WK 1: Respiratory Flashcards
how do we obtain labs?
Blood: vein, finger stick, artery
urine
stool
sputum
pulse oximetry
What is it?
what is a normal value?
AMOUNT OF HEMOGLOBIN that is carrying oxygen
-non-invasive, intermittent or continuous
-commonly used to titrate O2 levels in hospitalized pt
NML is > or = 95
the relationship between RBC’s and oxygen
bus analogy
RBC= bus
HGB= the seats
RBC’s carry O2
iron= what seats are made of
O2= passenger
Hct= total volume of highway (blood) made up of busses
what does a decreased Pulse Ox indicate?
hypoventilation
atelectasis
PNX
other lung issues
three types of sputum studies
culture and sensitivity (C&S)
cytology -CA pt
Acid fast bacillus (AFB) -testing for active TB
when collecting sputum
needs to be sputum from gut, not saliva in mouth
-steriel container
-send to lab soon
-morning specimen best
expectorate
coughing up sputum
CXR
remove all metal between waist and neck
-Common views: PA and lateral
what does a CT scan show?
structures in a cross section
what does contrast do?
fills the hollow organs within the body to highlight their internal structure
-usually iodine based
if you have a patient that has a scheduled CT with contrast, what are some things you need to consider prior to administering the contrast?
-assess BUN/Creatinine (renal function)
contrast is nephrotoxic
-assess allergies to shellfish
-“feeling of warm flush”
-force fluids afterwards
why would an MRI be used over a CT scan?
it can assess lesions that are difficult to assess by CT scan
-distinguishes vascular from nonvascular
what is better for assessing the lungs? CT or MRI?
usually CT scans
what is an MRI?
considerations for it
magnetic resonance imaging
-uses contrast medium, but not iodine
-Pt may be claustrophobic, sedation
-remove ALL metal
PET scan
positive emission tomography
-use radioactive substance called “tracer” to look for lung Dz/CA
difference between CT/MRI versus a PET scan?
CT/MRI look at STRUCTURE while PET looks at FUNCTION such as blood flow, use of O2, uptake of sugar
what does PFT stand for?
pulmonary function test
TB skin test
injection intradermal (10-15 degree angle)
-“bleb” of med under skin
bronchoscopy
using a scope to look at the bronchi
-can obtain biopsy specimen
-can remove excretions
-can be naso or oropharyngeal (anesthetized)
nursing care PRIOR to a bronchoscopy
sign consent
NPO for 6-12 hours prior to test
give sedation
why would a patient be NPO prior to a bronchoscopy
so they do not get nauseated and vomit, causing risk for aspiration
nursing care POST bronscopy
keep NPO until gag reflex returns
blood tinged mucous is an expected finding (from trauma of experience)
monitor for hemorrhage or PNX
what are some different methods to obtaining a lung biopsy?
bronchoscope (endoscopic suite)
transthoracic needle aspiration (CT guided)
open lung biopsy (done in OR)
VATS /video assisted thoracic surgery (done in OR
thoracentesis
large bone needle into pleural space
-obtaining fluid for Diagnosis
-remove PLEURAL fluid (pleural effusion)
-instill medication
what is the issue with having a pleural effusion and the reasoning behind needing to do a thoracentisis ?
it impacts the surface area for oxygenation delivery and can cause respiratory problems
third spacing
fluid is in an area where it serves no purpose
nursing care prior to a thoracentesis
-obtain signed consent
-Pt is upright with elbows on overhead table in room
-instruct them to not talk during procedure
nursing care after a thoracentesis
CXR
assess for hypoxia or PNX
pulmonary function test (PFT)
measures lung function with respect to time (seconds)
-usually done with RT
-measuring lung volumes
forced expiratory volume in one second (FEV1)
deep inhale and push it out as fast as possible to see how much they can get out
Peak flow meter
what is it?
