Respiratory

SMART goals

Specific, Measurable, Attainable, Realistic, Timely

Asthma

-A chronic allergic disorder characterized by episodes of severe breathing difficulty, coughing, and wheezing. -With mild persistent asthma, symptoms occur between two and six times a week. -With mild intermittent asthma, symptoms occur twice a week or less. Exacerbations last hours to days, but the client has no symptoms in between exacerbations. Nocturnal symptoms occur occasionally. -With moderate persistent asthma, daily symptoms occur, affecting the level of physical activity. The daily use of a beta-agonist inhaler is usually required, and exacerbations occur at least twice weekly, lasting for days. Nocturnal symptoms occur at least once a week. -With severe persistent asthma, symptoms are continuous, impacting the client's physical activity levels. Nocturnal symptoms and exacerbations occur frequently.

acute respiratory distress syndrome (ARDS)

-ARDS occurs from inflammation or injury to the lung from various processes. It ultimately leads to increased permeability of the pulmonary capillaries and subsequent leakage of fluid in the interstitial space of the lungs -caused by shock -s/s: confusion, tachpnea, crackles -a condition of diffuse alveolar injury that prevents diffusion of oxygen into the bloodstream. ARDS is an acute syndrome with rapid onset. Pulmonary edema and decreased surfactant production increase the thickness of the alveolar capillary space, increasing the distance oxygen must travel to reach the blood. This results in hypoxemia and respiratory acidosis, not metabolic alkalosis. ARDS is a complication caused by another condition, such as sepsis or trauma. ARDS develops from inflammation and increased capillary permeability, leading to pulmonary edema, decreased surfactant production, and acidosis. Decreased blood flow to the pulmonary vessels may lead to an acute lung injury. The acute lung injury may ultimately lead to ARDS, but the decreased blood flow is not the ultimate cause of ARDS. Increased retention of carbon dioxide and decreased lung compliance occur as a result of ARDS, but they do not cause ARDS.

Acute exacerbation of COPD

-All acute exacerbations need a short-acting bronchodilator (like albuterol AND ipratropium bromide) -Can also use a short course of systemic steriods to reduce the length of exacerbation and risk or relapse (like prednisone 40 mg x 10-14 days) -An acute exacerbation of COPD is a sudden worsening of symptoms (shortness of breath, increase or change in phlegm) lasting several a minimum of 48 hours and is often triggered by a respiratory infection. Clients often require hospitalization and treatment with systemic corticosteroids to control the increase in inflammation and an increase in bronchodilator therapy to counter the increased bronchoconstriction. The client may also require antibiotic therapy. -s/s: productive cough, expiratory wheezes, elevated serum bicarbonate (compensates for resp. acidosis), A client is admitted with a diagnosis of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The nurse assesses for what findings directly related to the pathological changes of AECOPD? Select All That Apply Elevated serum bicarbonate Compensation for chronic hypercapnia and respiratory acidosis results in an elevation on the bicarbonate levels in an attempt to increase pH level toward normal. Productive cough Mucus gland hyperplasia and increased goblet cell activity leads to increased mucus production in the client with AECOPD leading to a productive cough. Expiratory wheezes Chronic inflammation of airways causes bronchoconstriction and a narrowing on bronchioles which can manifest as wheezing. NOT: Bilateral coarse crackles Pulmonary edema typically presents as crackles bilaterally and COPD is not associated with the condition. Localized consolidation with scattered crackles could support pneumonia for which the client with COPD is at risk for but unless acute respiratory distress syndrome were to develop, there should not be bilateral pulmonary edema present. Anemia of chronic disease Anemia is not associated with COPD and clients may actually experience secondary polycythemia and elevated red blood cell volume and hemoglobin levels in response to chronic hypoxia.

