Med surg interventions unit 1

Acid and base balances

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Care and complications of a chest tube

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Methods to facilitate coughing

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Normal and abnormal breath sounds

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Oxygen delivery systems

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Respiratory distress nursing interventions

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Respiratory meds

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Use of inhaler

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Orthopnea or tripod positioning

A body position that enable the patient to breathe comfortably. Usually it is one in which the patient is sitting up and bent forward with the arm supported on a table or chair.

Viral and bacterial pharyngitis

A sore throat an inflammation of the pharyngeal mucous membranes. Can be bacterial or viral. Can be caused by bacteria, viruses, organisms, trauma, dehydration, irritants, tobacco, and alcohol. May exhibit soreness and dryness, throat pain, pain on swallowing, trouble swallowing, and fever. Viral and bacterial are often hard to distinguish on physical assessment. Redness may be seen with or without enlarged tonsils and with or without exudate. A common bacteria causing pharyngitis is group a strep. complications of group a strep include rheumatic fever, acute glomerulonephritis, peritonsillar abscess, otitis media, sinusitis, mastoiditis, bronchitis, pneumonia, and scarlet fever. Scarlet or rheumatic fever is when strep goes down into your heart. Viral: low grade or no fever, retracted or dull tympanic membrane, scant or no tonsillar exudate, slight redness of pharynx and tonsils, no rash, trouble swallowing, rhinitis, mild hoarseness, headache, CBC is usually normal, white blood cell count usually less than 10000, negative throat culture results onset is gradual. Bacterial: high temperature, retracted or dull tympanic membrane, severe hyperemia of pharyngeal mucosa, redness of tonsils with yellow exudate, a possible rash, trouble swallowing, pain upon speaking, headaches, arthralgia, myalgia, complete blood count abnormal, white blood cell count usually greater than 12000 common throat culture results positive for strep, has an abrupt onset. Assessment: look for enlarged red tonsils, exudate, purulent nasal discharge, local lymph node enlargement, ask about history of strep infections, rheumatic fever, valvular heart disease, diphtheria, pneumonia, influenza, rubella, meningitis, mumps, and pertussis. Is diagnosed with throat cultures a CBC and a latex agglutination to test for strep. Treatment : Viral pharyngitis does not require antibiotic therapy and responds to supportive interventions. Teach the patient to rest, increase fluid intake, humidify the air, and use analgesics for pain. Gargling several times each day with warm saline and using throat lozenges can increase comfort. Management of bacterial pharyngitis involves antibiotics and the same supportive care as with Viral pharyngitis. For streptococcal infection and oral penicillin or cephalosporin is prescribed. Use droplet precautions and health teaching to clients to complete all antibiotics, use good hand hygiene, and to avoid sick people and large crowds.

COPD

Chronic obstructive pulmonary diseases include infazema and chronic bronchitis. Emphysema: involves loss of lung elasticity and hyper inflation of the lung results in dyspnea and the need for increased respiratory rate. It has a slow onset. upon assessment you will find progressive dyspnea, cough, increase in sputum, anorexia, barrel chest, clubbed fingers, and a pink puffer appearance. To be diagnosed you can use pulmonary function test, chest x-ray, ABG, or CBC. Bronchitis: inflammation of the bronchi and bronchioles caused by exposure to irritants. The irritants trigger inflammation, vasodilation, mucosal edema, congestion, and bronchospasm. Bronchitis affects only the airways and not the alveoli. Causes cough with sputum. Enlargement of hyperactivity of mucus glands causes inflammation and narrowing of airways reducing ciliary efficiency. Upon assessment you will find a productive cough for at least 3 months for the last consecutive 2 years. A smoker's cough, lots of sputum, prone to development of right sided heart failure, with the blue bloater appearance. Diagnosed with pulmonary function tests, chest x-ray, ABG's, beauty and culture. Risk factors for COPD: smoking is the number one risk factor. Air pollution, occupational exposure to respiratory irritants, allergies, autoimmunity, infection, genetic predisposition, aging, chronic bronchitis, exposure to secondhand smoke, & a missing alpha 1 antitrypsin enzyme <only in emphysema > Intervention: assess lungs, lung sounds, breathing, and use of accessory muscles. Encourage orthopnea positioning and assess secretions. Use oxygen cautiously. You should not have a person with COPD on oxygen higher than 2 liters nasal cannula unless ordered. High levels of oxygen will lower co2 and decrease the drive to breathe. Monitor intake and output and weight. Provide small frequent meals, increase fluids, and teach pursed lip breathing. cough and deep breathe and use incentive spirometer. Teach abdominal and diaphragmatic breathing techniques. Provide chest physiotherapy. Perform oral care frequently to promote comfort and appetite. Monterey BeeGees and pulse ox. Monitor chest x ray. Take cultures. Administer medications and treatments as prescribed. Assess ability to use inhaler and metered dose inhaler correctly and provided pain management. Asthma: chronic condition where reversible airflow obstruction in the airways occurs intermittently. Can occur in two ways, inflammation, and airway hyperresponsiveness that leads to bronchoconstriction. Usually more of a childhood disorder but can be present in adults as well. Kids tend to outgrow this. Upon assessment you will find chest tightness, dyspnea, cough, wheezing expirations that are strenuous and prolonged compared to inspiration, use of accessory muscles, hypoxia with restlessness, anxiousness, cyanosis, weak pulse and diaphoresis. Can be diagnosed using pulmonary function test, chest x-ray, ABG's, culture, and laugh for toxicity of medications. Insert step system for medication pg 24 in spiral book. Health teaching: small feedings of soft food, avoid spicy foods or MSG to prevent abdominal distention, eat high calorie foods first, splint chest when coughing, use abdominal muscles for more productive cough, mobilize secretions by increasing fluids, perform pursed lip breathing, high fowlers position for better lung expansion, plan activities and leave rest for activities, avoid stress, destroye dust mites, avoid irritants and triggers, use of reliever or rescue inhalers verses daily control use inhalers, how to use and read a peak flow meter and when to seek emergency care.

