Respiratory pt. 1 Flashcards
review: purpose of URT
- delivers O2 and expel CO2
- warms, filters, and humidify air
structures of URT
- nose
- sinuses/nasal passages
- pharynx
- tonsils + adenoids
- larynx - epiglottis, glottis, vocal cords, adjacent cartilage
- esophagus
- trachea - surrounded by carriage
structures of LRT
- main stem bronchi
- lobar and segmental bronchi
- bronchioles
- lungs: left (2 lobes), right (3 lobes)
- alveoli (gas exchange, produces surfactant)
- pleura (fibrous membrane, cavity contains fluid that allows fluidity between structures w/o friction)
- diaphragm (assessor muscles that pulls everything down -> air to throat) (negative pressure in lung fields)
alveoli surfactant function
- protein lipid
- coats alveoli to keep lungs open
- patient and inspiratory effect
types of pleura (2)
- visceral pleura (lungs)
- parietal pleura (chest wall)
clicker: what is the purpose of cilia
move mucus upwards towards the larynx (up and out of airway)
describe inspiration
muscle activity required
- diaphragm: descent of diaphragm -> enlarge thoracic space -> intrathoracic pressure falls -> air enters thoracic cavity (negative pressure)
- accessory muscles: intercostal muscles helps with inspiration
describe expiration
passive process normally with elastic recoil
- counterbalanced by the chest wall coupled to pleural membrane/space
oxygen pressure in the alveoli is ________ than in the capillaries. why?
- higher
- O2 diffuses (high solute to low solute) into bloodstream, binds to hemoglobin
- O2 pumped throughout body via perfusion
describe V/Q
- ventilation (oxygen) & perfusion (blood)
- normally 1:1 match
- diseases can lead to mismatch
iclicker: if a person comes in w/ chronic GIB and a hemoglobin reflecting 6.4 mg/dL, what changes would this cause to O2 sat?
none, no correlation
review: ABG levels
PaO2: 80-100 mmHg (blood gas)
PaCO2: 35-45 mmHg (CO2)
PaHCO3: 22-26 mmHg (bicarb)
pH: 7.35-7.45 mmHg (pH)
describe oxyhemoglobin dissociation curve
- shows relationship between PaO2 and CO2
- shifts to the right and left
- significance of the shape to clinical situation
- PaO2 =/= SpO2
- tip: pulse ox (spO2) can be very unreliable, ABGs are more important
assessment for respiratory tract
- age and related changes
- hx (medical (HF), family, smoking)
- meds
- ax
- occupation/exposure hx (industrial)
- current symptoms/complaints
why is smoking history important to note
direct correlation -> lung ds.
what are symptoms/complaints of respiratory
- cough (productive/non-productive)
- sputum production (yellow = pneumonia nclex)
- chest pain (pattern w/ deep inspiration = normal r/t pneumonia BUT deep pain r/t COPD = more serious)
- dyspnea (impacts on ADL, paroxysmal nocturnal dyspnea), orthopnea (lay flat, SOB)
physical assessment for repisratiry
- IPPA
- lab tests
- radiograph
- other: invasive tests, pulse, pulmonary function test, exercise testing
what is included in IPPA assessment ( normal vs. abnormal)
auscultation - normal (tone differs, top = high pitch, low = low pitch)
- bronchial (Upper)
- bronchovesicular (upper)
- vesicular (lower alveoli)
abnormal
- wheezing (airway constricting -> asthma)
- crackles (fluid in lungs -> atelectasis)
- friction rub ( shuffling gravel -> pleural infiltrates)
- dull resonance (fluid in lungs) vs. hyper resonance (air in lungs -> COPD)
what is included in lab tests for resp
- ABGs
- CBC (wbc - infection, increased RBC/HgB)
- sputum (important to get deep sputum out for culture)
what is included in radiograph assessment in resp
- CXR (AP/Lateral, portable)
- CT/MRI (underlying issues with lungs, MRI - cancer, metastatic)
- angiography (dye in veins courses through body for PE assess and blood flow)
what are the 2 types of invasive tests
bronchoscopy, thoracentesis
describe bronchoscopy (uses, nurse interventions)
uses
- camera inserted to see bronchioles
- used for pt. with chronic cough
- diagnosis/biopsy
- removal of secretions (mucus plugs developed on ventilator)
nursing interventions
- teaching about anesthesia inhibiting ability to cough
- maintain NPO status
- monitoring patient resp. function
describe thoracentesis
uses
- removes fluid from sac
- diagnosis/biopsy (cancer, pleural fluid)
- decompression (allow for pulmonary expansion)
nursing interventions
- teaching: what to expect
- positioning: (sit at side of bed, leaning over bedside table)
- monitoring: lidocaine, post (chest pain - normal)
describe pulmonary function test
measures lung capacity
- tidal volume: inspiratory vol. during quiet resp.
