Respiratory

Endoscopy (Bronchoscopy)

- NPO at least 6 hrs - Consent - Outpatient procedure - Fiberoptic scope used to procure specimen (lung tissue, foreign bodies, mucous plugs), biopsy, lavage lungs, laser therapy, electrocautery, cryotherapy, stents - Post procedure: check gag reflex prior to eating

Interventions to facilitate secretion removal in clients with pneumonia include:

- Performing chest physiotherapy (percussion, vibration, postural drainage) to loosen and break up thickened secretions - Assisting the client to perform huff coughing, which raises secretions from the lower to the upper airway for expectoration - Ensuring adequate hydration through increased oral fluid intake (≥2-3 L/day) and administration of prescribed IV fluids, which thins pulmonary secretions to promote improved secretion clearance - Positioning the head of the bed to 45-60 degrees (ie, Fowler position) to promote effective coughing and optimal lung expansion

Trach care

- suction with inner cannula if pt is on fenestrated tube so the cath won't hurt the trachea - wet inner cannula should not be put in place - keep a tracheostomy obturator and tube of same size for emergency replacement. -suction set at 80-100 -no more than 3 times and ventilate between them -Don't instill NS into the trach (NS will flush the particles down to lungs and increase bacterial colonization) -Clean trach and site with NS only -Avoid using a hydrogen peroxide mixture unless the site is infected -Do not change trach tapes until after the 1st 24 hrs of insertion (neck is swollen and if trach falls out)

Chronic obstructive pulmonary disease (COPD)

-Airflow limitation resulting from small-airway disease and parenchymal destruction -includes emphysema (damages alveoli) and bronchitis (airway swollen + filled with mucous) -Chronic air trapping and reduced gas exchange by decreasing venitlation

acute asthma exacerbation S/S

-Arterial pH <7.35 -PaCO2 55 -Pa O2: 58 -Paradoxical breathing -restlessness and drowsiness airway obstruction + air trapping Acute severe asthma exacerbations (status asthmaticus) occur when severe airway obstruction and lung hyperinflation (air trapping) persist despite aggressive treatment with bronchodilators and corticosteroid therapy.

What need to be cautious on pt with chest tube?

-Drainage >100ml/hr -diminished breath sounds infection at the drainage site o Following lung surgery, a chest tube is inserted into the pleural space to create a negative vacuum to re-inflate the lung and prevent air from re-entering the space. A client with a chest tube should be assessed for signs of air/fluid in the chest (eg, diminished breath sounds), excessive drainage (>100 mL/hr), pain, and infection at the drainage site. o The collection chamber should be inspected every hour for the first 8 hours following surgery, then every 8 hours until it is removed. o Excess drainage of frank red blood is indicative of hemorrhage and must be managed immediately. The priority action is to contact the health care provider for further management.

Peritonsillar abscess S/S

-Fever -sore thorat -Trismus -Muffled "hot potato" voice -Uvula deviation away from enlarged tonsil -pooling of saliva

Rhonchi

-Rhonchi are continuous, low-pitched wheezes usually heard on expiration that sound like moaning or snoring. -The sound originates from air moving through large airways (bronchi) filled with mucus secretions and are expected in clients with chronic bronchitis. -Although they require treatment (eg, medication, mobilization of secretions), this is not the priority assessment.

The nurse is caring for a client with a chest tube to evacuate a hemopneumothorax after a motor vehicle accident. The drainage has been consistently 25-50 mL/hr for the majority of the shift. However, over the past 2 hours there has been no drainage. Which actions should the nurse take?

-auscultate breath sounds - instruct client to cough and deep breath -reposition the client When chest drainage stops abruptly, the nurse must perform assessments and interventions to ascertain if this is an expected finding. Auscultating breath sounds helps the nurse detect whether breath sounds are audible in all lung fields, potentially indicating that the lung has re-expand and there is no more drainage. Other interventions to facilitate drainage include include having the client cough and deep breathe (Option 3) and repositioning the client (Option 5). If a client has been in one position for a prolonged period, drainage may accumulate and a position change may facilitate improved drainage.