Pneumonia

In excess of fluid in the lungs resulting from an inflammatory process. Can be caused by inhaled infectious organisms or irritating agents such as fumes or aspirated foods or fluids. Is classified as community-acquired or hospital-acquired/ nosocomial. Community-acquired pneumonia: contracted outside healthcare setting, acquired in the community. Most common bacterial agents are streptococcus and haemophilius influenza. most common viral agents are influenza and RSV. Antibiotics are often empirical based on multiple patient and environmental factors. the treatment length is a minimum of 5 days. Prompt initiation of antibiotics is required. Healthcare associated pneumonia: the onset or diagnosis of pneumonia occurs less than 48 hours after admission in patients with specific risk factors. living in nursing home or assisted living facility, receiving IV therapy, wound care, antibiotics, chemotherapy in the past 30 days or seen in a hospital or dialysis clinic within the past 30 days. May have multidrug-resistant organisms and hand hygiene is critical. Hospital-acquired pneumonia: onset or diagnosis of pneumonia more than 48 hours after admission to hospital. Encourage pulmonary hygiene and progressive ambulation, provide adequate hydration, assess risk for aspiration, monitor for early signs of sepsis, hand hygiene is critical. Ventilator-associated pneumonia: onset or diagnosis of pneumonia within 48 to 72 hours after endotracheal intubation. Presence of ET tube increases risk for pneumonia by bypassing protective airway mechanism and by allowing aspiration of secretions from the oropharynx and stomach. Clinical manifestations: fever, elevated white blood cell count, headache, flushed cheeks, tachycardia, diaphoresis, chills, persistent cough, increased sputu, production, malaise, myalgia, fatigue, weakness, pleuritic pain, chest discomfort, crackles, wheezing, dyspnea, diminished chest expansion, weak chest muscles, rails and rhonchi on auscultation, rust colored sputum, blood tinged sputum, hypoxia, increased respirations. How to diagnose pneumonia: sputum Gram stain, CBC, blood culture, ua, ABGs, electrolyte panel, chest x-ray, o2 saturation, trans tracheal aspiration, bronchoscopy, and needle aspiration of lung. Patient recovering from pneumonia: monitor rate, rhythm, depth, and effort of respiration. Make sure the head of bed is up at least 30 degrees. Administer oxygen as ordered and needed. Monitor for fever, diaphoresis, cyanosis, tachycardia, adventitious breath sound, weakness, dyspnea. Promote deep inhalation and high interest thoracic pressure for forceful exppulsion of air. Monitor beautiful color and white blood cell count, administer anti-infective, pain, steroids as ordered, administer breathing treatments as needed. Follow universal precautions and isolate procedure if development of mRSA or DRSP occurs. Risk factors for community-acquired pneumonia: older adult, has not received the pneumonia vaccination or received it more than 5 years ago, did not receive the flu vaccine in the previous year, has a chronic health problem or other coexisting condition that reduces immune responses, has recently been exposed to respiratory viral or influenza infections, and uses tobacco or alcohol or is exposed to high amounts of secondhand smoke. Risk factors for health care acquired pneumonia: older adult, has a chronic lung disease, has presence of gram-negative colonization of the mouth throat and stomach, has an altered level of consciousness, has had a recent aspiration event, have presence of endotracheal, tracheostomy, or nasogastric tube, have poor nutritional status, has immuno-compromised status from disease or drug therapy, uses drugs that increase gastric pH or alkaline tube feedings, and is currently receiving mechanical ventilation. Preventing pneumonia: know your risk for pneumonia, have the annual flu vaccine, discuss the pneumonia vaccine and have the vaccine as recommended, avoid crowded public areas during flu and holiday season, if you have a mobility problem, cough, turn, move about as much as possible, and perform deep breathing exercises, clean any use respiratory equipment, avoid indoor pollutant such as dust, secondhand smoke, and aerosols, do not smoke, be sure to get enough rest and sleep, eat a healthy balanced diet, and drink at least three liters of non-alcoholic fluid every day.