- vital capacity: max amount inhaled/exhaled
- functional residual capacity: amt. of air in lungs after normal expiration
- residual volume: amount of air remaining in lung after max expiration
- total lung capacity: sum of VC + RV
- forced vital capacity: max amt. air exhaled as quickly as possible after max inspiration
- FEV1/FVC ratio: 70% (lower = obstructive issue (COPD), pulmonary fibrosis (can’t expand lungs) = restrictive issue)
clinical applications for pulmonary function tests
- preoperative screening ( returning to baseline)
- disability screening
- defining obstructive/restrictive diseases
- assessing effectiveness of treatment
what is considered obstructive disease
emphysema
- increased airway resistance
- decreased FVC, decreases FEV1 and FEV1/FVC and increased FRC
- basically, retaining air in lungs
what is considered restrictive disease
- restriction in the expansion of the thorax or lung tissue
- reduction in lung volumes but normal flows
what are nursing implications for pulmonary function test
patient preparation (education)
follow up with pulmonologist
which organ is pivotal in acid-base balance. why?
- lungs d/t fastest to respond to alterations in acid/base
- hydrogen ions (H+) are formed by from acids -> bound to CO2 in blood
what is the relationship between pH and hydrogen ions
- pH is measure of the body’s hydrogen ion concentration and is inversely relation
- high H+ = low pH
- low H+ = high pH
- normal pH = 7.35-7.45
- Important: small changes in pH lead to big physiological changes and even death!
what abg is the only one indicator of effective respirations
PaO2 d/t oxygen being carried on hub molecule as oxyhemoglobin
what are the sources of acid
- glucose metabolism
- fat/protein metabolism
- anaerobic metabolism (drives pH, running on treadmill increases acid, decrease pH)
- cell destruction (apoptosis = acid release in blood stream when dead)
what are the sources of bases (HCO3)
- absorption of bicarb by intestines and reabsorption by kidneys (release bicarb into bloodstream to increase pH)
what are the 2 buffers for acid base balance
lungs and kidneys
what are the respiratory mechanisms of acid base
- sensitive to CO2 levels (drive for inspiration/expiration)
- hyperventiliation: “blow it off” to bring pH up
- hypoventilation: retain CO2 to bring pH down
- rapid response: can change RR in minutes
what are the renal mechanisms of acid base
- slower to take effect
- absorption or excretion of HCO3 (buffer acid)
- formation of acids
- formation of ammonium -> loss of hydrogen and drop in pH
acidosis manifestations
- CNS depression (fatigue, flaccid)
- decrease in muscle tone
- increased resp. rate/depth (increase base to bring pH up, compensating)
- myocardial irritability (heart will stop working if pH increases)
- DKA, kausmal breathing
alkalosis manifestations
- CNS excitement/seizures
- tetany, cramps, twitches but weakness
- myocardial irritability
how to evaluate ABGs
henderson-hassalbach equation
- pH will represent primary cause of imbalance
if an oxygen level is less than 80 mmHg (hypoxemia), what to do?