pneumonia

-An inflammation of lung tissue, wherer the alveoli in the affected areas fill w/fluid -s/s: fever, productive cough, dyspnea, pleuritic chest pain w/ inspiration, increased respiratory rate, crackles (fluid in alveoli) + wheezes (inflammation) and chills. Signs and symptoms of pneumonia include fever, productive cough, dyspnea, pleuritic chest pain, increased respiratory rate, and chills. Bronchophony is assessed by having the client say the word ninety-nine in a normal voice while the nurse auscultates the posterior lung fields. Normal bronchophony is present if the nurse is unable to distinguish what the client is saying. Abnormal bronchophony is present if the word the client is saying can be heard clearly when auscultated due to consolidation, such as in the case of pneumonia, because air does not transmit sounds as clearly as an area of consolidation. The nurse continually assesses for findings that suggest pneumonia complications. When complications are suspected, the nurse notifies the health care provider immediately. Septic shock is a life-threatening complication, so the nurse does more than document and monitor with this finding. Other complications include lung abscess, pleural effusion, and respiratory failure. A client is admitted for respiratory distress and suspected pneumonia. Which assessment findings consistent with this diagnosis require continued monitoring? Select All That Apply Chest pain with inspiration Pleuritic chest pain is a clinical symptom of pneumonia. The nurse asks questions to ensure it is the type of chest pain expected with pneumonia (such as only with inspiration) and not any other type of chest pain, documents the pain characteristics, and monitors for changes. Respiratory crackles and wheezes Crackles and wheezing occur secondary to fluid in alveoli and inflammation in the airways. Fremitus increases over lung areas with pneumonia, too. Dyspnea with ambulation Dyspnea, the client's perception of shortness of breath, is a symptom of pneumonia. Dyspnea may even be present at rest, but it is common with any exertion in the client with pneumonia. Temperature 101.4 °F (38.56 °C) Fever (hyperpyrexia) is a common finding in pneumonia, and it may be accompanied by chills and diaphoresis. NOT: Blood pressure 109/78 mmHg The nurse assesses all vital signs and would notify the health care provider of a low blood pressure reading in the event the health care provider wanted to provide intravenous fluid support. This helps differentiate dehydration, which is common in pneumonia, from sepsis. Incentive spirometry helps maximize alveolar inflation and ventilation, promoting airway clearance. Frequently position changes allows maximum expansion on alternate sides of the chest, allowing for optimal airway clearance. Deep breathing encourages oxygenation before controlled coughing, which allows for airway clearance. Adequate hydration helps the client expectorate mucus by thinning out pulmonary secretions. Placing the client in semi-Fowler's position allows for maximum chest expansion, maximizes the client's ability to clear the airway. A client is admitted with pneumonia. Which nursing interventions does the nurse start to assist with airway clearance? Select All That Apply--> all correct Provide adequate hydration. Adequate hydration thins the pulmonary secretions, promoting improved airway clearance. Encourage client to turn side-to-side frequently. Frequent repositioning helps to mobilize retained secretions and assists in airway clearance. Position the client in semi-Fowler's. Elevation of the client's head of bed greater than 30 degrees helps to prevent pooling of secretions and bacterial colonization of the airways from aspiration of oral secretions. Additionally, elevation of the client's head of bed improves diaphragmatic excursion and improves ventilation, aiding in airway clearance. Encourage the use of incentive spirometry. Incentive spirometry is an important tool to help maintain alveolar inflation and encourage mobilization of secretions. Encourage deep breathing and coughing exercises. Deep breathing and coughing helps to mobilize retained pulmonary secretions and provides for airway clearance.

chronic obstructive pulmonary disease (COPD)

-COPD is a pattern of chronic airway obstruction and chronic inflammatory response that is progressive. -Signs and symptoms of COPD include clubbed fingers and toes, dyspnea on exertion, hyperinflation of the chest, increased respiratory rate, and prolonged expiratory phase. -pursed lip breathing and diaphragmatic breathing (breathing with help of diaphragm muscle)

hyper-resonance on percussion

-Emphysema, pneumothorax, asthma? -lower pitched breath sound -occurs when theres too much air in lungs

emphysema

-a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness. -loss of lung elasticity and hyperinflation of the lungs resulting from excess protease (Proteases eliminate organisms and particulates inhaled during breathing. Emphysema creates an excess which damages alveoli.) -pO2 of 65 (normal is 75-100) -respiratory drive is triggered by low oxygen levels because of long-standing hypercapnia. Therefore, increasing the oxygen flow rate more than 2 L/min. may diminish the client's respiratory drive and place the client at risk for respiratory failure. (Normally, our respiratory drive is triggered by high levels of CO2. Oxygen administration above 2 L/min. is done cautiously with the health care provider's permission in limited circumstances. Emphysema causes loss of lung elasticity and hyperinflation of the lungs resulting from excess protease. Clients with emphysema often have "air hunger" due to flattening of the diaphragm and the subsequent muscle weakening that occurs from lung hyperinflation. To compensate for the weak diaphragm muscles, accessory muscles are used in the neck, chest wall, and abdomen during inhalation and exhalation. This increased respiratory effort increases oxygen needs, giving the client an "air hunger" sensation. Emphysema is a chronic lung condition that refers to the destruction of the alveoli. Appropriate nursing interventions for a client with emphysema include postural drainage, chest physiotherapy, low-flow oxygen, high Fowler position, and increase of fluid intake to liquefy secretions. Postural drainage involves positioning the client in specific positions for 5-10 minutes each to help clear the different lung fields of secretions. The client should be placed in the high Fowler position to improve ventilation, not a prone or supine position. Teach the client postural drainage. Teaching the client postural drainage is appropriate, because this provides the client with techniques of airway clearance. This is the appropriate nursing action for this client. Which intervention does the nurse implement when caring for a client recently diagnosed with emphysema? Teach the client postural drainage. Teaching the client postural drainage is appropriate, because this provides the client with techniques of airway clearance. This is the appropriate nursing action for this client. NOT: Reduce the client's fluid intake. The nurse would encourage an increase in fluid intake, not a decrease. Increased fluid intake promotes the liquification of retained secretions, promoting easier removal. Advise the client to get an annual pneumonia vaccine. Pneumococcal vaccination is necessary to prevent critical illness in the client with emphysema; however, this vaccine is administered every five years. Annual vaccination is not harmful but is not the recommended use. Keep the client in a supine position. The client should be placed in the high Fowler position to improve ventilation.