Chest Tube Suction Control Chamber

-has gentle, continuous bubbling o The suction control chamber (Section A) maintains and controls suction to the chest drainage system; continuous, gentle bubbling indicates that the suction level is appropriate. o The amount of suction is controlled by the amount of water in the chamber and not by wall suction. Increasing the amount of wall suction would cause vigorous bubbling but does not increase suction to the client as excess suction is drawn out through the vent of the suction control chamber. o Vigorous bubbling would increase water evaporation and therefore decrease the negative pressure applied to the system. The nurse should check the water level and add sterile water, if necessary, to maintain the prescribed level.

What you can teach to pt with acute bronchitis to decrease cough or make it more comfortable?

-increase fluids to at least 8 glasses of water a day -sleep with a cool mist humidifier -take prescribed guaifenesin cough medicine before bedtime -use abdominal breathing and the huff cough technique at bedtime

When does COPD pt need to seek medical help?

-increase sputum -worsening SOB -lack of relief from prescribed emergency medications (albuterol, ipratropium)

cor pulmonale

-right ventricular hypertrophy and heart failure due to pulmonary hypertension -• Caused by COPD, pulmonary HTN • Symptoms: DOE, tachypnea, cough, fatigue, loud S2, polycythemia • Nursing care: - Assess lungs, O2 prn - Bronchodilators prn, vasodilators, Ca channel blockers, anticoagulants - Monitor lytes, ABGs

Pt care for Cystic Fibrosis

1) Aerobic exercise 2) chest physiotherapy 3) Financial needs 4) High-calorie diet 5) promote fluid hydration o Chest physiotherapy helps remove sticky secretions that cause ineffective airway clearance. o Aerobic exercise is beneficial to promote removal of airway secretions, improve muscle strength, and increase lung capacity . o Financial needs must be discussed, as clients with CF have a large financial burden due to health care costs, medications, and special equipment. o A diet high in fat and calories is recommended due to defective digestive enzymes and impaired nutrient absorption. o Fluids are not restricted; liberal intake is recommended to assist in thinning respiratory secretions.

Effects of positioning in a pt with pneumonia

1) Affected lung positioned upward: gravity increase blood flow to unaffected lung, leading to adequate gas exchange 2) affected lung positioned downward: Gravity increase blood flow to affected lung but pneumonia causes decrease gas exchange; Good ventilation to the unaffected lung but decrease blood supply Side-lying positioning is utilized in hypoxic clients with unilateral pneumonia to increase perfusion to the healthy lung by gravity and improve oxygenation by positioning the client with the unaffected (good) side down. However, side-lying position alone does not improve secretion clearance

How to use peak flow meter?

1) Before each use, slide the indicator on the numbered scale on the flow meter to 0 (or the lowest value), and stand or sit as upright as possible 2) Inhale deeply, place the mouthpiece in the mouth, and close the lips tightly around the mouthpiece to form a seal 3) Exhale as quickly and completely as possible and note the reading on the numbered scale 4) Repeat the procedure 2 more times, with a 5- to 10-second rest period between exhalations 5) Record the highest reading (ie, personal best) in the peak flow log When performing peak flow measurements, set the indicator to the lowest value; assume an upright position; inhale deeply; place the mouthpiece in the mouth and form a seal with the lips; exhale quickly and completely; note the value; repeat 2 more times; and then record the highest value in the peak flow log.

Active TB priority

1) Droplet precaution (N95) 2) negative air room 3) pt has to wear mask if leaving room

pursed lip breathing steps

1) Relax the neck and shoulders 2) Inhale for 2 seconds through the nose with the mouth closed 3) Exhale for 4 seconds through pursed lips. If unable to exhale for this long, exhale twice as long as inhaling The pursed-lip breathing technique helps to decrease shortness of breath by preventing airway collapse, promoting carbon dioxide elimination, and reducing air trapping in clients with chronic obstructive pulmonary disease. Clients are taught to relax the shoulders and neck, inhale through the nose for 2 seconds with the mouth closed, and exhale through pursed lips for 4 seconds (or twice as long as inhalation).