- independent ABG
- correct underlying problem (improves perfusion) or increase oxygen delivery (improve diffusion)
- deceased PaO2 = anaerobic metabolism -> respiratory issues
what are some O2 toxicities
- CO2 retention (lots of CO2 in blood for long time, causes body to lose drive to breathe and get O2 in, COPD)
- washout atelectasis (nonrebreather displaces O2, causing it to go to blood stream, leading to atelectasis)
- free radicals can damage end-organ cells (can’t always give O2, increased oxygen given leads to damaged free radical) ?
what percent is considered RA
21%
what is hypoexmia
decrease in arterial O2
what is hypoxia
decrease in O2 in tissue
goal of oxygen therapy
use least amount of supplemental oxygen necessary to achieve acceptable oxygenation of the patient (improves hypoxemia, subsequent hypoxia, reduces myocardial demand)
additional complications of oxygen
- combustion
- pressure injuries
- dryness of mucous membranes (subsequent infection) (cracking of skin, should humidify always to prevent dryness)
total concentration of oxygen received by patient is dependent on?
patient’s own rr and tidal volume (patient effort)
- part of tidal volume inspired by patient is room air therefore achieved concentration of oxygen delivered to a patient is variable
- low flow: inexpensive, easy to use, fairly comfortable
types of low flow delivery system
nasal cannula
simple face mask
partial rebreather mask
non-rebreather mask
describe nasal cannula
2-6 L
24-44% oxygen delivered
ineffective if mouth breathing
describe simple face mask
5-8 L
40-60% oxygen delivered
don’t let fall to chin, difficult to eat with
describe partial rebreather mask
6-11 L
50-75% oxygen delivered
flaps “off” - air from wall + atmosphere (RA 21%), flap is open
describe non rebreather mask
10-15 L
80-100% oxygen delivered
flaps “on” - exhale (CO2 leaves vent holes), inhale (flaps close, air from wall only)
what are the safety concerns with non-rebreather mask
- atelectasis
- free radical damage
- delirium if hypoxic (will decompensated quickly)
what is the purpose of keeping non-breather mask reservoir filled?
to make sure there is enough oxygen for the patient during inspiration and at end of inspiration
what are types of high flow delivery system
venturi mask
high flow nasal cannula
describe high flow nasal cannula
- easily titratable
- can provide high oxygen concentration
- causes positive pressure
purpose of home O2
- usually ordered for chronic lung disease and resting O2 88-89% OR reduction of O2 88-89% with exercise
describe noninvasive mechanical ventilation
- noninvasive method to administer positive pressure ventilation
- force air to airway to open alveoli
- no sedation, less incidence of HAP (hospital acquired pneumonia)
what are the noninvasive mechanical ventilation advantages
- decreased frequency of HAP
- increased comfort
- doesn’t require sedation or the host of other problems that accompany intubation (ICU)
describe CPAP (noninvasive mechanical ventilation)
- one flow pressure
- assist spontaneous breathing to improve oxygenation by increasing end-expiratory pressure
describe BiPAP (noninvasive mechanical ventilation)
- 2 levels of positive pressure support: inspiratory pressure (IPAP), expiratory pressure (EPAP)
- do not use if weak cough or a large amount of thick secretions (will make situation worse)
describe noninvasive bilateral positive pressure ventilation mode (BiPAP)
- with airtight mask patient receives two different pressure support levels (IPAP, EPAP: same as CPAP)
- used in patients with worse hypoventilation & hypercapnia to prevent intubation (COPD w/ steroids -> decrease respiratory distress)
- requires intact respiratory drive
- causes significant drying of oral mucosa (provides oral care q2, sips of water)
what are some contraindications of noninvasive mechanical ventilation
- hemodynamic instability (ICU)
- dysrhythmias
- apnea
- uncooperativeness
- intolerance of mask
- recent upper airway or esophageal surgery
