NUR 2110- Exam 3

The Patient Receiving Mechanical Ventilation Assessment Diagnosis Complications Planning/Goals

-ASSESSMENT: Evaluate physiologic status Vital signs, respiratory rate/pattern, breath sounds, ventilatory effort, hypoxia (skin color) Increased adventitious breath sounds HOB = 30 degrees Evaluate settings and function Address neurologic status, coping, comfort level, ability to communicate * weaning from mechanical ventilation requires adequate nutrition( assess the system and nutritional status -DIAGNOSIS: Impaired gas exchange Ineffective airway clearance Risk for trauma/inf Impaired physical mobility Impaired verbal communication Defensive coping and powerlessness -COMPLICATIONS: Ventilator problems Alterations in cardiac functions Barotrauma Pulmonary Infection and sepsis Delirium -GOALS: Optimal gas exchange Patent Airway Absence of trauma/infection Optimal mobility Nonverbal communication Coping Measures Absence of complications

The Patient Receiving Mechanical Ventilation Monitoring and Managing Potential Complications

-Alterations in Cardiac Function: pt may have decreased cardiac output, tissue perfection, oxygenation *Observe for hypoxia (restlessness, apprehension, confusion, tachycardia, tachypnea, pallor progressing to cyanosis, diaphoresis, transient hypertension, and decreased urine output) **If a pulmonary artery catheter is in place, cardiac output, cardiac index, and other hemodynamic values can be used to assess the patient's statu -Pulmonary Infection: Report fever/change in color/odor of sputum -Delirium ABCDE 1)Awakening and spontaneous breathing trials 2) Monitoring and management of delirium 2) Early Mobility Fill humidifier as needed and check its level three times a day

Thoracic Surgery: Postoperative Nursing Management -Monitoring Respiratory and Cardiovascular Status -Improve Gas exchange and Breathing -Improving Airway Clearance -Relieving Pain and Discomfort -Promoting Mobility and Shoulder Exercises -Maintaining Fluid Volume and Nutrition -Monitoring and Managing Potential Complications

-Monitoring Respiratory and Cardiovascular Status: monitor heart rate, rhythm by auscultation, ECG Detect early signs of fluid volume disturbances -Improve Gas exchange and Breathing: In the immediate postoperative period measure vital signs every 15 minutes for the first 1 to 2 hours ABGs Breathing techniques (diaphragmatic, pursed-lip breathing, taught prior to surgery should be performed every 2 hours) Elevate HOB 30-40 degrees patient should be repositioned from back to side frequently and moved from a flat to a semi-upright position as soon as tolerated *After a pneumonectomy, the operated side should be dependent so that fluid in the pleural space remains below the level of the bronchial stump and the other lung can fully expand -Improving Airway Clearance: Retained secretions are a threat to the patient after thoracotomy surgery patient should cough at least every hour during the first 24 hours and when necessary thereafter. If audible crackles are present, it may be necessary to use chest percussion with the cough routine until the lungs are clear. Aerosol therapy is helpful in humidifying and mobilizing secretions so that they can easily be cleared with coughing. To minimize incisional pain during coughing, the nurse supports the incision or encourages pt -Relieving Pain and Discomfort: IV PCA, PCEA important to avoid depressing the respiratory system with excessive opioid analgesia EMLA cream, which is a mixture of the two medications, may be effective in treating pain from chest tube removal *analgesia is not typically indicated when removing chest tubes, because the pain, although severe, is of short duration (usually less than a few minutes) and the analgesia might interfere with respiratory effort -Promoting Mobility and Shoulder Exercises: arm and shoulder must be mobilized by full ROM (within 8-12 hours), painful at first but then subsides 3-4 g of acetaminophen daily (relieve shoulder pain) -Maintaining Fluid Volume and Nutrition: During the surgical procedure/immediately after pt may receive a transfusion of blood products followed by continuous IV infusion Fluids at low hourly rate *monitor infusion site for signs of infiltration, including swelling, tenderness, redness Pts undergoing thoracotomy may have poor nutritional status before surgery b/c of dyspnea, sputum production, poor appetite **DIET: liquid diet is provided as soon as bowel sounds return pt is progressed to a full diet as soon as possible Small, frequent meals are better tolerated and are crucial to the recovery and maintenance of lung function -Monitoring and Managing Potential Complications: Identify and manage early monitors pt at regular intervals for signs of respiratory distress or developing respiratory failure, dysrhythmias, bronchopleural fistula, hemorrhage and shock, atelectasis, and incisional/pulmonary infection Supplemental oxygen ***Pulmonary infections or effusion, often preceded by atelectasis, may occur a few days into the postoperative course Bronchopleural fistula Hemorrhage and shock are managed by treating underlying cause NOTE: pulmonary edema from overinfusion of IV fluids is a significant danger Early symptoms are dyspnea; crackles; tachycardia; and pink, frothy sputum = emergency, must be reported and treated immediately

The Patient Receiving Mechanical Ventilation Nursing Interventions

-NURSING INTERVENTIONS: Determined by underlying diseases process and pts response 1) Pulmonary Auscultation 2) ABGs *nurse is usually the first to notice changes -Enhancing Gas Exchange: Optimize gas Assess for adequate gas exchange, hypoxia, response to treatment Adequate fluid balance (peripheral edema) Daily input and output Morning daily weights meds for primary disease, check side effects -Promoting Effective Airway Clearance: *Continuous positive-pressure ventilation increases production of secretion Assess for secretions (auscultate lungs every 2-4 hours) Sputum is not produced continuously/every 1 to 2 hours but as a response to a pathologic condition (no rationale for routine suctioning of all patients every 1 to 2 hours) Periodic sighs prevent atelectasis and further retention of secretions Humidification to help liquefy secretions Bronchodilators (acute kidney injury,COPD) Mucolytic agents - Side effects include nausea, vomiting, bronchospasm, stomatitis (oral ulcers), urticaria, and rhinorrhea (runny nose) -Preventing Trauma and Infection: *maintaining endotracheal or tracheostomy tube is an essential part of airway management positions the ventilator tubing so that there is minimal pulling or distortion of the tube in the trachea, reducing the risk of trauma to the trachea. Cuff pressure is monitored every 8 hours to maintain the pressure at 20 to 25 mm Hg Frequent oral hygiene Position pt with head elevated above the stomach -Optimal Level of Mobility: help pt with stable condition to get out of bed and move to a chair If pt is unable to get out of bed AROM every 6-8 hours If the patient cannot perform these exercises, the nurse performs passive range-of-motion exercises at least every 8 hours to prevent contractures and venous stasis -Coping Ability: Alternative methods of communication Stress reduction techniques

Pleural Effusion (collection of fluid space) Normal amount: 5-15 mL Complication of: heart failure, TB, pneumonia, pulmonary infections (particularly viral infections), nephrotic syndrome, connective tissue disease, PE and neoplastic tumors Most common - bronchogenic carcinoma Pathophysiology Clinical Manifestations - caused by underlying disease Assessment and Diagnostic Findings Medical Management Nursing Management