Sarcoidosis

-chronic inflammatory disease in which small nodules (granulomas) develop in lungs, lymph nodes, and other organs (skin) -unknown cause Bronchoscopy is an endoscopic technique of visualizing the inside of the airways for diagnostic and therapeutic purposes. An instrument is inserted into the airways, usually through the nose or mouth, or occasionally through a tracheostomy. A nurse provides discharge instructions to a client recently diagnosed with sarcoidosis. When explaining the cause of the disease, which statement does the nurse include? "The cause of sarcoidosis is not known." The cause of sarcoidosis remains unknown. It is thought that an altered immune response in some genetically susceptible individuals is a causative factor for the development of the disease. NOT: "The cause of sarcoidosis is exposure to asbestos." Exposure to asbestos may lead to mesothelioma, a tumor of the lining of the lungs. Exposure to asbestos is not directly linked to the development of sarcoidosis. "The cause of sarcoidosis is smoking." Bacterial infection and smoking lead to a wide variety of diseases and conditions, but these are not directly linked to the development of sarcoidosis. "The cause of sarcoidosis is bacterial infection." Bacterial infection and smoking lead to a wide variety of diseases and conditions, but these are not directly linked to the development of sarcoidosis.

atelectasis

-collapsed lung; incomplete expansion of alveoli -increased risk by weak, nonproductive, cough, mild dyspnea -Without the removal of secretions, atelectasis can form mucus plugs and cause airway obstruction. -can be caused by COPD with HF Atelectasis refers to the collapse of alveoli. The client in an inpatient setting with both heart failure and COPD is at increased risk for breathing complications. Enough atelectasis can decrease the lungs' ability to diffuse oxygen and carbon dioxide. A weak, nonproductive cough increases the risk of developing atelectasis. Without the removal of secretions, atelectasis can form mucus plugs and cause airway obstruction. A pulmonary embolism (PE) may cause a cough; however, a client with a PE usually reports sudden and severe dyspnea. Pulmonary hypertension and pleural effusions are not caused by secretion buildup and are not characterized by a weak cough. A client with chronic obstructive pulmonary disease (COPD) is admitted with heart failure. The nurse assesses a weak, nonproductive cough and mild dyspnea. Which complication does the nurse recognize as most likely to occur? Atelectasis Atelectasis is most likely to occur because the client has a weak cough. Deep breathing and coughing helps to prevent atelectasis (collapse of the alveoli) and if the client is unable to cough correctly, atelectasis may occur. NOT: Pulmonary embolism The client suffering from a pulmonary embolism, or blood clot in the lungs, generally has severe and sudden-onset shortness of breath due to impaired or absent perfusion and oxygen within the lungs. Pulmonary hypertension Pulmonary hypertension, increased pressure of the pulmonary vasculature, can be caused by COPD. Signs typically include shortness of breath and tachypnea. Pleural effusion Pleural effusion is fluid accumulation in the pleural space. Heart failure can cause a pleural effusion. The cough associated with pleural effusion is forceful because the body is trying to get more oxygen into reduced alveoli.

silicosis

-disease due to silica or glass dust in the lungs; occurs in mining/glass occupations Silicosis is a lung disease caused by breathing in tiny bits of silica, a mineral that is part of sand, rock, and ores such as quartz. It mostly affects workers exposed to silica dust in occupations such as mining, glass manufacturing, and foundry work. Over time, exposure to silica particles causes scarring in the lungs, which can harm the ability to breathe. There are four main types of silicosis: -Accelerated silicosis: This rare form of the disease is characterized by shortness of breath and worsening shortness of breath; however, this occurs after ten years of exposure to silica. -Simple chronic silicosis: This is the first stage of chronic silicosis, during which lung condition is slowly worsening. Manifests with an opacification or "ground glass" appearance on chest x-ray. -Complicated silicosis: This is characterized by severe scarring and fibrosis of the lung tissue. -Acute silicosis: This develops within a few weeks or years after exposure to silica dust and is characterized by rapid onset of dyspnea, cough, and weight loss. X-ray reveals a ground-glass appearance. A nurse cares for a client with silicosis after occupational exposure to silica. The client tells the nurse, "My breathing seemed to get bad just since my last birthday." Which type of silicosis does the nurse suspect the client is suffering from? Acute Acute silicosis causes cough, weight loss, and fatigue within a few weeks or years of exposure to silica. Rapid decline of breathing would be a symptom of acute silicosis. NOT: Complicated Complicated chronic silicosis involves more organs other than the lungs and develops over 20-30 years. Acute decline of breathing is not associated with this condition. Simple Simple chronic silicosis is the first stage of chronic silicosis and does not manifest with rapid worsening of the client's condition. In this stage, lung condition is slowly worsening, and the client does not typically find a sudden change in breathing. Accelerated Accelerated silicosis is a rare form of the disease and may develop after severe exposure to disease-causing chemicals. It typically develops within ten years of exposure.

flail chest

-fracture of two or more adjacent ribs in two or more places that allows for free movement of the fractured segment -S/s: paradoxical chest motion, pieces of ribs move into the chest during inspiration, and pop out of the chest during expiration

Histoplasmosis

-fungal infection of the lungs -usually affects immunocompromised -The signs and symptoms of histoplasmosis are similar to pneumonia and are characterized by nonspecific respiratory symptoms: cough, flu-like symptoms, dyspnea, and fever. Histoplasmosis is an opportunistic fungal infection that can affect immunocompromised patients. The signs and symptoms of histoplasmosis are similar to pneumonia and are characterized by nonspecific respiratory symptoms: cough, flu-like symptoms, dyspnea, and fever. The majority of histoplasmosis cases resolve without treatment. Severe cases require the use of antifungal medication. Symptoms of histoplasmosis are not closely related or similar to pulmonary fibrosis or pulmonary hypertension symptoms.