- inability to maintain patent airway, clear secretions or properly fit mask (take off q2H)
- pressure injury
describe incentive spirometer
- device encourages patient to inhale slowly and deeply to maximize lung inflation and alveoli (lung) expansion
- used to prevent or treat atelectasis
- indicated post operatively, post extubation, pneumonia (anesthesia can affect lungs)
- done to be 10 times/hour)
describe tracheostomies indications 4
- acute or chronic obstruction (including sleep apnea - epiglottis)
- secretion management/airway protection (post stroke)
- prolonged intubation
- trauma or surgical repair
describe complications of tracheostomies 4
- obstruction
- dislodgment (can come out, risk infection)
- others
- located below vocal cords, so patient can’t talk
types of tubes for tracheostomies
- cuffed v. non cuffed (with vent to prevent escape)
- disposable v. reusable
- fenestrated or not (allows for air to escape through upper airway)
- know your institution’s tubes and policies
what are the patient care issues with tracheostomies
- tracheal ischemia and erosion (similar to PI)
- humidication
- suctioning
- trach care
- oral care (not actively breathing -> candidas)
- nutrition and swallowing
- communication
- emotional issues
- weaning
- home care
indications of suctioning
- Q8..(concerned about airway obstruction)
- hypoxemia
- course crackles over the trachea
- elevated peak inspiratory pressure
- decreased tidal volume
- visible secretions
- suspected aspiration
- assess strength of cough
contraindications of suctioning 4
- hypoxia
- severe hypertension
- elevated intracranial pressure
- pulmonary bleeding
complications of suctioning
- pain
- hypoxemia
- bradycardia
- trauma
protocols/procedure of suctioning
- hyperoxygenation: vents often have “suction” buttons which provide 100% fiO2 for 15-30 seconds
- catheter external diameter size
- proper cuff inflation
- no greater than 120 mmHg suction
- instillation of normal saline may contribute to hypoxemia and lower airway colonization
why should normal saline not be used for suctioning
evidence states to avoid (instill saline) d/t colonization of bacteria
describe nebulizer
- needs to stay upright (5-10 min to work)
- albuterol
describe chest physiotherapy (CPT)
- includes many things
- C & DB ambulation
- percussion/vibration
- postural drainage
what are the goals of chest physiotherapy (CPT)
- remove secretions
- improve ventilation
- increased efficiency of respiratory muscles
describe percussion
- cupping of hands and striking the chest wall
- stimulates coughing
describe vibration
- manual compression and tremor to chest wall during exhalation
- cystic fibrosis
describe postural drainage
- allows gravity to assist secretion removal
- movement of secretions usually stimulate coughing (lay to left side to allow to drain)
- turning patients provides benefits for secretion situation
what are indications chest tubes
- post op thoracic surgery
- pneumothorax
what is the purpose of chest tubes
provides a way to remove fluid and air from the pleural cavity while maintaining a closed system and allowing lung expansion
what do chest drainage systems have?
- a suction source (full vac)
- a collection chamber for pleural drainage (serosanginous, purulent, sanguineous)
- a mechanisms to prevent air from reentering the chest with inhalation (water seal or wall suction)
if the chest tube is inserted in mid clavicular area, what is indicated
air in cavity
if the chest tube is inserted in anterior axillary area, what is indicated
fluid in cavity
when is it not okay for bubbles to appear in chest tube
when there are bubbles in the water seal
normal - suction monitor bubbles, cough with bubbles
what are the interventions for enhancing gas exchange
- analgesics to relieve pain w/o suppressing respiratory drive
- frequent repositioning to diminish pulmonary effects of immobility
- monitor for adequate fluid balance (assess peripheral edema, I&O, daily wts.)