-PATHOPHYSIOLOGY: fluid may accumulate in the pleural space to a point at which it becomes clinically evident finding of a transudative effusion generally implies that the pleural membranes are not diseased -Clinical Manifestations: Pain,SOB, Pneumonia: fever, chills, and pleuritic chest pain Malignant effusion: dyspnea, difficulty lying flat, coughing Large pleural effusion: dyspnea (shortness of breath) small-to-moderate pleural effusion: minimal/no dyspnea -ASSESSMENT AND DIAGNOSTIC FINDINGS: Decreased/ absent breath sounds,decreased fremitus; and a dull, flat sound on percussion Extremely large pleural effusion:acute respiratory distress, tracheal deviation Physical exam, chest x ray, chest CR, thoracentesis confirm the presence of fluid -MEDICAL MANAGEMENT: Objective: discover underlying cause, prevent reaccumulation,relieve discomfort, dyspnea, respiratory compromise *If the pleural fluid is an exudate, more extensive diagnostic procedures are performed to determine the cause. Treatment of the primary cause is then instituted Thoracentesis to remove fluid. If the underlying cause is a malignancy, the effusion tends to recur w/i a few days/weeks Repeated thoracenteses result in pain, depletion of protein and electrolytes, pneumothorax chest tube is clamped for 60 to 90 minutes and the patient is assisted to assume various positions to promote uniform distribution of the agent and to maximize its contact with the pleural surfaces surgical pleurectomy -NURSING MANAGEMENT: Support medical regimen Prepare and position pt for thoracentesis Monitor chest tube drainage system Pain management from the chest tube inserted for talc instillation Evaluate pt's pain level and administer analgesic agents as prescribed as needed **If the pt is to be managed as an outpatient with a pleural catheter for drainage, the nurse educates pt and family about management and care of the catheter and drainage system

Pleural Conditions: Pleurisy (inflammation of both layers of the pleurae) Pathophysiology Clinical Manifestations Assessment and Diagnostic Findings Medical Management Nursing Management

-PATHOPHYSIOLOGY: inflammation of both layers and when the inflamed membranes rub together (esp inspiration) there is a severe, sharp, knifelike pain -CLINICAL MANIFESTATIONS: *key characteristic = relationship to respiratory movement Deep breath, coughing/sneezing worsens pain (usually on 1 side) Pain may be minimal/absent when breath is absent, may be localized/radiate to shoulder/abdomen Later: pleural fluid develops so pain decreases -ASSESSMENT AND DIAGNOSTIC FINDINGS: Early: little fluid has accumulated, pleural friction rub can be heard w/ stethoscope which disappears later b/c more fluid accumulates and separates the inflamed pleural spaces Diagnostic: chest x-rays, sputum analysis, thoracentesis (obtain specimen of pleural fluid, pleural biopsy) -MEDICAL MANAGEMENT: Objectives: underlying condition,relieve pain Monitor for signs of pleural effusion (SOB, pain, position that decreases pain, decreased chest wall excursion) Analgesic agents and topic applicants of heat. cold provided relief NSAID provides pain relief while allowing the pt to take deep breaths and cough more effectively -NURSING MANAGEMENT: b/c the patient has pain on inspiration - enhance comfort (turning frequently onto the affected side to splint the chest wall and reduce the stretching of the pleurae) Educates pt to use the hands or a pillow to splint the rib cage while coughing

Acute Respiratory Failure (deterioration of gas exchange function) decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to >50 mm Hg (hypercapnia), with an arterial pH less than 7.35. Hypoxemia, hypercapnia Pathophysiology Clinical Manifestations Medical Management Nursing Management

-PATHOPHYSIOLOGY: Ventilation/perfusion mechanisms are impaired impaired function of the CNS (drug overdose, head trauma,inf,hemorrhage, sleep apnea), neuromuscular dysfunction ( spinal cord trauma), musculoskeletal dysfunction (i.e., chest trauma, kyphoscoliosis, and malnutrition), and pulmonary dysfunction (i.e., COPD, asthma, and cystic fibrosis) Postoperative (major thoracic/abdominal surgery, inadequate ventilation and respiratory failure) -acute respiratory failure by effects of anesthetic, analgesic, and sedative agents (depress respiration= hypoventilation. Pain interferes w/ deep breathing and coughing *Early phase:vague signs and symptoms (restlessness, anxiety, fatigue,headache) make it difficult to determine what the patient is experiencing As oxygenation becomes more impaired: hypoxemia increases and leads to more obvious signs such as tachycardia, tachypnea, circumoral cyanosis, diaphoresis, accessory muscle use, inability to speak in full sentences, and altered mental status *Pain usually is not present Some pts may progress through these phases over several hours, whereas others progress w/i seconds -CLINICAL MANIFESTATIONS: Early:restlessness,fatigue, headache,dyspnea,air hunger,tachycardia, increased BP Hypoxemia progresses (more obvious signs): confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis Finally: respiratory arrest Physical findings: acute respiratory distress (accessory muscles, decreased breath sounds if pt can't adequately ventilate, and other findings r/t specifically to underlying disease process and cause of acute respiratory failure) -MEDICAL MANAGEMENT: Objectives: correct underlying cause, restore adequate gas exchange Endotracheal intubation and mechanical ventilation to maintain adequate - resp system is checked by auscultating lung sounds -NURSING MANAGEMENT: Assist w/ intubation, maintain mechanical ventilation Managed in ICU, assess respiratory status, level of responsiveness, mouth care, skin care

Empyema (accumulation of thick, purulent fluid w/i the pleural space, often with fibrin development and loculated (walled-off) area where infection is located) Pathophysiology Clinical Manifestations Assessment and Diagnostic Findings Medical Management Nursing Management

-PATHOPHYSIOLOGY: complications of bacterial pneumonia/ lung abscess from penetrating chest trauma First: thin pleural fluid, low leukocyte count Finally: encloses the lung within a thick exudative membrane (loculated empyema) -CLINICAL MANIFESTATIONS: pt is acutely ill and has signs and symptoms similar to acute respiratory infection/ pneumonia (fever, night sweats, pleural pain, cough, dyspnea, anorexia, weight loss) Immunocompromised? symptoms may be vague Received antimicrobial therapy? less obvious -ASSESSMENT AND DIAGNOSTIC FINDINGS: Chest auscultation: decreased/absent breath sounds over affected area, dullness on chest percussion, decreased fremitus Diagnosis by chest CT, diagnostic thoracentesis (ultrasound guidance) -MEDICAL MANAGEMENT: Objective: drain pleural cavity, complete expansion of the lung, fluid is drained, antibiotics (IV), sterilization of emphysema cavity (4-6 weeks) Drainage of pleural fluid depends on the stage by: thoracentesis, tube thoracostomy, chest drainage Exudate must be removed surgically, drainage tube is left in place until the pus-filled space is obliterated completely Complete obliteration of the pleural space is monitored by serial chest x-rays, and inform the pt that treatment may be long term (weeks to months) Pts are frequently discharged from the hospital with chest tube in place w/instructions to monitor fluid drainage at home -NURSING MANAGEMENT: Prolonged process lung-expanding exercises, method of drainage *When pt is discharged home w/drainage tube or system in place,instruct pt and family on care of the drainage system and drain site, measurement and observation of drainage, signs and symptoms of infection, how and when to contact the primary provider