pleuritis, pleurisy

-inflammation of both the visceral and parietal pleura -common s/s: sharp pain during inspiration, friction rub during auscultation Pleurisy often causes a sharp, knife-like pain that intensifies with inspiration. The term pleurisy actually refers to inflammation of the pleural membrane. This pain is due to friction between the pleural surfaces and can be heard on auscultation as a pleural friction rub. Crackles on auscultation are not a characteristic of pleurisy. Rather, crackles reveal pulmonary edema or fluid in the alveoli. Although very painful, pleurisy does not cause dyspnea or tachypnea. A nurse cares for a patient diagnosed with pleurisy. Which assessment findings does the nurse expect? Select All That Apply Friction rub on auscultation Pleurisy results from inflammation of the pleura, the layers surrounding the lung. This condition is very painful and causes sharp pain with breathing, especially with inspiration. A pleural friction rub is a classic finding with pleurisy and results from the inflammation of the pleural lining. Sharp pain on inspiration Pleurisy causes sharp pain on inspiration. NOT: Dull pain on expiration Pleurisy causes sharp pain on inspiration, not dull pain on expiration. Tachypnea with rest Although pleurisy may be very painful, it is not associated with dyspnea or tachypnea. Crackles on auscultation Crackles on auscultation typically reveal pulmonary edema or fluid in the alveoli. Crackles are not a finding with pleurisy.

pulmonary embolism (PE)

-occlusion in the pulmonary circulation, most often caused by a blood clot --Signs and symptoms: dyspnea, pleurisy, low-grade fever, hemoptysis, and tachycardia. The onset of symptoms is usually sudden and intense.

FiO2 (fraction of inspired oxygen)

-ranges from 45-100% -toxic levels considered to be >50%, goal should be 50% or less FiO2 -prolonged high concentrations runs the risk of nitrogen washout causing atelectasis & haldane effect -titrate down to 21% or room air when weaning off O2 Prolonged FiO2 of 50% or greater can lead to oxygen toxicity and atelectasis, so the goal is to titrate the FiO2 to 50% or less, as tolerated. Prolonged exposure to increased FiO2 leads to the accumulation of free radicals and results in oxidative stress on body tissues. This may manifest as central nervous system symptoms (vertigo and nausea) and pulmonary symptoms (interstitial fibrosis, airway collapse, and air trapping). Ideally, the FiO2 should be titrated down to 21%, or room air, but the FiO2 must be slowly decreased, and a client who is currently requiring 80% FiO2 likely needs much more than 21% oxygen in order to maintain adequate blood oxygen levels. A nurse cares for a client who is mechanically ventilated with an FiO2 setting of 80%. The nurse consults with the health care team about reducing the client's ventilator-related complication risk. The nurse advocates for which FiO2 setting? 50% 50% FiO2 represents the goal of oxygen therapy, because it both supplements the client's need for supplemental oxygen and reduces the risk of oxygen toxicity, which may occur with increased FiO2. NOT: 21% 21% FiO2 represents room air. The client is currently on 80% FiO2 and requires high amounts of FiO2. If the nurse decreased the FiO2 to 21%, the client will likely experience severe complications, such as hypoxemia. 30% 30% FiO2 is too low to titrate the client when the client is currently receiving 80% FiO2. If the nurse decreases the FiO2 to 30% from 80%, the client will likely experience severe complications, such as hypoxemia. 75% Elevated FiO2 for an extended period of time increases the likelihood of oxygen toxicity. 75% FiO2 is elevated, and the nurse should work to titrate the FiO2 lower to avoid toxicity.

cor pulmonale

-right ventricular hypertrophy and heart failure due to pulmonary hypertension -right-sided heart failure arising from chronic lung disease

laryngectomy

-surgical separation of larynx from nose and mouth -tracheostomy minimal leak technique: minimal pressure to allow air to escape at end of inspiration, prevents overinflation and damage to surrounding tissues -suction as needed A laryngectomy is the removal of the larynx and the separation of the trachea from the nose and mouth. This procedure is usually a treatment for laryngeal cancer. In order to prevent damage to the tracheal mucosa, the nurse should use the minimal leak technique. The nurse measures and deflates the cuff slightly until a small air leak is heard on the end of inspiration. This ensures that adequate ventilation is achieved, as well as decreased pressure on the tissues of the airway due to excessive pressure from an overinflated tracheostomy. The client's head of bed should be at least 30° or higher in order to decrease edema and prevent ventilator-acquired pneumonia (VAP). A client who is mechanically ventilated must achieve nutrition either from enteral feedings or total parenteral nutrition. Suctioning the client every 30 minutes is excessive and could cause damage to the airway. The client should be encouraged to cough and breathe deeply.