- administer medications to control primary disease
what are the interventions for effective airway clearance
- assess lung sounds q2-4 hours
- measures to clear airway: suctioning, CPT, position changes, promote increased mobility
- humidification of airway
- administer meds
what are the interventions of trauma and infection
- infection control measures
- tube care
- cuff management
- oral care
- elevation of HOB
- hand hygiene
describe upper respiratory infections (URIs)
- most common reason for seeking healthcare
- treated in community settings
- early detection of signs and symptoms & appropriate interventions are necessary to avoid complications
- patient teaching focus on prevention and health promotion
rhinitis vs. rhinosinusitis
rhinitis- inflammation of nasal mucosa
rhinosinusitis- similar including sinuses with mucus production
pharyngitis
inflammation of posterior pharynx (back of throat/mouth) (strept)
- beefy red/swollen
- sometimes white exudate
what are some traditional strep throat infection complications
- rheumatic fever
- scarlet fever rash (kids - sore throat, paratonsil abscess, sand paper skin feel)
- nephritis (kidney failure)
- treatment with amoxicillin
what are the URI complications
- airway obstruction
- hemorrhage
- sepsis
- meningitis/brain abscess (nuchal rigidity - stiff neck, pupillary assessment)
- medicamentosa (dry nasal airways d/t overuse)
- acute otitis media (ear infection)
- trismus (lock jaw)
- dysphagia (diff. swallowing)
- aphonia (loss of voice)
- cellulitis (infection of tissue - danger r/t closeness of brain)
URI assessment
- health history (travel, vaccine)
- signs and symptoms: headache, cough, hoarseness, fever, stuffiness, generalized discomfort, fatigue
- allergies
- inspection of nose (nasal), neck, throat (tracheal) mucosa
- palpation of lymph nodes
URI interventions + evaluations
interventions: warm packs to reduce congestion (viral infection, avoid in bacterial)
evaluation: maintenance of patient airway, expresses relief of pain, communicate needs, evidence of positive hydration, absence of complications
patient education for URI
- # 1 prevention of infections
- hand hygiene
- know when to contact healthcare provider
- need to complete antibiotic treatment regimen (bacterial only)
- annual influenza vaccine for those at risk (75% URIs)
types of obstruction of upper airway
- obstructive sleep apnea
- epitaxis
- nasal obstruction
- fractures of the nose
- laryngeal obstructions
- foreign body aspiration
describe obstructive sleep apnea
- tx: CiPAP, BiPAP, oxygen therapy, surgery
describe s/sx of nasal obstruction
deviated septum, turbinate hypertrophy, polypsde
describe s/sx and tx of fractures of the nose
s/sx: traumatic obstruction
tx: reduction of fracture, control epitaxis, edema
describe s/sx of laryngeal obstruction + tx
s/sx: edema
tx: subcutaneous/IV epinephrine, tracheotomy
describe epitaxis
- hemorrhage from nose
- anterior septum, most common site
- may result in airway compromise or significant blood loss in some populations
describe risk factors of epitaxis
- infection (local/systemic)
- drying of mucus membranes
- nasal steroids
- elicit drug use
- trauma
- arteriosclerosis/HTN
-tumors - thrombocytopenia
- liver disease
nursing management of upper airway obstruction
- airway, breathing, circulation
- vital signs, possible cardiac monitoring, pulse ox
- reduce anxiety
- patient teaching: avoid nasal trauma, nose picking, forceful blowing, spicy foods, tobacco, exercise, adequate humidification to prevent dryness, pinch nose to stop bleeding (if bleeding does not stop in 15 min., seek medical attention)
what is the main cause of epitaxis
lack of humidification
describe laryngeal cancer
- half of all head and neck cancers
- most common in people over age 65 years/men
- treatment: radical neck dissection with total laryngectomy (losing muscles/vasculature in face + vocal cords)
- risk factors: tobacco (chewing), asbestos, paint fumes, wood dust, cement dust, chemicals, tar
s/sx of laryngeal cancer early
- hoarseness
- persistent cough
- sore throat or pain burning in throat
- raspy voice lower pitch
- lump in neck (cervical enlargement)
s/sx of laryngeal cancer late
- dysphagia, dyspnea
- nasal obstruction
- persistent hoarseness
- persistent ulceration
- foul breath
- general debilitation
diagnostics of laryngeal cancer
- h & P
- laryngoscopy: direct visualization
- FNA biopsy: cancer
- barium swallow study: dysphagia
- endoscopy, CT, MRI, PET scan
post op care of laryngectomy
- reduce anxiety
- maintain patent airway, control secretions
- promote positive body image, self esteem
- support alt. communication
- promote adequate nutrition and hydration
- self care management
post op complications of laryngectomy
- respiratory distress
- hemorrhage
- infection
- wound breakdown
- aspiration
- tracheostomy stenosis
4 types of pulmonary infections
- lung abscesses
- tuberculosis
- tracheobronchitis
- pneumonia
describe lung abscess
- bacterial pneumonia
- symptoms may vary from mild productive cough -> acute illness; pleural friction rub
- drainage achieved through postural drainage and chest physiotherapy OR invasive pleural drainage (typically)
- IV antibiotic therapy for 3 weeks or longer -> oral antibiotics 4-12 weeks (prevention of pneumonia)
nursing management for lung abscess 4
- admin IV abx.