Aspiration (inhalation of foreign material, complication that causes pneumonia: tachycardia, dyspnea, central cyanosis, hypertension, hypotension, and potentially death) Risk Factors Pathophysiology

-RISK FACTORS: Seizure, brain injury, decreased LOC, drug/alcohol intoxication, excessive sedation, general anesthesia, flat body positioning, stroke, swallowing disorders, cardiac arrest -PATHOPHYSIOLOGY: A full stomach contains solid particles of food when aspirated mechanical blockage can occur During periods of fasting, aspirated gastric acids can be very destructive to the alveoli and capillaries Fecal contamination increases death Esophageal conditions may also be associated with aspiration pneumonia *When a nonfunctioning nasogastric tube allows the gastric contents to accumulate in the stomach, condition known as silent aspiration may result. Silent aspiration occurs unobserved, if untreated, massive inhalation of gastric contents develops in a period of several hours -Compensating for Absent Reflexes: Aspiration occurs if pt can't adequately coordinate protective glottic, laryngeal, cough reflexes Increased if pt has distended abdomen, is supine, has the upper extremities immobilized,receives local anesthetic agents to the oropharyngeal/ laryngeal area for diagnostic procedures, has been sedated, long-term intubation **Clinical interventions are key to preventing aspiration Swallowing assessment is done and pts deemed at risk are then assessed by a speech therapist Semirecumbent/ upright prior setting, soft diet, small bites, keep chin tucked and head turned w/ repeated swallowing no straws *When vomiting sit up /turn on the side and coordinating breathing, coughing, gag,glottic reflexes **If these reflexes are active, oral airway shouldn't be inserted If an airway is in place, pull it out the moment pt gags to not stimulate the pharyngeal gag reflex and promote vomiting and aspiration Suctioning of oral secretions w/ catheter should be performed w/ minimal pharyngeal stimulation

Acute Asthma attack

-Start bronchodilators first ABGs, chest x ray - lung disorders oxygen is given but not before the bronchodilators

Pneumonia

-antibiotics for 10 days follow up appointment frequently turn drink 51-101 oz per day of clear liquids

Pulmonary contusion

-based on severity of bruising and parenchymal involvement Common signs and symptoms: crackles decreased/ absent bronchial breath sounds dyspnea tachypnea tachycardia chest pain blood-tinged secretions hypoxemia respiratory acidosis moderate? constant, ineffective cough can't clear secretions

Mini-Nebulizer Therapy

-frequently evaluate progress -cough frequently -hold breath at the end of inspiration for a few seconds

COPD

-have manual resuscitation bag at bedside

Improve Gas Exchange

-monitoring pulmonary status as directed and needed - assessing vital signs every 2 to 4 hours -encouraging deep breathing exercises PaCo2 : 60-95

Closed water-seal drainage system

-regularly measure and document amount of chest tube drainage -bubbling indicates a leak -keep chamber below chest level -don't strip chest tubes (may traumatize/dislodge tube)

Bacterial Pneumonia

-retained secretions cause dyspnea -respiratory tract inflammation causes wheezing -productive cough,fever PNEUMONIA: Ineffective airway clearance

Tracheostomy

-suction pts secretions -endotracheal suctioning is performed when adventitious breath sounds are detected/ when secretions are obviously present Thoracotomy: 2 people assist with tie changes dislodged = emergency wound and plate are cleaned w/ sterile cotton tip applicators moistened w/ saline/sterile water/ hydrogen peroxide if inf is present

Weaning the Patient from the Ventilator Criteria for Weaning Patient Preparation Methods of Weaning Removal of the Tracheostomy Tube Nutrition

3 stages: patient is gradually removed from the ventilator, then from either the endotracheal or tracheostomy tube, and finally from oxygen -CRITERIA: Stable vital signs and arterial blood gases Dietary intake Maintain patent airway -PATIENT PREPARATION: Consider the pt as a whole -METHODS OF WEANING: assess for tachypnea, tachycardia, reduced tidal volumes, decreasing oxygen saturations, and increasing carbon dioxide levels *Successful weaning from the ventilator is supplemented by intensive pulmonary care (oxygen therapy; arterial blood gas evaluation; pulse oximetry; bronchodilator therapy; CPT; adequate nutrition, hydration, and humidification; blood pressure measurement; and incentive spirometry) ^ pt may still have borderline pulmonary function and need vigorous supportive therapy before their respiratory status returns to a level that supports activities of daily living -REMOVAL OF THE TRACHEOSTOMY TUBE: considered when the patient can breathe spontaneously; maintain an adequate airway by effectively coughing up secretions, swallow, and move the jaw *Secretion clearance and aspiration risks are assessed to determine whether active pharyngeal and laryngeal reflexes are intact -NUTRITION: Sepsis can occur if bacteria enter the bloodstream and release toxins that, in turn, cause vasodilation and hypotension, fever, tachycardia, increased respiratory rate, and coma. Aggressive treatment of sepsis is essential to reverse this threat to survival and to promote weaning from the ventilator when the patient's condition improves

What may be one of the first indications that the patient needs oxygen therapy?

A change in the patient's respiratory rate or pattern ( may result in hypoxemia or hypoxia)

Tuberculosis

A chest radiograph Complete history and physical examination Drug susceptibility testing

Respiratory Infections: Acute Tracheobronchitis Pathophysiology Clinical Manifestations Medical Management Nursing Management

Acute inflammation follows URT -PATHOPHYSIOLOGY: Inflamed mucosa produces mucopurulent sputum *Sputum culture is essential Prevent VAP -CLINICAL MANIFESTATIONS: Initially: dry, irritating cough, small amount of mucoid sputum, sternal soreness from coughing, fever, chills, night sweats, headache, malaise Progression: SOB, noisy inspiration and expiration, purulent sputum Severe: blood-streaked secretions due to irritation of mucosa of airways -MEDICAL MANAGEMENT: Antibiotics No antihistamines (drying) Increase fluid intake Suction,bronchoscopy to remove secretions since coughing doesn't remove them Increase vapor pressure to reduce airway irritation *Cool vapor therapy or steam inhalations may help relieve laryngeal and tracheal irritation. Moist heat to the chest may relieve the soreness and pain, and mild analgesics may be prescribed. -NURSING MANAGEMENT: Acute tracheobronchitis: treated in home setting Primary function: encourage bronchial hygiene Assist pt to sit up frequently to cough, prevent retention of mucopurulent sputum Antibiotics Fatigue Caution pt over overexertion (leads to relapse/exacerbation) Advise pt to rest

Shock treatment MODS are older clients, clients who are malnourished, and clients with coexisting disease.

Adrenergic drugs (receptors if sympathetic nervous system) shallow, rapid respirations Alpha- and beta-adrenergic receptors work synergistically to improve hemodynamic stability. Alpha receptors constrict blood vessels in the cardiorespiratory and gastrointestinal systems, as well as in the skin and kidneys. *patient at risk for shock must be monitored closely before the blood pressure drops. decrease in stroke volume when narrowed pulse pressure (normal is 30-40 mmHg) Assess the client who is at risk for shock. Administer intravenous fluids. Monitor for changes in vital signs.

