Respiratory pt. 2 Flashcards
what is restrictive lung disease
impair ability to fully expand lungs
- atelectatsis
- pleural conditions (pleurisy, empyema)
- ARDS
- pneumoconoises
- lung cancer
- chest wall injuries
what is obstructive lung disease
prevent exhalation
- asthma
- COPD (chronic bronchitis, emphysema)
- bronchietasis
- cystic fibrosis
what are vascular diseases we learned
- pulmonary HTN
- pulmonary embolisms
describe atelectasis (r/t, sx)
- closure or collapse of alveoli
- most common is acute atelectasis (d/t post anesthesia)
- symptoms: increasing dyspnea, cough, sputum production
acute symptoms of atelectasis
tachycardia (decrease O2)
tachypynea (decrease O2)
pleural pain
central cyanosis if large areas of lung affected
chronic symptoms of atelectasis
similar to acute, pulmonary infection may be present
- can’t expand lungs
- vent dependent
-non ambulatory
- functional or development ds.
how to identify atelectasis
auscultation posterior base of lungs
assessment / diagnosis of atelectasis 3
- increased work of breathing and hypoxemia
- increased temp
- decreased breath sounds/crackles over affected area (base)
what may suggest atelectasis before clinical sysmptoms appear
chest x-ray
pulse ox low O2 sat (less than 90%)
prevention of atelectasis
strategies to expand lungs and manage secretions
- q2 turning
- early mobilization post op
- IS
- voluntary deep breathing
- secretion management (coughing)
- CPT
- MDI
- thoracentesis (pleural effusions)
4 types of pleural conditions
visceral pleura (pleura covering lungs) and parietal pleura (pleura covering chest wall)
- pleurisy
- pleural effusion
- empyema
- pulmonary edema
describe pleuritis/diagnosis/sound on stethoscope
inflammation of both layers of pleurae
- pleuritic pain is associated with respiratory movement (rubbing of pleural layers together, sharp inspiratory pain)
- pleural friction rub = heard in stethoscope
- diagnostics: chest xray, sputum analysis, thoracentesis (used for infectious etiology)
nursing role in pleuritis
- treat underlying cause
- provide analgesia (allows for more appropriate expansion)
- splint rib cage when coughing (hold pillow while coughing to clear airways)
describe pleural effusion (s/sx, diagnostic, sound on stethoscope)
fluid collection in pleural space usually secondary to heart failure, TB, pulmonary infections, cancer (recurrent)
- s/sx: fever, chills, pleuritic pain, dyspnea
- decreased/absent breath sounds, decreased fremitus, dull sound on percussion
-diagnostic: chest RX, chest CT, thoracentesis
which pleural condition has tracheal deviation away from affected side
pleural effusion (more common with tension pneumonia)
describe empyema (s/sx, diagnostic, sounds on stethoscope)
accumulation of thick, purulent fluid in pleural space (pleural effusion with thick fluid/pus)
- (S/D) complication of bacterial pneumonia or lung abscess
- acutely ill
- s/sx: similar to acute respiratory infection/pneumonia
- decreased breath sounds over affected area, dull sound on percussion
- diagnostic: chest CT, thoracentesis
how to relieve empyema
drain fluid via thoracentesis
- antibiotics for 4-6 weeks
describe ARDS (acute respiratory distress syndrome) - NOT ON EXAM
sudden, progressive pulmonary edema
- increased B/L lung infiltrates visible on chest XR (white opacities = decreased airflow)
- absence of an elevated left atrial pressure (independent of HF)
- worsening PaO2/FiO2 ratios (untreatable)
- rapid onset of severe dyspnea
ARDS management
- identification/treatment of underlying cause
- intubation, mechanical vent with PEEP to keep alveoli open
- hypovolemia treated
- prone positioning (BEST FOR OXYGENATION)
- nutritional support, enteral feeding preferred
- reduce anxiety
describe pulmonary hypertension (cause, s/sx, diagnosis, management)
HTN isolated to pulmonary arteries (running flight of stairs and taking break after to catch breath)
causes: vascular ds., congenital heart disease, HIV, illicit drug use
s/sx: exertional dyspnea (exercise), SOB, weakness, fatigue
diagnosis: right sided heart Cath/pulmonary artery catherization
mangement: anti-hypertensives, selective PA vasodilators (remodulin, sildenafil)
what are the s/sx of right sided heart failure in pulmonary HTN
peripheral edema, ascites, distended neck veins (JVD)
describe pulmonary embolism (PE)
blocked pulmonary artery or one of its branches by a clot (thrombus) in the venous system or in the right side of the heart -> lungs