-usually for asthma patients
-at home use
-used to check FEV1, if personal best is going down then they may be having signs of an early asthma attack
what are some causes of epistaxis ?
irritation
trauma
infection
FB
tumor
systemic Dz: HTN, blood dyscrasias (complications)
systemic Trx: chemo, anticoagulants
care for an anterior epistaxis
position upright, lean forward
reassure/calm
lateral pressure and ice (vasoconstriction)
nasal tampons
what to teach a patient when they have an anterior nosebleed
avoid blowing nose
posterior epistaxis care
emergency, hospitalization
posterior packing (ballon catheters)
assess respiratory status
humidification, O2, bedrest, pain control, oral care
teaching for patient with a posterior epistaxis
salien spray, humidification
avoid aspirin or NSAIDS
avoid strenuous activity
where to pinch the nose with an anterior nosebleed
below to nasal bone
while leaning forward and breathing through mouth
OSA (obstructive sleep apnea)
respiratory effort related arousals caused by repetitive collapse of upper airway durning sleep
risk factors for OSA
increased age, males, obesity, nasopharyngeal structural abnormalities, smoking
S/Sx of OSA
daytime sleepiness
snoring, choking, gasping during sleep
morning HA
-talk with significant other to see what they have noticed
PE of a patient with OSA
obesity
large neck or waist
other signs: MVAs, neuropsychiatric dysfunction, HTN, HF, metabolic syndrome
what is the best diagnostic test for OSA?
polysomnography
(sleep test)
CPAP
CPAP= continuous positive airway pressure
-used most often for OSA
- no add. O2 used, does not augment ventilation
-20-40% of Pts dont use their CPAP, time to educate
CPAP versus BiPAP
what are they? how are they different?
what kind of patient would each one be used for?
CPAP: for spontaneously breathing pt to improve oxygenation. to prevent upper airway obstruction in OSA
noninvasive BiPAP: uses two pressures, one during inhalation, one during exhalation.
-for nocturnal ventilation in Pt with neuromuscular Dz, CW deformity, OSA and COPD
-to prevent intubation
OSA Trx
weight reduction
avoid alcohol and smoking
sleep on side (prevent mandible dropping)
improve sleep hygiene (sleep routine)
oral appliances (mild to moderate)
surgery (tissue removal, reposition jaw, implant, tracheostomy)
trach parts
tie strings
flange (plate)
outer cannula
cuff
inner cannula
inflation tube/pilot ballon
obturator
shiley vs jackson
shiley= plastic, disposable inner cannula, cuff
jackson= longterm, metal, no cuff, reusable inner cannula
steps for tube dislodgment and accidental decannulation
keep obturator taped at bedside
insert obturator into outer cannula
extend neck/ open tissue, insert obturator / outer cannula
remove obturator
check bilateral breath sounds
secure trach
acute pharyngitis
what is it?
what are the different types ?
inflammation of pharynx or tonsils
viral pharyngitis: most common
bacterial pharyngitis: 1/10 cases (strep throat)
fungal pharyngitis: caused by candida albicans
streptococcal pharyngitis: sudden onset ST with tonsillar hypertrophy and erythema. tender lymphadenopathy and fever
what kind of pharyngitis receives antibiotics?
bacterial pharyngitis
what kind of treatment is used for candida infections (fungal pharyngitis)
nystatin swish and swallow
T/F: it is easy to distinguish between bacterial and viral pharyngitis based on symptoms alone?
FALSE
-need antigen testing
symptomatic care of pharyngitis
local soothing treatment (warm/cool fluids) and analgesics or antipyretics
- what causes 85% of head and neck cancers ?
- who is more at risk for head and neck cancers?
- tobacco
- men, >50 y/o, HPV infection
treatments for head and neck cancer
- surgery (first line)
- radiation
- chemotherapy
different kinds of surgical therapies for head and neck cancer
vocal cord stripping
laryngectomy (cant speak)
tracheostomy (always get with laryngectomy)
lymph mode removal (with metastasis)
neck dissection
what are some different ways to restore oral communication after loosing the larynx ? (voice box)
- artificial larynx (electrolarynx) : provides vibratio, easy to use
- tracheoesophageal (TE) voice restoration: hands-free valve
- esophageal speech: hand-free, no extra devices, hard to learn low quality of speech. air into esophagus “burping words up”
when a patient undergoes a radial neck dissection, what kind of tissues are removed from the body?
all tissues on one side of the neck from the mandible to the clavicle (muscles, nerves, salivary glands, major blood vessels)
-usually NG feeding tube and trach in place
post op care for a radical neck dissection
airway maintenance
trach collar with O2 humidification
pulmonary toilet
oral and trach secretion suctioning (blood tinged sputum 1-2 days)
stoma care
pain management
nutrition (feeding tube usually)
PT
speech therapy
PNA
definition
acute infection of the lung parenchyma (functional unit of an organ)
RF for PNA
older (>65)
AMS
weakened cough (cant expectorate excretions)
bedrest / prolonged immobility
debilitating illness
malnutrition
smoker
tracheal intubation
describe a patient that would be at risk for PNA
an elderly gentleman with a h/o smoking who recently had a stroke and was admitted from the nursing home that he lives at.
what are the two classifications of PNA?