The nurse taking care of a patient evidencing signs of shock empties the urinary catheter drainage bag after her 12-hour shift. The nurse notes an indicator of renal hypoperfusion. What is the relevant urinary output for this condition?

An indicator of renal hypoperfusion is a urinary output of less than 30 mL/hr. An output of 300 mL in 12 hours is less than 30 mL/hr, which is indicative of oliguria

Acute bacterial rhinosinusitis Acute bacterial pneumonia

Antibiotic - amoxicillin clavulanic acid PaO2 of 90 mm Hg or higher

Atrial Fibrillation

Anticoagulation therapy Warfarin? regular blood levels drawn In the acute care setting, when ventricular fibrillation is noted, the nurse should call for assistance and defibrillate the client as soon as possible. If defibrillation is not readily available, CPR is begun until the client can be defibrillated, followed by advanced cardiovascular life support (ACLS) intervention, which includes endotracheal intubation and administration of epinephrine.

Anatomical location for apical pulse

Apex of the heart

Bradycardia

Atropine

Permanent Pacemaker

Avoid undergoing an MRI (magnet could disrupt pacemaker function. cause injury to the client) Avoid vigorous arm and shoulder movement for the first 6 weeks after pacemaker implantation Notify airport security guards Restrict movement until incision heals Do not raise arms above the head for 2 weeks Avoid contact sports V/S? Document pts heart rate and rhythm by ECG

Emergency Management of Upper Airway Obstruction

Causes: food particles vomitus blood clots anything that obstructs larynx/ trachea enlargement in airway pressure on walls of the airway *pt with altered LOC = risk for upper airway obstruction b/c of loss of protective reflexes (coughing,swallowing), loss of tone of the pharyngeal muscles (tongue blocks airway) Nurse makes rapid observations for s&s of upper airway obstruction Inspection (conscious?inspiratory effort? chest symmetry? skin color? obvious signs of obstruction? trachea midline?) Palpitation: both sides of chest rise equally w/ inspiration? tenderness, fracture, subcutaneous emphysema (crepitus?) Auscultation: audible air movement, stridor, wheezing? breath sounds over lower trachea and all lobes?

hypoxemia (a low level of oxygen in the blood)

Changes in: mental status dyspnea increase blood pressure changes in heart rate dysrhythmias diaphoresis cool extremities central cyanosis (late sign) *usually leads to hypoxia

Pulmonary Embolism

DVT is indicated by pain in the calf When assessing - client lies on their back and lift their leg and foot (pain? DVT) DVT Chest pain Dyspnea

At what point in shock does metabolic acidosis occur? Decompensation

Decompensation (Progressive) -The client's condition spirals into cellular hypoxia, coagulation defects, and cardiovascular changes. As the energy supply falls below the demand, pyruvic and lactic acids increase, causing metabolic acidosis. LUNG DECOMPENSATION: Intubation, mechanical ventilation

Ventricular fibrillation

Defibrillation

Lung abscess Lung disease

Diet: high protein (chicken, fish,beans) and high calories Cardinal sign: cough or change in chronic cough Lung disease: fiber optic changes in the lung

Pleural Effussion

Dullness over the involved area Friction rub Diminished or absent breath sounds over the involved area when auscultating the lungs

Septic shock

Early: BP normal HR tachycardic RR increased Fever -Warm,flushed skin

Pneumococcal and Influenza Infections

Encourage vaccinations

ARDS

Factors: aspiration r/t to bear drowning/ vomiting drug ingestion/overdose hematologic overdose (DIC) direct damage to the lungs (smoke inhalation) trauma multiple fractures head injury Acute phase: rapid onset of severe dyspnea (less than 72 hours after precipitating event) Elevated B-type natriuretic peptide (BNP) levels

Aspiration Prevention

HOB at 30-45 degrees, use sedatives sparingly, confirm tip location before enteral feeding , asses placement of feeding tube at 4 hour intervals,assess for gastrointestinal residuals (<150 mL before next feeding) to the feedings at 4-hour intervals, avoid bolus feedings for pts w/ tube feedings, swallowing eval before oral feedings for patients who were recently extubated but were previously intubated for >2 days, endotracheal cuff pressure at appropriate level **Prolonged endotracheal intubation or tracheostomy can depress the laryngeal and glottic reflexes because of disuse. Patients with prolonged tracheostomies are encouraged to phonate and exercise their laryngeal muscles

Lung cancer

Hallmark: Cough that changes in character Mortality rate is high because lung cancer produces few early symptoms

Client has ejection fraction of 25% (this is bad). What does this mean?

Heart is hardly putting out any blood

Stable angina. What will the nurse find?

Increased pain with increased activity

Which of the following nursing diagnosis is the highest priority for a client undergoing thrombolytic therapy?

Ineffective protection (risk for bleeding and falling)

Hypovolemic Shock

Initial stage - Pulse volume becomes weak and thready, circulating volume diminishes Later stages - slow pulse, imperceptible and pulse rhythm changes from regular to irregular Low CVP - increases with effective treatment and is significantly increased with fluid overload and heart failure *The nurse is caring for a client admitted to the emergency department with hypovolemic shock. What most appropriate ratio of IV replacement fluids does the nurse anticipate? 3:1 Prolonged vomiting and diarrhea - modified trendelenburg The most common colloid solution used to treat hypovolemic shock is 5% albumin Colloid - 5% albumin --> if colloids are used to treat tissue hypoperfusion, albumin is the agent prescribed.expensive but rapidly expands plasma volume When caring for a patient in hypovolemic shock who is receiving large volumes of IV isotonic fluids, the nurse should monitor for symptoms of: pulmonary edema -hypernatremia occurs (decreased urinary output)

Septic Shock

Initial stages - rapid,bounding pulse The nurse administers fluids to achieve a target central venous pressure of 8 to 12 mm Hg, mean arterial pressure >65 mm Hg, urine output of 0.5 mL/kg/hr, and an ScvO2 of 70%. *Nutritional supplementation is initiated within 24 hours of the start of septic shock. If the client has reduced peristalsis, then parenteral feedings will be required.

Intensity of chest pain

Is the pain 0-10

Acute pulmonary edema, give morphine 2 mg. Nurse does what?

It should be PRN Morphine is given for pain

Low Flow High Flow

Low Flow contribute partially to inspired gas, breathes some room air with oxygen no constant or precise concentration or precise concentration high flow provide total inspired air constant and precise oxygen

Endotracheal pressure cuff

Low pressure in the cuff can increase the risk for aspiration pneumonia. High pressure in the cuff can cause tracheal bleeding, ischemia, and pressure necrosis pressure: 20-25mmHg Endotracheal suctioning: suctioning while withdrawing and gently rotating catheter 360 degrees for no longer than 10 seconds Initially plug opening in tracheostomy for 5-20 minutes Asculatate bilateral sounds for a client with ET tube -deflate before ET tube is removed -check cuff pressure every 6 - 8 hours - introduce humidified oxygen through the tube

Cardiac

Mobitz Type 1: Dizziness and secondary degree heart block - IV bolus of atropine *electrical current is initiated at the R wave when ventricular depolarization occurs. 2nd degree heart block - atropine sulfate 3rd degree AV heart block - alert HCP

Nasal Cannula

Nasal Cannula: low to medium concentration of oxygen move in bed,talk,cough without interruptions to the oxygen flow Flow rates in excess of 4L/min may lead to swallowing air, irritation and drying of nasal and pharyngeal mucosa nasal catheter: rare short term low to moderate changed every 8 hours alternate nostrils (prevent nasal irritation and infection)

Implantable Cardioverter Defibrillator (ICD)

No shooting with left hand

Acute Respiratory Failure

PaO2 requires supplemental oxygen Hypercapnia Hypoventilation Hypoxemia Respiratory Distress Syndrome PacO2 requires PEEP -decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia),increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia),arterial pH less than 7.35 ventilation or perfusion mechanisms in the lung are impaired Acute respiratory failure occurs suddenly in a client who previously had normal lung function.