- inflammatory process further obstructs area, results in diminished or absent blood flow (tissue perfusion abnormalities)
- bronchioles constrict, increasing pulmonary vascular RESISTANCE, pulmonary arterial pressure, and right ventricular workload (extra workload of heart)
what does PE result in (3)
- ventilation perfusion imbalance (vent > perf)
- right ventricular failure
- obstructive shock
risk factors of PE
trauma, surgery, pregnancy, HF, hyper coagulability, immobility, venous stasis (sitting still for hours)
s/sx of PE
concomitant DVT, SOB, chest pain, coughing, anxiety, dizziness, cyanosis, hypoxemia, low O2 sat
prevention of PE
- exercises to avoid venous stasis (early ambulation, antiembolism stockings)
treatments: - measures to improve respiratory and vascular status (low flow to mechanical vent, fluids/pressors (increase BP)
- anticoagulation ad thrombolytic therapy (bolus heparin IVP followed by IV drip and subsequent direct oral anti coagulation (DOAC) or Coumadin therapy) - eliquis
- thrombolytics: TPA, altepase when hemodynamically unstable (dangerous, breaks clots in path)
- surgical interventions (mechanical/percutaneous clot removal/embolectomy)
what happens if patient is contraindicated to anticoagulations
IVC filters that sit in IVS -> Catch potential clots that break off to prevent going into lungs
describe pneumoconioses
occupational lung ds. and includes asbestosis, silicosis, coal workers pneumoconiosis
- nonneoplastic alt. of lung resulting from inhalation of mineral/inorganic dust (may lead to neoplasms)
- preventable but NOT TREATABLE (reduce exposure, wear gear)
- role of nurse: advocate and education patient
describe lung cancer
leading causes of cancer deaths in US
- 85% contributed cigarette smoke (1st or 2nd hand)
- classicification: SCLC/NSCLC tumors
treatment: surgery (wedge resection (remove part lung), lobectomy (remove whole lobe), pneumonectomy (remove one side of lung), radiation/chemo
what is the nursing care for lung cancer
- drain rangement
- airway clearance - track or oral airway
- dyspnea
- fatigue, pain, psychosocial support (end of life)
- palliative care/end of life goals
- risk reduction: SMOKING CESSATION
- screening: adults 50+ w/ 20+ pack per year (annual CA screening, CT screen)
describe chest injuries causes
- blunt trauma
- sternal, rib fractures
- flail chest (sucked in when inspiration)
- pulmonary contusion (supp. O2)
- penetrating trauma (surgical correction)
- pneumothorax (collapse lung) (spontaneous or simple, traumatic, tension pneumothorax)
what is tension pneumothorax
one way valve air leaks occurs from lung or through the chest wall/lung itself
treatment of chest injuries (tension pneumothorax)
- chest tube 2nd intercostal space
iclicker: an initial characteristic symptom of a simple pneumothorax is sudden onset of chest pain (t/f)
true
describe asthma
chronic inflammatory disease of the airways that cause (1) hyper responsiveness, (2) bronchial, mucosal edema, (3) mucus production
- inflammation leads to cough, chest tightness, wheezing, dyspnea
- largely reversible (spontaneously with/without treatment
- very uncontrolled in US
- can cause scarring
what part of the lung does asthma only affect?
bronchi and bronchioles -> bronchoconstriction
- goblet cells in bronchioles produce mucus
- lack of oxygen, build up of CO2 -> acidosis (hypercapnia resp. failure)
asthma triggers and meds
- allergy (eosinophilia) is a strong predisposing factor
- triggers: stress, smoke, URIs/infections, cold weather, exercise
drugs: - NSAIDS (naproxen, ketorolax)
- beta blockers (nonselective specifically bc it prevents bronchodilation & cause bronchospasm (if allergic to metoprolol)
clinical manifestations of asthma
- cough (productive/nonproductive)
- diaphoresis
- tachycardia
- hypoxemia/cyanosis
what does ASTHMA stand for
A - accessory muscle use (paradoxical breathing (with whole thorax) or diaphragmatic fatigue (CRITICAL)
S - SOB/dyspnea (single word dyspnea..say one word per breath)
T - tightness in chest/tachycardia (increased RR, shallow breaths)
H - high pitched wheezing (d/t narrowed airways)
M - minimal diminished breath sounds
A - absent breath sounds, acidosis, air trapping (prolonged exhalation)
what is the hallmark of asthma
wheezing
iclicker: what ABGs would you expect to see in a patient with acute asthma attack?