- CPT (chest physical therapy)
- educate regarding coughing/deep breathing/ambulation/IS
- encourage oral intake
describe pulmonary tuberculosis
- acid fast bacillus
- mycobacterium tuberculosis bacillus
- TB skin test: Mantoux method (antibiotic testing)
- chest xray: visualization of lungs
- sputum testing
- drug susceptibility testing
- medications: tx 6-9 months
risk factors for TB 5
- close contact living (dorms, prisons, etc.)
- alcohol and illicit drug use
- immunosuppression diseases
- occupational exposure (nursing)
- living or visiting endemic areas (vaccine for endemic countries)
how to prevent spread of TB
- negative pressure room, N95 for HC workers
s/sx of TB
- low grade fever
- cough;nonproductive or mucopurulent;hemoptysis
- *night sweats, fatigue, *weight loss (red flag *)
what is TB - casting granuloma
- consolidation of dead cells/nectroic debris with cheese like pattern on imaging
describe pneumonia
- inflammation of lung parenchyma (organ tissue) caused by various microorganisms, including bacteria, mycobacteria, fungi, and viruses
classifications of pneumonia
- community acquired (CAP)
- healthcare associated (HCAP)
-hospital acquired (HAP) - ventilator associated (VAP)
risk factors of pneumonia
conditions that interfere w/ gag reflex: stroke, MS, ALS, dementia, alzihemer’s disease (brain CNS)
- hospitalization
- smoking, second hand
- drug/substance abuse/alcoholism
- cystic fibrosis (difficult to clear sputum)
- extremes of >65 years
- COPD
- DM
- kidney disease
- sleep apnea
- HF
- allergies/asthma
- mechanical ventilation
clinical manifestations of pneumonia
varies depending on type, casual organism, and presence of underlying disease
- fever
- tachycardia
- tachypnea
- pleuritic chest pain
- headache
- myalgia
- rash
- change in sputum production
- crackles
- orthopnea
- pharyngitis
- AMS - restlessness, agitation, confusion (PRIORITY)
what can AMS cause
tissue hypoxia, pH imbalance
pneumonia assessment and diagnosis
- h & P
- chest xray
- blood culture
- WBCs
- ABGs
- sputum examination
-bronchoscopy may be used for acute severe or recurring infection
pneumonia medical management
- viral: no antibiotics, predispose patients to secondary bacterial infections
- antibiotics for bacterial infection (empirically dosed, or based upon health hx., severity of illness, recent exposure)
- supportive treatment: fluids, oxygen for hypoxia, antipyretics, decongestants, antihistamines, HOB elevated, humidified air, positioning, IS
AVOID: antitussives (stops cough), smoking
pneumonia nursing assessment
- vs
- secretions: amount, odor, color
- cough: frequency, severity
- tachypnea: SOB
- inspect and auscultate chest
- assess for changes in mental status, fatigue, edema, dehydration, heart failure
prevent pneumonia
pneumococcal vaccination
- recommended for adults 65 years and 19 years with conditions that weaken immune system
influenza, covid
post op: ambulation, hand hygiene, oral care, I/S, Pt/ot, pain meds
pneumonia subtype
aspiration pneumonia
- secondary to inhalation of foreign material into lungs
- 3 main concerns: chemical pneumonitis, bacterial aspiration, mechanical obstruction
pneumonia risk factors
- impaired mental status
- impaired swallowing, gag reflex
- poor oral health/dentition
- impaired cough
- immunocompromised status
- impaired mobility
- dependence on feeling
prevention of pneumonia subtype
- HOB 30 degrees or higher
- avoid stimulation of gag reflex with suctioning or other procedures
- check for placement before tube feedings
- thickened fluids for swallowing problems
aspiration pneumonia treatment
- immediate pharyngeal or trach suctioning
- antibiotics long term
- pulmonary hygiene/toileting (cough, deep breathing)
- prevention of future instances (Hard to treat)
what is always highest priority with respiratory
altered mental status