Pacemaker

Pacemaker- restrict movement of the arm until incision heals, don't raise the arm above the head for 2 weeks afterward to avoid dislodging the leads, avoid contact sports

Flail chest

Paradoxical chest expansion and respiratory distress During inspiration as the chest expands the detached part of the rib segment moves in a paradoxcial manner that is pilled inward by inspiration On expiration b/c intrathoracic pressure exceeds atmospheric pressure the flail segment bulges outward impairing the pts ability to exhale

Laryngectomy Information

Partial laryngectomy - portion is removed w/ one vocal cord, and tumor (airway is intact, no difficulty swallowing) Supraglottic laryngectomy - tracheostomy is left in place until glottic airway is established Total laryngectomy- complete removal, can't speak Laryngeal Cancer - Initial hoarseness (longer than a month), sensation of swelling or lump in throat/ in the neck Weight loss often occurs later in the progression of laryngeal cancer Burning in the throat when swallowing hot or citrus liquids

Preventing Postoperative Cardiopulmonary Complications After Thoracic Surgery

Patient Management Auscultate lung sounds and assess for rate, rhythm, and depth. Monitor oxygenation with pulse oximetry. Monitor electrocardiogram for rate and rhythm changes. Assess capillary refill, skin color, and status of the surgical dressing. Encourage and assist the patient to turn, cough, and take deep breaths. Chest Drainage Management Verify that all connection tubes are patent and connected securely. Assess that the water seal is intact when using a wet suction system, and assess the regulator dial and water seal chamber in dry suction systems. Monitor characteristics of drainage, including color, amount, and consistency. Assess for significant increases or decreases in drainage output. Note fluctuations in the water seal chamber for wet suction systems and the air leak indicator in dry suction systems. Keep system below the patient's chest level. Assess suction control chamber for bubbling in wet suction systems. Keep suction at prescribed level. Maintain appropriate fluid in water seal in wet suction systems. Keep air vent open when suction is off.

Breathing

Pursed lip breathing - prolongs exhalation Inhale through nose, count to 3 then exhale through pursed lips and count to 7 *improves oxygen transport, helps induce a slow, deep breathing pattern and assists the client to control breathing, even during periods of stress. This type of breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema.

Chest Drainage

Re-expand lung, remove excess air, fluid, and blood, treat spontaneous pneumothorax The amount of bubbling in the suction indicates the strength of the suction *When the wall vacuum is turned off, the drainage system must be open to the atmosphere so that intrapleural air can escape from the system. This can be done by detaching the tubing from the suction port to provide a vent **The manual vent should not be used to lower the water level in the water seal when the patient is on gravity drainage (no suction) because intrathoracic pressure is equal to the pressure in the water seal.

Cancer of the Larynx Clinical Manifestations Medical Management

Recurrence occurs within first 2-3 years after diagnosis -RISK FACTORS: Tobacco, alcohol, asbestos, paint fumes, nutritional deficiencies, 65+, men, African Americans and Caucasians, weakened immune system -CLINICAL MANIFESTATIONS: Hoarseness for more than 2 weeks (harsh, raspy, lower in pitch) not an early sign! Complaints of persistent cough/sore throat and pain and burning in the throat (hot liquids/citrus juices) Lump in the neck Late symptoms: dysphagia, nasal obstruction/discharge, persistent hoarseness, persistent ulceration, foul breath Metastasis: Cervical lymph adenopathy, unintentional weight loss, a general debilitated state, and pain radiating to the ear -ASSESSMENT AND DIAGNOSTIC FINDINGS: Initial assessment: Complete history, physical exam of head and neck Indirect laryngoscopy Mobility of vocal cords Palpate neck and thyroid gland for enlargement Diagnostic procedures (FNA, barium swallow - pt initially presents w/ chief complaint of difficulty in swallowing, endoscopy, CT/MRI scan) HPV affects is implicated in oral cancers PET scan - detect recurrence -MEDICAL MANAGEMENT: Goals: Cure, safe and effective swallowing, avoid permanent tracheostoma Surgery, radiation, therapy, chemoradiation -Surgical Management: Goals: minimize effects of surgery, swallowing, breathing while maximizing the cure of cancer *Early vocal cord lesions are initially treated w/ radiation Partial Laryngectomy: early stage, portion of the larynx is removed, along with one vocal cord and the tumor; all other structures remain. The airway remains intact, and the patient is expected to have no difficulty swallowing. The voice quality may change, or the patient may sound hoarse. Total Laryngectomy: The tongue, pharyngeal walls, and most of the trachea are preserved. A total laryngectomy results in permanent loss of the voice and a change in the airway, requiring a permanent tracheostomy Develop alternate method of communication Drains are removed when secretions are minimal (less than 30 mL for 48 straight hours)

Pt has an MI. What is the highest priority?

Relief of pain Treatment = oxygen, morphine (for pain), aspirin

Thoracic Surgery Preoperative Management Postoperative Management

Relieve disease conditions (lung abscesses, lung cancer, cysts, benign tumors, emphysema) Exploratory thoracotomy (diagnose lung or chest disease) -PREOPERATIVE MANAGEMENT: Chest auscultation (in all lung regions) Note crackles, wheezes, ronchi, wheezing Pulmonary function tests Clear airway -POSTOPERATIVE MANAGEMENT: reduce risk of atelectasis and infection include humidification, postural drainage, and chest percussion after bronchodilators estimate volume of sputum if the patient expectorates large amounts of secretions PCA, PCEA Check vital signs are checked frequently Oxygen Fluids at low hourly rate (prevent fluid overload and pulmonary edema) After the patient is conscious and the vital signs have stabilized, the head of the bed may be elevated 30° to 45° Medication for pain Splint when coughing Increased temperature or white blood cell count may indicate an infection, and pallor and increased pulse may indicate internal hemorrhage. Dressings are assessed for fresh bleeding The pleural space, located between the visceral and parietal pleura, normally contains 20 mL or less of fluid, which helps lubricate the visceral and parietal pleura **When the wall vacuum is turned off, the drainage system must be open to the atmosphere so that intrapleural air can escape from the system. This can be done by detaching the tubing from the suction port to provide a vent If the chest tube and drainage system become disconnected, air can enter the pleural space, producing a pneumothorax. To prevent pneumothorax if the chest tube is inadvertently disconnected from the drainage system, a temporary water seal can be established by immersing the chest tubes open end in a bottle of sterile water.