pneumonectomy

A pneumonectomy is the surgical removal of the lung. Clients in the postoperative period following pneumonectomy surgery may be positioned in the side-lying position on the operated side or in the semi- or high-Fowler position in order to facilitate diaphragmatic excursion and prevent atelectasis of the remaining lung. Planning chest physiotherapy sessions at times when pain medication is maximally effective is best to allow for the best client participation and motivation. Offering frequent sips of water helps to address airway clearance by encouraging hydration, which keeps secretions thinner and makes coughing more effective. Closed-chest drainage is not typically used after pneumonectomy, but if a chest tube is in place, the nurse should not milk or strip the tubing, because this increases pleural pressure and may worsen the client's outcome. A nurse cares for a client who is post-pneumonectomy. The nurse forms a plan of care to treat ineffective airway clearance related to increased secretions and decreased coughing effectiveness due to pain. Which nursing interventions does the nurse include in the client's care? Select All That Apply Plan chest physiotherapy sessions based on client pain level. Chest physiotherapy includes percussion, postural drainage, vibration, deep breathing exercises, and coughing. Chest physiotherapy techniques help to mobilize secretions, promoting airway clearance. However, these techniques are often painful, particularly for a client who has undergone thoracic surgery. In order to improve technique and compliance in these sessions, the nurse should plan these sessions when the client's pain is tolerable. Offer the client sips of water frequently. Offering frequent sips of water helps to maintain the client's hydration status and acts to keep pulmonary secretions thin, which aids in airway clearance. Assist the client to cough and deeply breathe frequently. Demonstrating and helping the client to take deep breaths and cough frequently improves airway clearance by mobilization of pulmonary secretions. NOT: Milk or strip the client's chest tubes to improve pleural suction. A pneumonectomy is the complete removal of the lung, and chest tubes are typically not needed after the procedure but may be, based on surgeon preference. Additionally, milking or stripping the chest tube should not be performed, because it creates too much pressure within the pleural space. Position the client in the side-lying position on the non-operated side. The client should be positioned either in the side-lying position on the operated side or in the semi- or high-Fowler position postoperatively. Positioning in the side-lying position on the non-operated side may result in atelectasis of the only lung the client has remaining.

Bronchophony

A variety of techniques are used to assess lung field changes in the client with a respiratory pathology such as pneumonia. Often, these are used to determine areas of consolidation, which indicates possible infiltrates present in respiratory infections. A nurse assesses a client with pneumonia for bronchophony. The nurse uses what procedure? Have the client say "ninety-nine" while auscultating the lungs. This is the procedure for assessing bronchophony. Normally, the voice transmission is muffled, but if there is an increase in lung density, the nurse will hear a clear "ninety-nine" in the stethoscope. NOT: Have the client say a long E sound while auscultating the lungs. This assesses egophony, which helps identify consolidation. Over the area of consolidation, the E sound changes to a long A sound. Have the client say "ninety-nine" while placing the palms on the chest wall. This procedure assesses tactile fremitus, which is a palpable vibration. Ask the client to whisper a phrase while auscultating the lungs. This procedure assesses consolidation. Normally, the whispered phrase should be barely audible. When consolidation is present, the words present with more clarity than normal.

heparin infusion

Bleeding, presenting as hematuria, could result from over-anticoagulation. This should be reported to the health care provider for further evaluation. Depending on the reason for the heparin infusion, other symptoms, and additional lab work, the health care provider could choose to administer an antidote, decrease the heparin infusion, or stop the heparin infusion. A nurse cares for a client receiving a heparin infusion. The nurse observes bright red urine in the client's catheter drainage system. Which action does the nurse take first? Notify the health care provider. The client is showing evidence of bleeding (hematuria), and the health care provider should be notified. NOT: Prepare a dose of protamine sulfate. Although protamine sulfate is given for a heparin overdose, the nurse must first notify the health care provider of the client's condition. Heparin has a short half-life, and a reversal agent or antidote may not be needed. Change the heparin infusion rate. The nurse should not decrease the infusion rate of the heparin. This is not within the nurse's scope of practice and is the reason the health care provider should be notified immediately. Depending on many factors, the provider may choose to continue the heparin without changes. Send blood to the laboratory for coagulation studies. Although it is correct to check the client's activated partial thromboplastin time and other coagulation results, the health care provider must be notified prior to this action. The nurse is concerned about the client's symptoms regardless of the laboratory results.

bronchoscopy

Bronchoscopy is an endoscopic technique of visualizing the inside of the airways for diagnostic and therapeutic purposes. An instrument is inserted into the airways, usually through the nose or mouth, or occasionally through a tracheostomy. Bronchospasms are an unexpected side effect and should be reported to the health care provider immediately to prevent respiratory failure. Cough and drowsiness (from conscious sedation) are expected side effects. Red sputum is expected after a biopsy for several hours in small amounts. A nurse cares for a client who undergoes a bronchoscopy with biopsy. Which immediate post-procedure finding does the nurse report to the health care provider? Bronchospasm Bronchospasm is an unexpected finding post-bronchoscopy and requires immediate attention from the nurse. This can manifest as reports of chest tightness, auscultated wheezing, decreased oxygenation with continual coughing, or audible stridor. NOT: Dark red sputum Dark red sputum indicates old blood, which is not a finding that needs to be immediately reported to the health care provider. If the client has copious, bright red blood, this finding is immediately reported to the health care provider. Drowsiness Drowsiness post-procedure is an expected finding due to the sedative effects of medications given prior to and during the procedure. This does not need to be reported to the health care provider. Cough Cough is an expected finding after bronchoscopy due to the nature of the procedure. This finding does not need to be reported to the health care provider.