- CAP (community acquired PNA)
-have not been hospitalized or been in a long term care facility within the last 14 days of symptoms - HAP (hospital acquired PNA)
-PNA in non-intubated pt that started within 48 hrs (or longer) after admission that was not present prior to admission. - VAP (Ventilator associated PNA)
- type of HAP
viral PNA
most common
- can be mild/ self limiting or life threatening
-usually resolves in 3-4 days
bacterial PNA
may require hospitalization
-can be more intense than viral
aspiration and opportunistic PNA
- aspiration: abnormal entry of material from mouth or stomach into trachea/ lungs
what are some RF for aspiration PNA?
Loss of consciousness
dysphagia
NG tube
may be “silent”: no significant event lead to it
opportunistic PNA happens in what kind of patients?
immunocompromised
PNA clinical manifestations
-preceded with a URI
-F, chills, cough, malaise, CP with inspiration & cough, dyspnea, fatigue, myalgia, confusion in elderly
bacterial PNA cough characteristic
productive
purulent (green or rusty red)
viral PNA cough characteristics
non-productive
scanty coughs
what you see on a CXR with PNA
infiltrates (haziness)
WBC with differential in regards to PNA
you will see …
- leukocytosis with bacterial
- shift to the left indicates bacterial (increase immature neutrophils)
positive sputum for C&S with PNA identifies what ?
specific bacteria and antibiotics that will kill the bacteria
-if it is a viral infection then nothing will come back
illness prevention with PNA
patient education and what to do during hospitalization
- patient education:
pneumococcal vaccine
stope smoking
adequate rest/sleep
balanced diet - during hospitalization
know who is at risk
pulmonary toilet, early ambulation
standard precautions and hand hygiene
acute nursing interventions with a patient who has PNA
VS/ pulse ox
lung auscultation (compare to baseline)
supplemental O2 as needed
pulmonary toilet, chest physiotherapy
IS
increase fluid intake if able to
ambulation
energy conservation
drug therapy (analgesics, antibiotics antipyretics)
teaching needs
what is OPD (obstructive pulmonary Dz) ?
it is an umbrella term
-can mean asthma (Peds), emphysema or chronic bronchitis
difference between emphysema and chronic bronchitis
emphysema= alveolar damage (over inflated/stretched)
chronic bronchitis = excessive secretion production
COPD is preventable and treatable
what is the most common cause of a COPDE?
respiratory infections
Dx of COPD is based on ?
Hx, Sx, spirometry results
do patients with COPD has issues with getting air into the body or getting air out of the body?
getting air out of the body
key characteristics with COPD
-increased AP diameter d/t hyperinflation
-breath sounds: decreased sounds with wheezing, rales, or rhonchi
-prolonged expiration
signed of advanced COPD include
pursed lip breathing
neck vein distention
peripheral edema
cachexia (extremely thin)
nursing problems related to COPD
activity intolerance
ineffective breathing pattern
ineffective airway clearance
impaired gas exchange
anxiety
poor nutritional status
COPD related nursing implications
smoking cessation (most effective)
teach influenza and PNA vaccine
teach early detection of resp. infections
inhaler therapy
O2 administration
teach tripod position & pursed lip breathing
review cough techniques
teach energy conservation and relaxation exercises
will need extra calories d/t increased work of breathing
psychosocial support
what are the different medications used in inhaler therapy for COPD?
long acting beta agonist (bronchdilate)
long acting muscarinic antagonist (bronchodilate)
inhaled corticosteroids (anti-inflammatory)
what is the SPO2 target number for COPD patients
88-92%
bodies have adapted to less high oxygenation levels d/y obstructive nature of Dz process
Sx of ACOPDE
management of ACOPDE
Sx: worsening dyspnea, C, or sputum beyond baseline
management: Keep SPO2 > 90% in hospital
-never withhold O2
-positive pressure ventilation (non-invasive) when hypercapnic
-bronchodilators (MDI or wet neb)
-CPT
-sometimes Abx (if bacterial in nature)
CO2 narcosis
Pt with CO2 retention (COPD Pt)
-stimulus to breath becomes low oxygenation
-normal Pt’s stimulus to breath is a normal CO2
concern: if you are a CO2 retainer and are given high levels of O2, in theory they can stop breathing b/c the drive to breath (low O2) is taken. This is CO2 narcosis
what is the ONLY way to test if a patient is a CO2 retainer?