pH: low
PaCO2: high
PaO2: low
sx of hypoxia
agitation
restlessness
drowsiness
describe status asthmatics
asthma attack that is refractory to medication (r/t resp. acidosis)
- primary intervention: endotracheal intubation (however, still difficult d/t distal bronchioles still constricted)
- demand > supply
what are the quick relief medications for asthma (rescue)
beta 2 adrenergic agonists
- bronchodilator, improve airflow
- ADR: tachycardia, insomnia, tremors
- ex: ALBUTEROL (rescue drug)
Anticholinergics
- dries secretions, dilates airways, inhaled
- ex: IPRATROPUM BROMIDE (duoneb - albuterol + anticholinergic)
methylxanthines (not common)
- bronchodilator
- ex: theophylline 10-20 mg/dl
what re the long acting medications for asthma (maintenance)
corticosteroids
- causes oral thrush, decreases immune response (decrease airway edema), increases glucose
- ex: prednisolone, solumedrol (inhaled, PO, IV) - WASH MOUTH/INHALER AFTER USE
long acting beta 2 adrenergic agonists
- LABA
- ex: salmeterol
MDI use
during acute asthma attack - albuterol 2-4 puffs Q20m x3 times
- if not relieved, ER
- wash inhalers 2x/week
- steroid inhaler: wash after each use to prevent infection
- efficacy: improved O2 sat, reduced RR, patient states relief, palpitations d/t beta sympathetic stimulant
- other expected findings: increased productive cough (sputum
what is peak flow expiratory rate
how fast to get air out of airway (3 zones)
- green (no worsening symptoms)
- yellow (SABA Q4 for 1-2 days, follow up with MD)
-red (emergency tx)
describer COPD (chronic obstructive pulmonary disease) & associated respiratory diseases
slowly progressive respiratory disease of airflow obstruction
- emphysema (pink puffer)
- chronic bronchitis ( blue bloater)
- preventable and treatable, NOT REVERSIBLE
- involves airways, pulmonary parenchyma, or both
other associated respiratory diseases
cystic fibrosis, bronchiectasis, asthma (uncontrolled -> COPD)
describe pathophysiology of COPD
- airflow limitation is progressive, associated with an inflammatory response to noxious particles or gases (chronic inflammation damages tissue)
- scar tissue -> narrowing airway
- scar tissue in parenchyma -> decreases elastic recoil (stiff lungs, hard time expand)
- scar tissue in pulmonary vasculature -> thickens vessel lining and hypertrophy of smooth muscles (pul. HTN, RHF(for pulmonale)
risk factors of COPD 4
- smoking (primary)
- fume inhalation
- wood dust
- chemical exposure
chronic bronchitis - blue bloater (indication, what occurs, susceptibility)
inflammation of bronchioles
- cough & sputum production 3 months x2years
- ciliary function reduced, bronchial walls thicken, bronchial airways narrow, mucus plus airways
- alveoli damaged, fibrosed, alveolar macrophage function diminishes -> right HF
- MORE susceptible to respiratory infections (can’t get stuff out)
s/sx of chronic bronchitis
- cyanosis (blue bloater)
- long term chronic cough
- sputum production (some)
- crackles + wheezes (distal alveoli collapses, increases mucous production)
- edema/bloating (S/D right HF)
- decreased O2 expected
describe emphysema - pink puffer
abnormal distention of air spaces beyond the terminal bronchioles with destruction of walls of alveoli
- decreased alveolar surface area increases in “dead space” (large alveolar sacs) -> impaired oxygen diffusion (trapped air)
- hypoxemia results
- increased pulmonary artery pressure -> right sided heart failure (for pulmonale)
emphysema s/sx
- pursed lipped breathing: prolonged exhalation phase -> relapses O2
- barrel chest (A/P ratio 1:1)
- NO CHRONIC COUGH
- hyper resonant percussion (air trapping)
- tripodingto improve air exchange (lean forward, brings cardiac tissues off lungs)
COPD s/sx overal (emphysema & bronchitis)
- O2 sat 88-90%
- dyspnea/ SOB
- weight loss
- barrel chest
- clubbing fingernails
- restlessness, decreased ms, confusion (hypoxia)
labs: - increased WBCs, RBCs (r/t hypoxia to circulate gas)
- low paO2, high paCO2, normal pH (due to compensation)
