Respiratory Tract Disorders Flashcards
Tracheostomy
a surgical procedure to create an opening through the neck into the trachea
Why would a tracheostomy be performed?
- remove excessive thick secretions
- long-term mechanical ventilation (longer than 2 wks)
- prevention of aspiration (unconscious, paralysis)
- bypass obstruction of upper airway
3 Parts of a Trach Tube
- obturator
- outer canal
- inner canal
What are the 3 types of trach tubes?
- cuffed
- uncuffed
- fenestrated
Cuffed Trach Tube
seals the airway to prevent air from escaping through the nose and mouth
What type of tube allows talking when the end is covered?
uncuffed trach tube
Fenestrated Trach Tube
front of tube can be blocked to allow air to flow upwards to upper part of the trachea and larynx
Where can a tracheostomy be performed?
in the OR or at the bedside in critical care setting
What are the nursing responsibilities if a trach is placed at the bedside?
- call respiratory therapy
- record vitals
- ensure existing IV is patent
- assess bedside suction
- position patient supine
- administer analgesia/sedation
- emergency equipment nearby (bag-valve mask)
Nursing Objectives after Trach is placed
- keep patient calm
- supply means for communication
- prevent infection
How often should the trach be cleaned?
q 8 hours
What type of technique is used for cleaning a trach?
Sterile technique
Trach Care
- inform patient/fam about procedure
- hand hygiene
- gather equipment, position patient, don PPE, set up equipment
- don sterile gloves
- unlock and remove inner cannula; place in sterile saline, cleanse, rinse, reinsert
- cleanse stoma
Suctioning Trach
- explain procedure
- hand hygiene
- connect suction catheter to tubing w/ nondominant hand (becomes nonsterile)
- suctioning is done using sterile glove
- hyper-oxygenate patient
- DO NOT suction going in
- remove catheter over 10-15 secs w/ circular motion
- wait at least 1 min before going again
When is the greatest risk for accidental dislodgment of trach?
1st 5 days
What to do if Accidental Dislodgment Occurs
- immediately call for help
- spread the opening w/ a hemostat, insert replacement tube w/ obturator, remove obturator
- or insert suction catheter to allow passage of air and guide insertion of replacement tube
- ALWAYS keep extra tube of same size and original obturator at bedside
What to do is tube CAN NOT be replaced
- assess levels of respiratory distress
- position patient semi-fowlers position
- severe distress may progress to respiratory arrest
- cover stoma w/ sterile dressing and ventilate with bag valve mask until help arrives
You should always have second trach placed where?
Taped to the head of the bed
Speaking Valve/Passy-Muir Valve (PMV)
- thin diaphragm that opens on inspiration and closes on expiration
- air flows over vocal cords during exhalation
- cuff must be deflated or use cuffless tube
- evaluate ability to tolerate
Pleural Effusion
collection of fluid in the pleural space
How much humidification do you want for inspired air?
100%
When the fluid is pus what is a pleural effusion known as?
empyema
S/S of Pleural Effusion
- fever/chills
- chest pain (pleuritic) with inspiration/expiration
- dyspnea
- cough
- diminished/absent breath sounds
How can a pleural effusion be diagnosed?
- Chest x-ray
- CT scan
- thoracentesis to obtain fluid for culture
Nursing Role for Thoracentesis
- position patient
- provide support/keep calm
- order lab
- monitory respiratory status
- document patient tolerance
- administer antibiotics
Goals for Pleural Effusion
- prevent fluid from reaccumulating
- relieve/decrease discomfort and dyspnea
- treat infection if present
Acute Respiratory Distress Syndrome (ARDS)
- fluid builds up in the alveoli, preventing the lungs from filling with enough air
- less oxygen reaches the bloodstream, depriving the organs of oxygen they need to function
- life threatening
- MUST IDENTIFY CAUSE
S/S of ARDS
- pulmonary edema
- bilateral lung infiltrates
- worsening hypoxemia
- diminishing lung compliance
What are the most common risk factors/causes for ARDS?
- sepsis
- aspiration/near drowning
- smoke/chemical inhalation
- chest trauma
- severe pneumonia
- massive blood transfusion
What is a pleural effusion most often caused by?
Pneumonia or chest trauma
Treatment for ARDS
- aggressive mechanical ventilation w/ oxygenation
- circulatory support
- fluid/electrolyte maintenance
- nutritional support
- pain meds
- sedatives
- prophylaxis to prevent DVT
What vasopressors are used to maintain BP for a patient w/ ARDS?
dopamine/dobutamine
Complications of ARDS
- blood clots
- collapsed lung (pneumothorax)
- infection
- scarring (pulmonary fibrosis)
- chronic breathing probs
- depression
Pulmonary Embolism
occurs when blood clot gets lodged in an artery in the lung blocking flow to part of the lung
-often leads to sudden death
Where to pulmonary embolism often originate from?