home oxygen therapy

Clients going home on oxygen therapy should be well assessed for their understanding of equipment use prior to discharge. The nurse should have the client and family teach back the proper use of equipment to ensure oxygen will be used safely at home and that the client will receive effective oxygen therapy. Combustion may occur with improper oxygen use, and clients should be educated on combustible materials such as bedding, walls, and cigarette smoking. A client receives discharge instructions for going home on oxygen therapy. The nurse knows the instructions were understood when the client makes which statement? "I will notify emergency medical service (EMS) that I will be using home oxygen equipment." The client should notify EMS that oxygen equipment will be in their home. If a power outage occurs, EMS will check on the client and municipalities will often try to return power to these homes first. NOT: "I will make sure to ask visitors to only smoke in the basement or on the other side of the house." Smoking should not be allowed anywhere in the house when oxygen equipment is present due to the risk of combustion. "I will store my extra portable oxygen tanks out of the way on their sides under my bed." Oxygen tanks should be stored upright and away from bedding, curtains, and combustible materials to avoid the risk of combustion. "I will use a portable oxygen tank when doing my woodworking hobby in the garage." Oxygen should not be used around highly combustible materials, such as wood particles and wood dust. Qualifying for home oxygen therapy requires meeting criteria that can vary between jurisdictions but always centers on correcting conditions of chronic hypoxia. In the case of cor pulmonale, the client has developed the right ventricle hypertrophy secondary to chronic alveolar hypoxia, and the resulting pulmonary hypertension with increased afterload for the right ventricle. The correction of alveolar hypoxia requires continuous oxygen therapy rather than only when the client is dyspneic. The client also should be informed about the basics of oxygen safety and equipment maintenance. A client with cor pulmonale secondary to chronic obstructive pulmonary disease (COPD) is being discharged home on oxygen therapy at 2 L nasal cannula via portable oxygen tank. What information does the nurse include when teaching about home oxygen use? Select All That Apply "Ensure you have a regular delivery schedule and a spare source of oxygen available." The client should be taught to always have a spare source of oxygen available if using an oxygen tank and not to wait until the tank is running out of oxygen to replace the tank. "Do not allow open flame or smoking in the room where oxygen is being used." Oxygen does not burn but enhances combustion, so candles or cigarettes should not be in the same room during oxygen therapy. NOT: "Replace the nasal cannula and tubing every week or more often if soiled." Nasal cannula and tubing only need to be changed if soiled and not regularly every week. At 2 L, the client would not be receiving humidification with the oxygen therapy. "Even if your dyspnea is worse, never allow the administration of oxygen above three liters." If the client is acutely dyspneic and the oxygen saturation falls below 88%, the client may require high-flow oxygen, so the nurse should not directly instruct the client to never allow rates above three liters. "If you are not experiencing any dyspnea, remove the oxygen to reduce dependence." If the client has met the criteria for home oxygen and has cor pulmonale, the client should wear the oxygen at all times to prevent the progression of this condition even if not actively dyspneic.

Pneumothorax (PTX)

Collapsed lung due to trauma or a spontaneous small rupture of the lung

extubation

Extubation is the removal of the advanced airway, usually an endotracheal tube (ETT). Depending on the state and individual facility, this procedure may be performed by either a respiratory therapist or an RN. Prior to extubation, the nurse should position the client in the high-Fowler's position to allow for optimal diaphragmatic excursion. Additionally, placing the client on continuous pulse oximetry ensures adequate monitoring of the client's oxygen level. Once extubated, 100% oxygen is administered by mask and the nurse frequently assesses the client's breath sounds. A high-pitch inspiratory sound may indicate stridor, a severely narrowed airway which may occur after extubation. Stridor is a medical emergency and assessing breath sounds frequently helps to identify this life-threatening condition. The client should not be offered oral hydration in the immediate post-extubation period as the client may not have an adequate gag reflex and is at risk for aspiration. A nurse cares for a client whose endotracheal tube is being removed after successful weaning off mechanical ventilation. Which immediate post-extubation actions does the nurse perform? Select All That Apply Auscultate breath sounds frequently. It is important to auscultate the client's breath sounds frequently in the immediate post-extubation period in order to determine if the client's condition is worsening. Monitor continuous pulse oximetry. The client is being extubated and weaned from mechanical ventilation. Very close monitoring by the nurse is essential, including monitoring continuous pulse oximetry in order to ensure that the client is able to maintain adequate oxygenation while ventilating. NOT: Administer oxygen at 2 liters per minute (LPM). In the immediate post-extubation period, the client should be placed on high-flow oxygen at 100% FiO2 via NRB mask. After the immediate extubation, the nurse or respiratory therapist will begin to titrate to a lower flow, lower FiO2 oxygen supplementation, such as a nasal cannula. Encourage the client to take small sips of water. The client should not drink fluids in the immediate post-extubation period, as this increases the risk of aspiration. Position the client in the side-lying position. The client should be placed in the high-Fowler's position, allowing the client optimal diaphragmatic excursion and promoting airway patency.

pulmonary function tests (PFTs)

Pulmonary function tests (PFTs) are a series of respiratory tests that are used for diagnostic purposes. Forced vital capacity (FVC) is the volume of air that can be forcibly exhaled after full inspiration. Static lung capacity is the sum of total lung capacity (TLC), function residual capacity (FRC), and residual volume (RV). Tidal volume is the volume of air inhaled and exhaled during each respiratory cycle. While observing a client performing a pulmonary function test (PFT), the nurse notes the client forcibly exhales after a full inspiration. Which aspect of the PFT does the nurse recognize the client is performing? Forced vital capacity Forced vital capacity is the volume of air that can be forcibly exhaled after full inspiration. NOT: Functional residual capacity Functional residual capacity is the volume of air present in the lungs after passive exhalation. Static lung capacity Static lung capacity is calculated, not measured. Tidal volume Tidal volume is the volume of air inhaled and exhaled during each respiratory cycle.