assessment/diagnosis COPD
- health hx
- pulmonary function tests
- spirometry
- arterial blood gas (elevated paCO2, decreased paO2, decreased/normal pH, elevated pHCO3)
- chest XR (barrel chest, pneumonia)
complications of COPD 5
- respiratory insufficiency and failure (no abx unless long term COPD)
- pneumonia
- chronic atelectasis
- pneumothorax
- cor pulmonale
medical management of COPD
- BiPAP (acute exacerbations esp w/ high PaCO2) *AVOID SEDATION/RESP DEPRESSANT (benzos, narcs)
- promote smoking cessation
- reducing risk factors
- providing supp. O2 (caution d/t CO2 retention)
- vaccines: pneumococcal, influenza, covid)
- pulmonary rehabilitation (exercise regimen, intermittent PFTs)
- managing exacerbations
surgical management of COPD
- bullectomy ( remove large alveolar sacs)
- lung volume reduction
- lung transplant
pharmacological mangement of COPD
bronchodilators, MDI (rescue)
- beta adrenergic agonists: ALBUTEROL
- muscarinic antagonists (anticholinergics): ipratropium bromide (SABA), tiotroprium bromide (LABA)
- combination agents: DUONEB (ipratroprim + salbutamol)
corticosteroids (maintenance) (decrease rate exacerbation, improve response to bronchodilators, decrease dyspnea)
- inhaled: beclomethasone (QVR), budesonide (pulmicort), fluticasone (Flovent)
- PO: prednisone, medrol dose pack: regime to dose down medication
- IV: solumedrol
TIP: no difference PO vs. IV meds
long acting beta agonists
- formotreol, cilantro, salmeterol
combos (LABA + ICS)
- Symbicort (formotreol + budesonide)
- breo (vilanterol + fluticasone)
- Advair (salmeterol + fluticasone)
other
- antibiotics
- mucolytics (mucinex)
- antitussives (AVOID unless bronchitis)
- pulmonary vasodilators (remodeling, sildenafil)
nursing management of COPD
- history
- diagnostics test review
- achieve/maintain airway clearance (BIGGEST)
- improve breathing pattern (exercise)
- improve activity tolerance
- MDI patient education (wash out everything w/ steroids)
- nursing care plan
- oral care BEFORE meals
- secretion clearance: coughing, sitting upright, deep slow inhalation, hold breath, forceful exhale
- pursed lip breathing education: inhale through nose (3s), exhale (7s) through mouth (prevent air trapping)
describe bronchiectasis
chronic, irreversible dilation of bronchi and bronchioles
what is bronchiectasis caused by:
- airway obstruction, pulmonary infections
- diffuse airway injury
- genetic disorders
- abnormal host defenses
- idiopathic causes
bronchiectasis clinical manifestations and medical management
- chronic cough
- purulent sputum in copious amounts
- clubbing fingers (hypoxemia)
- postural drainage
Medical management - chest physiotherapy
- smoking cessation (IMPORTANT)
- antimicrobial therapy
- bronchodilators and mucolytics
bronchiectasis nursing management
focus on ALLEVIATING symptoms and clearing pulmonary sections
patient teaching:
- smoking cessation
- postural drainage
- early s/sx respiratory infections
- conserving energy
describe cystic fibrosis
- autosomal recessive disease among caucasian population
- genetic screening to detect carrier
- genetic counseling for couples at risk
- genetic mutation changes chloride transport, leading to thick vicious secretions in lungs, pancreas, liver, intestines, reproductive tract
- respiratory infections are leading cause of MORBIDITY and MORTALITY
medical management of CF (meds)
- chronic: control infections via abx
- acute: aggressive therapy involves airway clearance and abx.
- anti inflammatory agents
- corticosteroids: inhaled, oral, IV during exacerbations
- inhaled bronchodilators
- oral pancreatic enzymes supplementation with meals
nursing management of CF
- promote removal of pulmonary secretions (CPT, deep breathing exercises, vibrating vest)
- remind patient to reduce risk factors for respiratory infection
- adequate fluid and electrolyte intake
- palliative care (short life span)
- discuss end of life issues and concerns
- diabetes mangement (CF r/t diabetes -> increase glucose)