Acute Respiratory Distress Syndrome: (life threatening, severe inflammatory process causing diffuse alveolar damage leading to sudden and progressive pulmonary edema, hypoxemia, reduced lung compliance, major cause of death in ARDS is nonpulmonary MODS, often with sepsis) Pathophysiology Clinical Manifestations Assessment and Diagnostic Findings Medical Management

Risk Factors: aspiration, drug ingestion and overdose, hematologic disorders, prolonged inhalation, localized infection, metabolic disorders, shock, trauma, major surgery, fat/air embolism, sepsis) -PATHOPHYSIOLOGY: Narrow airways -CLINICAL MANIFESTATIONS: resembles severe pulmonary edema Acute: rapid onset of severe dyspnea occurs less than 72 hours after event acute lung injury progresses to fibrosing alveolitis with persistent, severe hypoxemia *Clinically pt is thought to be in recovery phase if hypoxemia gradually resolves,chest x-ray improves, and lungs become more compliant -ASSESSMENT AND DIAGNOSTIC FINDINGS: intercostal retractions and crackles may be present as the fluid begins to leak into the alveolar interstitial space -MEDICAL MANAGEMENT: focus: identification and treatment of underlying condition Aggressive, supportive care to compensate for severe respiratory dysfunction Adequate fluid volume, nutritional support *As hypoxemia progresses: intubation and mechanical ventilation are instituted PEEP (increases functional residual capacity) Systemic hypotension from hypovolemia Specific pharmacologic treatment of ARDS except supportive care *Adequate nutritional support is vital in the treatment of ARDS. Patients with ARDS require 35 to 45 kcal/kg/day to meet caloric requirements. Enteral feeding is the first consideration; however, parenteral nutrition also may be required -NURSING MANAGEMENT: Critically ill, close monitoring in ICU, frequent assessment of effective of treatment, positioning is imp, monitor deterioration in oxygen -pt is extremely anxious and agitated b/c of increasing hypoxemia and dyspnea Reduce pt's anxiety b/c anxiety increases oxygen expenditure by preventing rest Rest is essential to limit oxygen consumption and reduce oxygen needs pt may be anxious and fight the ventilator identify problems w/ventilation that be causing the anxiety reaction: tube blockage by kinking/retained secretions, other acute respiratory problems (e.g., pneumothorax and pain), sudden decrease in the oxygen level, level of dyspnea/ventilator malfunction Sedation may be required to decrease the patient's oxygen consumption, allow the ventilator to provide full support of ventilation, and decrease the patient's anxiety Sedatives that may be used are lorazepam (Ativan), midazolam (Versed), dexmedetomidine (Precedex), propofol (Diprivan), and short-acting barbiturates Use of neuromuscular blocking agents has side effects Eye care is important as well, because the patient cannot blink, increasing the risk of corneal abrasions. Neuromuscular blockers predispose the patient to venous thromboembolism (VTE), muscle atrophy, foot drop, peptic ulcer disease, and skin breakdown Analgesia is given w/ neuromuscular blocking agents **Nursing assessment is essential to minimize the complications related to neuromuscular blockade. The patient may have discomfort or pain but cannot communicate these sensations. In addition, frequent oral care and suctioning may be needed

Pneumothorax

Signs and Symptoms: Chest pain Dyspnea Shoulder/neck pain Irritability Palpitations Light headness Hypotension Cyanosis Unequal breath sounds Chest x ray reveals collapse on the affected lung Triple lumen catheter placed in his right subclavian veins BP is decreased from baseline

Nurse evaluates teach plan. Which of the following modifiable risk factor for heart disease?

Smoking

Pleurisy

Splint chest wall by turning on the affected side or use hands/pillow when coughing Analgesics Heat/cold packs Severe, knifelike pain relationship to respiratory movement

Oxygen Methods

The Venturi mask is the most reliable and accurate method for delivering a precise concentration of oxygen through noninvasive means. The mask is constructed in a way that allows a constant flow of room air blended with a fixed flow of oxygen. Nasal cannula, T-piece, and partial-rebreathing masks are not the most reliable and accurate methods of oxygen administration.

Oxygen Complication (oxygen is a medication)

given only when prescribed unless it's an emergency Assess for: confusion restlessness (to lethargy) diaphoresis pallor tachycardia tachypnea hypertension *pulse ox to monitor o2 levels

-Difficulty breathing (12 hours post surgery) -Petechiae over the chest -Acute chest pain complaints

These are signs and symptoms of pulmonary embolism Priority: maintaining respiratory function so first initiate oxygen therapy Physician will order anticoagulants such as heparin or antithrombolytic to dissolve the thrombus Analgesics are given to decrease pain and anxiety

24 hours previously with heart failure, lost 1 kg, 88 HR, crackles in base of lungs only. Nurse indicates that

Treatment regimen is reaching the describe affect, lungs are clearing up

When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently? (Select all that apply.)

Urinary output Mental status Vital signs

Meds

Vasoactive meds - check pt/15 mins, Used when fluid therapy alone does not maintain MAP Support hemodynamic status; stimulate SNS,Give through central line if possible Extravasation may cause extensive tissue damage Dosages usually titrated to patient response Inotropic effect - increase force of myocardial contraction Clients with a positive vasoreactivity test may be prescribed calcium channel blockers. Calcium channel blockers have a significant advantage over other medications taken to treat PH in that they may be taken orally and are generally less costly; however, because calcium channel blockers are indicated in only a small percentage of clients, other treatment options, including prostanoids, are often necessary Vasoactive drugs, which cause the arteries and veins to dilate, thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as sodium nitroprusside. Dobutamine - increase cardiac output Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Physicians use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension. - catecholamine agents may raise blood pressure atropine - increase dangerously slow heart rate potentially serious side effect of IV nitroglycerin (Tridil) is hypotension. Blood pressure needs to be monitored frequently according to the manufacturer's recommendation and institutional policy Heparin Therapeutic Range = 2.0-2.5 A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to: Constrict blood vessels in the cardiorespiratory system IV nitroglycerin - decreases BP

Monitoring ventilator

When monitoring the ventilator, the nurse notes the following: Controlling mode (e.g., A/C ventilation and SIMV). Tidal volume and rate settings (tidal volume is usually set at 6 to 10 mL/kg [ideal body weight] or 4 to 8 mL/kg for the patient with ARDS [ideal body weight]; rate is usually set at 12 to 16 breaths/min). FiO2 setting may be set between 21% and 100% to maintain an optimal PaO2 level (e.g., greater than 60 mm Hg) or SpO2 level greater than 92%. Peak inspiratory pressure (PIP) (Normal is 15 to 20 cm H2O; this increases if there is increased airway resistance or decreased compliance). Sensitivity (A 2-cm H2O inspiratory force should trigger the ventilator). Inspiratory-to-expiratory ratio (usually 1:2 [1 second of inspiration to 2 seconds of expiration] unless inverse ratio is ordered). Minute volume (tidal volume × respiratory rate). Sigh settings (usually set at 1.5 times the tidal volume and ranging from 1 to 3 per hour), if applicable. Water in the tubing, disconnection or kinking of the tubing. Humidification (humidifier filled with water) and temperature. Alarms PEEP and pressure support level, if applicable **To prevent alarm fatigue associated with mechanical ventilators, nurses can manage the physical layout of the critical care unit (e.g., avoid locating patients on mechanical ventilators in close proximity); protocols for setting of alarms, and educate staff on how to set alarms and when and how to respond to them.