Steps of a respiratory assessment

Patient history: genetic risk, current health problems, a physical assessment including assessment of the nose and sinuses, assessment of the pharynx, trachea, and larynx, assessment of the lungs and thorax, psychosocial assessment and diagnostic assessment including laboratory assessment, imaging assessment, and other non invasive diagnostic assessments.

Postural drainage

Postural drainage is one way to help treat breathing problems due to swelling and too much mucus in the airway of the lungs. With postural drainage, you get into a position that helps drain fluid out of the lungs.

Pursed lip breathing

Purpose: to create back pressure inside airways to splint them open. Close your mouth, and breathe in through your nose. Purse your lips as you would to whistle. Breathe out slowly through your mouth, without puffing your cheeks. Spend at least twice the amount of time it took you to breathe in. Use your abdominal muscles to squeeze out every bit of air you can.

Use of incentive spirometer

Purpose: to promote complete lung expansion and to prevent pulmonary problems. Put the mouthpiece in your mouth and close your lips tightly around it. Inhale slowly and deeply through the mouth piece to raise the indicator. When you cannot inhale any longer, remove the mouthpiece and hold your breath for at least 3 seconds. Exhale normally.

Radiation and chemotherapy nursing interventions

Radiation: the markings will be visible. Do not remove mark. Make sure you take care of skin. Dry skin properly, use mild soap, moisturize, use sunscreen. Can cause nausea and reduces energy levels. Chemotherapy: lowers your white blood cell count. increases your risk for infection. The patient should be on isolation precautions and neutropenic precautions. Causes hair loss, nausea and vomiting, mouth sores, and can deplete energy levels. Chemotherapy extravasation should be prevented. Any healthcare official handling chemotherapy agents should use gloves and personal protective equipment when doing so.

Lung cancer

Risk factors: cigarette smoking is the major risk factor. Other risk factors include a history of familial lung cancer and chronic exposure to pulmonary irritants, asbestos or air pollutants, exposure to cigarette smoke. Assessment: hoarseness, change and respiratory pattern, persistent cough or change in cough, blood streaked sputum, rust colored or purulent sputum, Frank hemoptysis, chest pain or chest tightness, shoulder, arm, or chest wall pain, recurring episodes of pleural effusion, pneumonia, or bronchitis, dyspnea, fever associated with one or two other signs, wheezing, weight loss, and clubbing of the fingers. Health teaching: explain possible causes, discuss strategies of smoking cessation, explain operative procedures and diagnostic procedures, explain side effects of disease and treatment of disease and treatment side effects, provide instruction on dealing with dyspnea such as positioning, prevent exposure to others, when to call the doctor, and safety precautions when using oxygen.