Endotracheal (ET) suction

Suctioning is indicated for the presence of wet respirations, rhonchi (a sound like snoring), increased peak inspiratory pressure, bubbling in the ET tube, restlessness, and increased respiratory and heart rates. A nurse cares for a client who is intubated and mechanically ventilated. Which assessment findings lead the nurse to perform endotracheal (ET) suction? Select All That Apply Coarse rhonchi bilaterally Coarse rhonchi indicate retained secretions and are a finding that indicates the need for ET suctioning. High peak inspiratory pressure Increased secretions in the airway occlude or impede the diameter of the airway, increasing the pressure. An increased peak inspiratory pressure indicates resistance in the tube and a need for suctioning. Increased oxygen requirements With retained secretions in the airway, oxygen requirements increase. The oxygen exchange surface area and ability of air to get through the airway decrease when increased mucus is present. Increased incidence of coughing A client who coughs with increasing frequency may be trying to clear an obstruction from the airway. NOT: Pulse of 62 beats/min. Typically, a client who requires suctioning may have tachycardia due to an increased need for oxygen and the body's compensatory mechanisms. Suctioning the client's endotracheal (ET) tube lowers the partial pressure of arterial oxygen, which can cause a cardiac arrhythmia, such as bradycardia. Hyper-oxygenating for 30-60 seconds with 100% oxygen helps prevent arrhythmias and oxygen desaturation. Pulmonary hypertension is elevated blood pressure within the arteries, affecting the lungs and the right side of the heart. Pulmonary hypertension is not associated with in-line tracheal suctioning. Coughing occurs with in-line tracheal suctioning due to stimulation of the client's cough reflex. Though hyperoxygenation helps to prevent hypoxemia, it does not prevent coughing. Subcutaneous emphysema is the presence of air or gas directly under the skin. It is not a complication of in-line tracheal suctioning. Prior to in-line suctioning a client who is mechanically ventilated, the nurse hyper-oxygenates the client. What complication does the nurse's action help to prevent? Cardiac arrhythmia Hyperoxygenation prior to suctioning increases the client's blood oxygen level to prevent hypoxemia (decreased blood oxygen levels). Hypoxemia may lead to cardiac arrhythmia due to lack of perfusion to the heart, and hyperoxygenation helps to prevent this complication. NOT: Pulmonary hypertension Pulmonary hypertension is elevated blood pressure within the arteries, affecting the lungs and the right side of the heart. Chronic conditions cause pulmonary hypertension, not in-line suctioning of the trachea while the client is intubated and mechanically ventilated. Severe coughing In-line suctioning of the client's endotracheal tube is likely to stimulate the client's cough reflex and cause coughing. Though hyperoxygenation does not prevent coughing, it is used to help prevent hypoxemia associated with severe coughing that can occur with suctioning. Subcutaneous emphysema Subcutaneous emphysema is the presence of air or gas directly under the skin. This most frequently occurs with surgical or traumatic events and may be palpated on the skin as a popping sensation. In-line tracheal suctioning does not cause subcutaneous emphysema.

Ventilator-associated pneumonia (VAP)

To prevent ventilator-acquired pneumonia (VAP), the nurse should perform oral care at least every four hours, reposition every two hours, and keep the head of the bed elevated to prevent aspiration and promote open airways. Restricting fluids can increase the risk of pneumonia. The use of prophylactic antibiotics for the prevention of VAP is not common and may actually increase the risk of developing resistant organisms. A nurse cares for a client who is orally intubated and mechanically ventilated. Which interventions does the nurse perform in order to reduce the client's risk of pneumonia? Select All That Apply Performing oral care every four hours Adequate and frequent oral hygiene removes bacteria and pathogens from the client's oral cavity. This helps to prevent these pathogens from colonizing the airway, leading to pneumonia. Repositioning the client every two hours Frequent repositioning of the client helps to mobilize retained pulmonary secretions, making removal of the secretions easier. Less retained secretions means a decrease in the client's risk for pneumonia. Elevating the head of the bed Elevation of the client's head of bed greater than 30° helps to prevent pooling of secretions and bacterial colonization of the airways from aspiration of oral secretions. This action helps to prevent pneumonia in a client who is mechanically ventilated. NOT: Restricting the client's fluids Unless contraindicated, intravenous fluid is encouraged for a client who is mechanically ventilated. Adequate intravenous hydration aids in thinning of pulmonary secretions and a decreased risk for developing pneumonia. Administering prophylactic antibiotics Prophylactic antibiotics are not a standard of care for the prevention of ventilator-acquired pneumonia. This does not reduce the client's risk of pneumonia.