Progressive Shock

When the nurse observes that the client's systolic blood pressure is less than 80 mm Hg, respirations are rapid and shallow, heart rate is over 150 beats per minute, and urine output is less than 30 cc/hour *client's skin appears mottled and mentation demonstrates lethargy; the client will be clinically hypotensive. In compensatory shock, the client's blood pressure is normal, respirations are above 20, and heart rate is above 100 but below 150. In refractory or irreversible shock, the client requires complete mechanical and pharmacologic support.

Preventing Complications Associated With Endotracheal and Tracheostomy Tubes

adequate warm humidity cuff pressure suction as needed skin integrity (change tape/dressing) auscultate lung sounds s&s of infection (temp,WBC) administer prescribed oxygen, monitor oxygen saturation monitor for cyanosis adequate hydration for pt use sterile technique (suction, trach care) *Check airway patency frequently

Tension Pneumothorax

air is not expelled unlike open pneumothorax trachea shifts to affected side increased intrathoracic pressure decreased cardiac output impaired peripheral circulation extreme case? undetectable pulse Sudden pain, pleuritic Tachypnea ARDS Anxious, air hunger, increased use of accessory muscles, central cyanosis (hypoxemia) Chest tube is inserted, supplemental oxygen is given In emergencies anything large enough is used to fill the chest wound, inhale and strain against a closed glottis Open pneumothorax - thoracentesis

Chronic Respiratory Failure

progressive loss of lung function with chronic disease

Sinus Tachycardia Sinus Bradycardia

causes: physiologic or psychological stress (acute blood loss, anemia, shock, hypovolemia, fever, and exercise). B - Vagal stimulation, hypothyroidism, and digoxin

Tracheostomy: Nursing Management

continuous monitoring, assessment newly made opening must be kept patent by proper suctioning of secretions after v/s are stable, semi-flower position *Analgesia and sedative agents must be given with caution because of the risk of suppressing the cough reflex **Major objectives: patent airway, monitor respiratory status, assess for complications, alleviate the pt's apprehension,provide effective means of communication. keep paper and pencil or a Magic Slate® and call light w/i the pt's reach at all times to ensure a means of communication ***cuff pressure must be monitored by respiratory therapist/nurse every 8 hours minimize dust/particles in the air, provide adequate humidification to make it easier for pt to breathe

Mechanical Ventilation Indications Clinical Manifestations

control respirations during surgery/treatment oxygenate blood, rest respiratory muscles many pts can breathe spontaneously (exhausting) -INDICATIONS resp failure, compromised airway, endotracheal intubation *Conditions such as thoracic or abdominal surgery, drug overdose, neuromuscular disorders, inhalation injury, COPD, multiple trauma, shock, multisystem failure, and coma may lead to respiratory failure and the need for mechanical ventilation -CLINICAL MANIFESTATIONS: Apnea or bradypnea Respiratory distress with confusion Increased work of breathing not relieved by other interventions Confusion with need for airway protection Circulatory shock Controlled hyperventilation (e.g., patient with a severe head injury) Adjusting the Ventilator: If pt is bucking the ventilator asses for hypoxia and manually ventilate on 100% oxygen with a resuscitation bag

Cardiogenic Shock

decrease myocardial oxygen consumption by Maintain activity restriction to bedrest Restricting activity to bedrest provides the best example of decreasing myocardial oxygen consumption. Inactivity reduces the heart rate and allows the heart to fill with more blood between contractions *monitors the client's hemodynamic and cardiac status to prevent cardiogenic shock. He or she promptly reports adverse changes in the client's status, such as adventitious breath sounds.

Hypoxia the body or a region of the body is deprived of adequate oxygen supply at the tissue level.

decrease oxygen supply to tissues and cells *severe hypoxia can be life threatening rapidly progressing hypoxia: changes in CNS (neuro) may rumble alcohol intoxication lack of coordination poor judgement Long standing hypoxia (ex-COPD,CHF): fatigue drowsiness apathy inattentiveness delayed reaction time

Small-Volume Nebulizer Therapy Indications Nursing Management

handheld, disperses moisturizing agent/medication (bronchodilator/mucolytic agents are given) connected through tubing effective: visible mist for pt to inhale INDICATIONS: difficulty clearing respiratory secretions reduces vital capacity with ineffective deep breathing and coughing unsuccessful trials delivering aerosol, expanding lung *for long term COPD NURSING MANAGEMENT: breathe through the mouth, slow deep breaths, hold breath for a few seconds at the end of inspiration encourage pt to cough, monitor effectiveness of therapy

Oxygen toxicity

higher than 50% for extended period (24 hours+) Clinical Manifestations (like ARDS): substernal discomfort paresthesias dyspnea restlessness fatigue malaise progressive respiratory difficulty refractory hypoxemia alveolar atelectasis alveolar infiltrates (chest x-rays) *PEEP or CPAP reverses/prevents microatelectasis

Incentive Spirometer Indications Nursing Management

method of deep breathing visual feedback inhale slowly and deeply maximize lung inflation prevent/reduce atelectasis 1) volume or 2) flow INDICATIONS: after surgery esp thoracic and abdominal surgery NURSING MANAGEMENT: set goals can be performed in any position but ideal semi-fowler or upright

Breathing Retraining Nursing Management

more efficient and controlled ventilation, decrease work of breathing *COPD and dyspnea (anxiety) pts diaphragmatic breathing, pursed lip breathing *many pts require additional oxygen (low flow method) Old, sedentary adults should do breathing exercises because of emphysema like changes -NURSING MANAGEMENT: breathe slowly, rhythmically. Inhale through the nose, prolong exhalation *adequate dietary intake (promotes gas exchange and increases energy levels) 0btain adequate nutrition w/o overeating (small, frequent meals and snacks) Have ready-prepared meals and favorite foods available (encourage nutrient consumption) Gas-producing foods such as beans, legumes, broccoli, cabbage, and Brussels sprouts should be avoided to prevent gastric distress pts lack the energy to eat so, instruct them to rest before and after meals to conserve energy.

Home Care Therapy: Oxygen Therapy

no smoking with people on oxygen no smoking sign no paint thinners, cleaning fluids, gasoline, aerosol sprays, flammable items 15 ft away from matches, candles, gas stove, or other source of flame, and 5 ft away from television, radio, and other appliances When traveling in automobile, place oxygen tank on floor behind front seat. If traveling by airplane, notify air carrier of need for oxygen at least 2 weeks in advance.

Compensatory Stage of Shock

normal blood pressure, tachycardia, decreased urinary output, confusion, and respiratory alkalosis Ex: A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next administers oxygen by nasal cannula at 2 liters per minute b/c the pt is exhibiting the compensatory stage of shock release of catecholamines, activation of the renin-angiotensin-aldosterone system, production of antidiuretic and corticosteroid hormones are all mechanisms activated in the compensation stage of shock.