TB

Risk factors: immune dysfunction or HIV, crowded living conditions, elderly, homeless or minorities, IV drug users, alcohol users, lower socioeconomic groups, and foreign immigrants especially from Mexico, Philippines, Vietnam, China, and Japan. Assessment features: low grade fever, fatigue, lethargy, weight loss, anorexia, chest pain, productive cough with purulent sputum, night sweats, and hemoptysis. The only way to absolutely confirm a diagnosis of TB perform a sputum culture. The only way to get TB is to inhale the bacteria and be exposed to active TB. For a TB test to be considered positive it must be indurated and have a diameter of 10 millimeters or greater. A positive reaction does not mean that active disease is present but indicates exposure to TB or the presence of inactive disease. Interventions: take medicine every day. Resistant strains or HIV positive people may require up24 anti-infectives at once for up to 12 months. For the hospitalized patient: hand washing, where N95 mask within 3 feet of patient, airborne precautions, negative pressure room, hydrate, proper nutrition, suction Airways, position in Fowler's or semi Fowler's position, administer oxygen, respiratory therapy, use incentive spirometer, if client leaves the room place mask on client. Health teaching: make sure client adheres to the drug regimen for 6 months or longer. Teach ways to minimize side effects such as no alcohol. Disease is usually no longer contagious after drugs have been taken for 2 to 3 weeks but client must continue to take drugs for at least 6 months. Sputum specimen are needed every two to four weeks once drugs have been initiated. When you have three consecutive negative sputum specimens the client is considered to be no longer infectious. Teach proper use of medications and incentive spirometer. Instruct patient to cover mouth and nose when coughing and sneezing. Instruct client to place tissues in plastic bag. Teach client that TB is spread airborne only and does not live on inanimate object. All members of the household need to be tested. wear a mask when in contact with crowds until drugs suppress infection. Maintain proper nutrition to prevent recurrence. TB infectives all carry a high risk of damage to the liver. First line of defense is INH or isoniazid. Take vitamin b6 with these medicine to prevent neuropathy.

Head and neck cancer

Risk factors: the two most important risk factors for head and neck cancer are tobacco and alcohol use especially in combination. Other risk factors include voice abuse, chronic laryngitis, exposure to chemicals or dust, poor oral hygiene, long-term or severe gastroesophageal reflux disease, oral infection with human papillomavirus obesity, increased fat intake, low fiber intake, low vitamin intake, no vegetables, smoked meats, salt or nitrate cured foods, chewing, sun exposure, exposure to industrial agents, immune function, age, and genetic predisposition. Warning signs of head and neck cancer upon assessment: pain, lump in the mouth, throat, or neck, trouble swallowing, color changes in the mouth or tongue to red, white, gray, dark brown, or black, or Lesion or sore that does not heal in two weeks, persistent or unexplained oral bleeding, numbness of the mouth, lips, or face, changing in the fit of your dentures, burning sensation when drinking a citrus juice or hot liquid, persistent, unilateral ear pain, hoarseness or change in voice quality, persistent or recurrent sore throat, shortness of breath, anorexia and weight loss. Diagnostic: CBC, bleeding time, UA, and blood chemistry Treatment: chemotherapy, radiation, and surgery. Interventions: chest pain to rule out complications, administer analgesics to relieve pain, wash radiated area with water only and pat dry to maintain skin integrity. Do not wash off target markers this will be a problem with treatment. Use sunscreen on radiated areas and wear protective clothing. Conserve your voice if hoarse. Switch or swallow antacid before meals to avoid gastric discomfort. Use KY jelly or lip balm to maintain skin integrity, use a soft toothbrush to maintain integrity. Don't use mouthwash with alcohol and perform frequent oral care. Encourage fluids, guard against exposure to others or isolate if necessary. Assess psychosocial as they may need counseling. Monitor white blood cell count and manage nausea vomiting and anorexia. Surgical procedures for laryngeal cancer and their effect on voice quality: Laser surgery: the tumor is reduced or destroyed by laser beam through laryngeal scope. voice quality is normal to hoarse. Transoral cordectomy: the tumor is reflected through the laryngeal scope. Voice quality is normal to hoarse and has a high cure rate. Laryngofissure: no cord is removed for early lesion. Voice quality is normal with a high cure rate. Supraglottic partial laryngectomy: hyoid bone, false cords, and epiglottis removed. Neck dissection on affected side performed if nodes are involved. Voice quality is normal or hoarse. Hemilaryngectomy or vertical laryngectomy: one true cord, 1 false cord, and one half of thyroid cartilage is removed. Voice quality is hoarse. Total laryngectomy: entire larynx, hyoid bone, strap muscles, one or two tracheal rings removed. Total neck dissection if nodes are involved. No natural voice. Post op care: complications after surgery include airway obstruction, hemorrhage, wound breakdown, and tumor recurrence. The first priorities after head and neck surgery or airway maintenance and gas exchange. Other priorities are wound, flap, and reconstructive tissue care, pain management, nutrition, and psychological adjustment, including speech and language therapy. Health teaching for patient: explain to the patient there will be odor and taste changes as well as tongue color changes. Avoid clothes that rub and shave with electric razors. Avoid the Sun, wear scarf outside to avoid heat loss and sunburn with hair loss, do not wash off target marks. Use a soft toothbrush. Remove dentures when not eating. Report lesions, redness, and anorexia. Also teach about decreased tolerance to temperature of food.