Ventilator alarms

Ventilator alarms can indicate a variety of problems that may cause client harm. A low-pressure alarm may indicate an air leak in the ET tube, a deflated cuff, or partial extubation; air pressure is being lost somewhere. If the ventilator alarm is sounding and the cause cannot be quickly determined and resolved, the possibility of causing harm to the client by allowing the ventilator to remain connected to the client is high. The nurse should disconnect the ventilator and begin manual ventilation while calling for help to troubleshoot the ventilator. This priority intervention confirms a client airway and ensures adequate ventilation. A high-pressure alarm often indicates a kink or obstruction in the tubing or the ET tube (such as the client biting the ET tube), pooling secretions, bronchospasm, or pulmonary edema. Pressure is building up in the closed system somewhere, and this pressure can damage the delicate tissues of the lungs. If there is low pressure, oxygen may simply leak out of the ventilator system. Ventilator settings are set according to provider orders, so it is not appropriate for the nurse to reset the ventilator without determining the cause and confirming new orders with the provider, as well as ensuring the client has adequate ventilation. Clients on ventilators should receive continuous monitoring of pulse oximetry, so this answer choice is incorrect. A client's ventilator alarm reads "low pressure," but after checking the ventilator and endotracheal (ET) tube, the nurse cannot determine the cause of the alarm. Which action does the nurse perform next? Ventilate the client manually. When a low-pressure alarm is sounding and cannot be immediately remedied, the nurse must disconnect the ventilator and manually ventilate the client in order to ensure that the client is adequately ventilated. NOT: Reset the ventilator. Maintaining the client's oxygen is the priority. Troubleshooting the machine further poses a risk to the client. Administer additional oxygen. Administering addition oxygen does not ensure the client is ventilating adequately. This is not the appropriate action when assessing the alarm. Connect the client to pulse oximetry. A client who is mechanically ventilated will always be on continuous pulse oximetry. The nurse does not wait until the client shows oxygen desaturation before addressing the potential equipment failure.

incentive spirometry

a common postoperative breathing therapy using a specially designed spirometer to encourage the patient to inhale and hold an inspiratory volume to exercise the lungs and prevent pulmonary complications

peak flow meter

a handheld device often used to test those with asthma to measure how quickly the patient can expel air The nurse should teach the client that the purpose of the peak flow meter is to assess asthma-related airflow limitation which helps guide treatment decisions. It offers a warning sign of poorer asthma control by establishing a baseline of the client's personal best that can be compared to subsequent readings. Note that this is a very different purpose compared to using an incentive spirometer for opening collapsed alveoli (atelectasis) in the postoperative client. An adult with asthma requires education about using a peak flow meter. What information does the nurse teach the client? Select All That Apply Initially, use the peak flow meter twice a day for at least two weeks when asthma is well-controlled. This is done to establish a baseline and a "personal best" against which subsequent results will be compared. If the peak flow is less than 80% of personal best, administer reliever drug and retest in a few minutes. A reduction of under 80% of personal best indicates airflow obstruction requiring bronchodilator therapy. The client should then assess response to treatment. Comparing ongoing results with the best, stable result helps determine medication requirements. When the client has a result less than the established personal best, this indicates a need for a change in treatment. This may be a single use of a reliever drug, or in the case of a sustained reduction in performance, a change in prescription. NOT: Regular use of the peak flow meter can reduce the number of asthma attacks experienced. The peak flow meter is an assessment rather than an intervention. It determines the degree of airflow obstruction and does not improve respiratory functioning. The peak flow meter estimates lung function by determining how much air is inspired into the lungs. Being an obstructive respiratory condition, asthma prevents exhalation of air rather than limiting air flow on inspiration. The peak flow meter offers an estimate of how much air the client is exhaling.

pleural effusion

abnormal accumulation of fluid in the pleural space

empyema, pyothorax, purulent pleuritis

accumulation of pus in the pleural cavity A client with hemothorax, or collection of blood in the pleural space, is at risk of empyema formation. Empyema is a collection of pus in the pleural space. Often the client presents with fever, chills, night sweats, and weight loss. A nurse cares for a client with a hemothorax. The nurse reports what findings as evidence of empyema? Select All That Apply Night sweats The inflammatory response becomes chronic with empyema, and clients experience low-grade fever, weight loss, and night sweats as a result. Diminished breath sounds Due to decreased lung expansion and the presence of thick fluid in the pleural space, the nurse may note distant or faint breath sounds that should be more notable on the side of the empyema. Fever Fever occurs as part of the inflammatory response to the empyema. NOT: Hyper-resonance on percussion On percussion, the finding of hyper-resonance (lower-pitched sound than normal) occurs when too much air is present, such as in emphysema or pneumothorax, rather than when consolidation or pleural effusions are present, which can reduce resonance and create a duller sound on percussion. Decreased respiratory rate The client would most likely present with tachypnea if experiencing empyema.

arterial blood gases (ABGs)

pH: (7.35-7.45) PaO2: (75-100 mmHg) PaCO2: (35-45 mmHg) HCO3: (22-26 meq/L)

thoracentesis

the surgical puncture of the chest wall with a needle to obtain fluid from the pleural cavity