Tracheostomy Procedure

opening is made into the trachea stoma may be temporary or permanent bypass upper airway obstruction, removal of tracheobronchial secretions, permit long term use of mechanical ventilation, prevent aspiration, for unconscious/paralyzed pt, replace endotracheal tube -PROCEDURE: in OR/ICU (aseptic) cuff minimizes risk of aspiration sterile gauze between tube and skin -COMPLICATIONS: early/late(years after) in the course Early complications: dislodgement,accidental decannulation, bleeding, pneumothorax, air embolism, aspiration, subcutaneous or mediastinal emphysema, recurrent laryngeal nerve damage, and posterior tracheal wall penetration Long term complications: airway obstruction from accumulation of secretions or protrusion of the cuff over the opening of the tube, infection, rupture of the innominate artery, dysphagia, tracheoesophageal fistula, tracheal dilation, tracheal ischemia, and necrosis *Tracheal stenosis may develop after tube is removed

Absorption Atelectasis

oxygen in alveoli is absorbed quickly into the bloodstream, not replaced rapidly enough in alveoli to maintain patency (alveoli collapse causing atelectasis)

Endotracheal Intubation

passing endotracheal tube through the nose/mouth into the trachea oral route is preferred (less trauma,inf) provides an airway tracheobronchial secretions are suctioned through the tube warm, humidified oxygen is given through the tube Disadvantages cough reflex is depressed thicker secretion swallowing reflexes are depressed used for no more than 14 to 21 days, tracheostomy is considered *great concern is pt not being able to talk/communicate needs **Inadvertent removal of an endotracheal tube can cause laryngeal swelling, hypoxemia, bradycardia, hypotension, and even death. Measures must be taken to prevent premature or inadvertent removal.

Positioning after Pneumonectomy and Lobectomy

patient is usually turned every hour from the back to the operative side and should not be completely turned to the unoperated side. This allows the fluid left in the space to consolidate and prevents the remaining lung and the heart from shifting (mediastinal shift) toward the operative side. The patient with a lobectomy may be turned to either side, and a patient with a segmental resection usually is not turned onto the operative side unless the surgeon prescribes this position

Chest Physiotherapy Postural Drainage Nursing Management

pt usually sits in an upright position secretions so secretions accumulate in the lower parts of the lungs NURSING MANAGEMENT: medical status lung lobes involved cardiac status Structural deformities of the chest wall and spine *auscultate the chest before and after the procedure positioning at home with cardboard boxes, pillows, cushions Postural drainage is performed 2-4 times daily before meals (prevent nausea, vomiting, and aspiration) and at bedtime *prescribed bronchodilators, water, or saline (nebulized/inhaled) before postural drainage first drain lower lobes then upper lobes make pt comfortable, provide emesis basin, sputum cup, paper tissues 10-15 minutes per position, breathes in slowly through the nose and out slowly through pursed lip to keep airways open *if pt can't cough suction secretions mechanically, chest percussion and vibration HFCWO After procedure: note skin amount, viscosity, character of sputum. evaluate skin color and pulse first few times oxygen may be needed during postural drainage if sputum is foul smelling postural drainage is performed in a room away from pts family aerosol sprays cause bronchospasm and irritation use deodorizers after the procedure: brush teeth and use mouthwash before resting

Atelectasis - collapse of alveoli Clinical Manifestations Assessment and Diagnostic Findings Management

seen on x-ray acute atelectasis: in postoperative setting or in people who are immobilized and have a shallow, monotonous breathing pattern chronic airway obstruction: insidious, chronic affected portion is airless reluctant to cough (pain) -CLINICAL MANIFESTATIONS: Insidious Dyspnea, cough, sputum Acute: respiratory distress, tachycardia, tachypnea, pleural pain, and central cyanosis (a bluish skin hue that is a late sign of hypoxemia) Difficulty breathing in supine position, anxious Chronic: like acute, infection distally (signs and symptoms of a pulmonary infection also may be present) **Tachypnea, dyspnea, and mild-to-moderate hypoxemia are hallmarks of the severity of atelectasis -ASSESSMENT AND DIAGNOSTIC FINDINGS: increased work of breathing and hypoxemia decreased breath sounds and crackles over affected area A chest x-ray may suggest a diagnosis of atelectasis before clinical symptoms appear; the x-ray may reveal patchy infiltrates or consolidated areas. Depending on the degree of hypoxemia, pulse oximetry (SpO2) may demonstrate a low saturation of hemoglobin with oxygen (less than 90%) or a lower-than-normal partial pressure of arterial oxygen (PaO2) -MANAGEMENT: Goal: Improve ventilation, remove secretions Prevent atelectasis: frequent turning, early ambulation, lung volume expansion and coughing PEEP , CPAB, bronchoscopy ICOUGH Incentive spirometry Coughing and deep breathing Oral care (brushing teeth and using mouthwash twice a day) Understanding (patient and staff education) Getting out of bed at least three times daily Head-of-bed elevation

Performing Incentive Spirometry

semi-fowler/upright position diaphragmatic breathing cough during,after each session splint incision when coughing postop ~ 10 times in succession each waking hour

Masks Older pts

simple masks: low to moderate gathers and stores oxygen between breaths openings partial rebreathing masks: reservoir bag must remain inflated during both inspiration and expiration moderate nonrebreathing: prevents gas from flowing back into the reservoir bad during exhalation venturi mask: most reliable and accurate constant flow of air and oxygen COPD pts snugly fitted mask check for skin irritation remove mask so pt can eat, drink, take meds (give nasal cannula during this) tracheal oxygen catheter: requires surgery OLDER PATIENTS: risk for aspiration and infection less lung surface area appropriate diet intake

Effective Coughing Technique

sitting position and bend slightly forward flex knees and hips (less strain on abdominal muscles) inhale slowly through nose and exhale through pursed lips several times cough twice during each exhalation which contracting abdomen splint incisional area with firm hand pressure/support with pillow or rolled blanket while coughing

Chest Percussion and Vibration Nursing Management

thick secretions that are difficult to cough up may be loosened by tapping (percussing) and vibrating the chest/HCFWO vest coughing+clearing sputum+hydration=reduced amount of sputum percuss, alternate with vibration 3-5 minutes for each position *percussion is performed cautiously in older pts (osteoporosis,rib fracture) flutter valve is used increase coughing NURSING MANAGEMENT: When performing CPT make sure the patient is comfortable, wearing no restrictive clothing, has not just eaten give meds for pain HFCWO - comfortable position, light activity during therapy STOP treatment if - increased pain, increased SOB, weakness, lightheadedness, hemoptysis Therapy is indicated until the patient has normal respirations, can mobilize secretions, and has normal breath sounds, and until the chest x-ray findings are normal. Nursing management of the patient using flutter valve therapy includes ensuring that the patient assumes the proper position, educating the patient on the technique for using the flutter valve, and setting realistic goals for the patient Gravity drainage by placing hips over a box, a stack of magazines, or pillows (unless a hospital bed is available) *maintain an adequate fluid intake and air humidity to prevent secretions from becoming thick and tenacious, recognize early signs of infection, such as fever and a change in the color or character of sputum **pt and family reports to pt's primary provider any deterioration in the patient's physical status or inability to clear secretions