Most often originate in the legs and travel up through the right side of the heart and into the lungs
Cause of Pulmonary Embolism
- disease or injury leading to prolonged immobility
- major surgeries
Thrombus
blood clot that forms in a vein and reduces blood flow beyond that area
Embolus
anything that travels through the blood vessels until it reaches a vessel that is too small to let it pass and proceeds to occlude blood flow beyond that area
S/S of Pulmonary Embolism
- sudden onset of embolism
- sharp, stabbing, burning chest pain w/ inhalation and exhalation
- persistent cough
- hemoptysis
- tachypnea
- tachycardia
PEEP for ARDS
keeping positive expiratory pressure in the lungs to keep alveoli open and improve gas exchange
How to Diagnosis Pulmonary Embolism
- chest x-ray
- venous doppler
- ABG’s
- D-dimer
- Spiral CT
- VQ Scan
VQ scan
- uses an IV/inhaled radioactive agent
- uses a ventilation (V) scan to measure air flow in your lungs and a perfusion (Q) scan to see where blood flows in the lungs
Saddle embolus
massive PE that straddles the main pulmonary artery trunk at its bifurcation
- medical emergency
- death can occur immediately or within hours
Nursing Management for Saddle Embolus
- stabilize
- oxygen
- IV lines
- ABGs/scans
- vasopressors to treat hypotension
- daily labs
- intubation if indicated
- foley catheter
- IV sedatives
- IV thrombolytics
Pharmacological Prevention Meds of PE
- heparin
- lovenox
- coumadin
- Xarelto
Heparin
- IV drip
- weight based protocol
- aPTT daily/ CBC at least weekly
- may continue until blood levels are therapeutic
Lovenox
- SUBQ every day or q 12 hours
- may be used in conjunction w/ oral meds until blood levels are therapeutic
Coumadin
- requires frequent blood draws
- INR 2-3; target is usually around 2.5/NOT > 3.5
Embolectomy
- surgical removal of embolus
- Rare
- high mortality rate
- involves cardiac bypass
IVC Filter
- small mesh-like trap placed in the inferior vena cava to trap emboli before they reach the lungs
- placed by radiology interventionist
- temporary or permanent
Pneumothorax
opening in the pleural space results in positive pressure leaving the lungs on the affected side unable to maintain inflation
What are the 3 types of pneumothorax?
- simple/spontaneous
- traumatic
- tension
What type of pneumothorax is usually the result of a bleb rupturing?
Simple/spontaneous
Traumatic Pneumothorax
- air enters the pleural space through a lung laceration
- air passes in and out freely with each breath taken
Tension Pneumothorax
Air enters the pleural space through a lung laceration, but the pleural membrane acts as a one-way valve and does not allow the air to escape back out w/ expiration
Mild/Severe Pneumothorax Symptoms
- sudden pleuritic pain
- dyspnea
- tachypnea
Large Pneumothorax w/ total lung collapse S/S
- anxiety/air hunger
- hypoxemia
- high use of accessory muscles
Goal for Pneumothorax
- remove air and reexpand lung
- chest tube
- needle aspiration
- monitor breathing/vitals
- help w/ anxiety
Why is a chest tube inserted?
drain air (pneumothorax) or fluid (hemothorax) from the pleural space
What does placement of a chest tube help?
Helps to restore negative pressure so that lung can reexpand
What are two types of drainage systems?
Wet and Dry Suction Control
Wet Suction Control (Water Seal)
suction is controlled by amount of water in water seal chamber
Dry Suction Control
- use one-way valve
- usually have a suction dial on collection apparatus
Suction Control Chamber
- common setting is 20 cm H2O
- more water=higher suction
- less water=lower suction
- may see bubbling
Water Seal Chamber
- one-way valve to prevent air from entering the pleural space w/ inhalation
- fill w/ water to 2 cm line
- water level gently rises and falls w/ breathing
- bubbling indicates air leak
Collection Chamber
may be to gravity or connected to wall suction
Nursing Management for Drainage System
- mark drainage q shift
- monitor for kinks, loops, occlusions
- turn q 2 hours
- pain meds prn
- gently milk tubing to prevent clots if blood appears
- monitor for s/s of respiratory distress
- encourage coughing/deep breaths
- encourage IS use
Important Chest Tube Considerations
- NEVER clamp tube unless ordered by provider or to change system
- change dressing in 24 hrs then q 48 or prn
- keep emergency supplies at bedside
Emergency Supplies for Chest Tube
- two guarded clamps
- sterile water
- Vaseline gauze
- 4x4 sterile dressing
- waterproof tape
- extra collection system
What to do if Chest Tube falls out
- immediately apply pressure to insertion site and apply sterile gauze or Vaseline gauze and dry dressing over insertions site and ensure tight seal
- notify provider to reinsert new chest tube
- monitor for respiratory distress
What to do if Chest Tube becomes disconnected from collection chamber
place end of tube in sterile water until collection system can be reconnected
What to do if leak is suspected in Chest Tube
- check all connections
- assess collection system
- using padded clamp, clamp momentarily
- when you place clamp b/t source of air and chamber bubbling will stop
If bubbling stops the first type you clamp the tube with a suspected leak what could that mean?
Air must be at the insertion site or the lung
What can cause a collapsed lung with ARDS?
PEEP