Obtain arterial blood gas
do you hold supplemental oxygen for a COPD patient? out of concern for CO2 narcosis
no. never hold O2 for a patient that has hypoxemia present b/c they can die without it. if they do start to get CO2 narcosis, you intubate and place in the ICU
TB is caused by what microorganism?
micobacterium tuberculosis
TB that is resistant to INH and rifampin is called what?
MDR-TB
Multidrug-resistant tuberculosis
RF for TB
poor/underserved/ minorities
IVDA
poor sanitation, crowded living conditions
immunosuppressed
classifications of TB
- Primary TB
-bacteria inhaled, starting inflammatory reaction
-encapsulate organisms for rest of lives
-usually asymptomatic - latent TB
-persistant state of immune response to bacterium w/ no clinical manifestations of active TB
-asymptomatic/ non-contagious
-positive skin test w/o Sx
-cannot transmit TB but cal develop active TB - reactivated TB
-develops after latent TB 5-10% of Pts
-risks much higher in elders/immunosuppressed
-transmissible
clinical manifestations of latent TB
+ TB test
possible “ghon nodule” on CXR
asymptomatic
clinical manifestations of active TB
+ sputum
fever, night sweats, weight loss, productive cough w/purulent or bloody sputum >3 weeks
diagnostic tests for TB
- tuberculin skin test (TST), also called Mantoux test
-measure area of induration - Interferon-gamma release assay blood test (IGRA)
*do one or the other
*one is not better than the other - CXR (ghon nodule)
- sputum for AFB (acid fast bacillus)
TST readings:
an induration of 15 or more millimeters is considered a positive reading for which group of people?
this is for any healthy normal patient w/o known RF
TST readings:
an induration of 10 or more millimeters is considered positive for which group of people
-recent immigrants (<5 years)
-IVD users
-residents/employees of high risk congregate settings
-mycrobacteriology lab works
-clinical conditions with high risk
-children <4 y/o
-infants, children, adolescents exposed to adults that are high risk
TST readings:
an induration of 5 or more millimeters is positive in which groups of people ?
-HIV +
-recent contact with TB person
-fibrotic changes on chest radiograph consistant with prior TB
-organ transplant
-immunosuppressed
what do you do if your patient has a new positive TST result for TB?
obtain CXR
-if CXR is negative= latent TB
-if CXR is positive = further testing to confirm or r/o active pulmonary TB
nursing management of TB
ultimat goal: eradicate TB
interpret diagnostic study results
identify recent contacts
drug therapy (strict adherence, DOT prn, assess adverse effects)
DOT for tuberculosis patients
direct observation therapy
-they go somewhere and are observed taking the pills needed to trx TB
notable side effects of antimicrobials
- isoniazid (INH): hepatotoxicity, peripheral neuropathy
- rifampin: red/orange discoloration of excretions
- ethambutol: decreased visual acuity, red/green colorblind
what are the two main drugs that are hard on the liver and have concerns with hepatotoxicity ?
tylenol and isoniazid
what kind of precautions are in place with a patient that has TB
airborne
negative pressure room
hepa mask (fit testing)
monitor annual TB status
home care of TB patient
-prevention drug therapy to high risk contacts
-cover mouth / nose
-wear mask in crowds
-sputum for ARB q2weeks
***3 negative cultures=no longer infectious)
clinical manifestations of lung cancer
CXR
clinically silent for majority of course
often masked by chronic underlying cough or Sx of smoking
most common symptom: productive cough
XR readings:
consolidation=
infiltrates =
consolidation= mass
infiltrates= haziness
diagnostic studies for lung cancer
CXR: mass/infiltrates
CT/MRI: assess for metastasis
sputum for cytology: only 20-30% specimens are +
biopsy: definitive diagnostic test
-fine needle, bronchoscopy, VAT
lung cancer nursing problems
ineffective airway clearance
ineffective breathing pattern
anxiety
poor nutritional status
fatigue
knowledge deficit (plan of care)
collaborative care for lung cancer Pt
smoking cessation
anxiety reduction
surgical therapy (pneumonectomy, lobectomy, segmental or wedge resection)
radiation
chemotherapy
pneumonectomy
removal of entire lung
