sleepiness. Excessive daytime sleepiness can lead to poor work performance, motor vehicle crashes, and increased mortality (Options 2 and 3).
At night, clients with obstructive sleep apnea experience repeated periods of apnea, loud snoring, and interrupted sleep. During the day, morning headaches, irritability, and excessive sleepiness are common.