Can nurse change the suction level in chest tube w/o prescription?

A change in suction level should be performed only after obtaining a health care provider (HCP) prescription. The nurse should perform the assessment of breath sounds, coughing and deep breathing, and client repositioning before notifying the HCP about a change in suction level. In general, suction above 20 cm H2O is not indicated.

thoracentesis

:Used to obtain specimen of pleural fluid for diagnosis, remove pleural fluid, or instill medication. Chest x-ray is always obtained after procedure to check for pneumothorax. Before: Explain procedure to patient and obtain signed consent before procedure. During: Usually performed in patient's room. Position patient upright with elbows on an overbed table and feet supported. Instruct patient not to talk or cough during procedure. After: Observe for signs of hypoxia and pneumothorax, and verify breath sounds in all fields. Encourage deep breaths to expand lungs.

acute sinusitis

<4 weeks. Viral client with epistaxis (ie, nosebleed) that does not resolve with external pressure will require further hemostatic interventions, such as cauterization or nasal packing (eg, gauze, nasal tampon, balloon catheter). This client should be assessed after the client with signs of impending airway obstruction.

tension pneumothorax

A life-threatening collection of air within the pleural space; the volume and pressure have both collasped the involved lung and caused a shift of the mediastinal structures to the opposite side. air enter the pleural space and cannot escape and this extra air pressure press against the lung and cause it to collapse. The air also push the trachea to the opposite side. If someone has chest tube and the nurse clamp it for a long period of time, it can cause tension pnemothroax to occur. And, if someone is doing CPR and provide too much ventilation it can cause a tension pneumothroax. The treatment is an medical emergency, they have to inset a needle to decompress it, the air pressure from that affected side and then they need to insert a chest tube. Symptoms: cyanosis, air hunger, extreme agitation, trachea would be deviated, subcataneous emphysema when you palpate the skin, the side that is affected, the skin will crackle, neck vein extension on that side

peak flow meter

A peak flow meter is a handheld device that measures the client's ability to push air out of the lungs. Measurements from a peak flow meter often guide the client's use of respiratory medications and the need to schedule an appointment with a health care provider.

Thoracentesis indication and complication

A thoracentesis involves the insertion of a large-bore needle through an intercostal space to remove excess fluid. The procedure has the following advantages: 1) Diagnostic - analysis of fluid to diagnose the underlying cause of the pleural effusion (eg, infection, malignancy, heart failure), including cytology, bacterial culture, and related testing 2) Therapeutic - removal of excess fluid (>1 L) improves dyspnea and client comfort Complications from insertion of the needle and removal of large amounts of fluid include iatrogenic pneumothorax, hemothorax, pulmonary edema, and infection. After the procedure, the nurse assesses for pain and difficulty breathing; monitors vital signs and oxygen saturation; and observes for changes in respiratory rate and depth, symmetry of chest expansion, and breath sounds. If any abnormalities are noted, a post-procedure chest x-ray is obtained. Decreased chest expansion with inspiration and breath sounds on the affected side, tachypnea, tracheal deviation to the opposite side, and hyperresonance (air) on the affected side are manifestations of a pneumothorax. These should be reported immediately.

ARF ABG values

ABG values that indicate the presence of ARF are PaO2 ≤60 mm Hg (8.0 kPa) or PaCO2 ≥50 mm Hg (6.67 kPa).

Acute Respiratory Failure Def

ARF is defined as inadequate gas exchange that is intrapulmonary (pneumonia, pulmonary embolism) or extrapulmonary (head injury, opioid overdose) in origin. -Respiratory failure associated with an alteration in O2 transfer or absorption is type I hypoxemic failure (eg, acute respiratory distress syndrome, pulmonary edema, shock). -Respiratory failure associated with carbon dioxide (CO2) retention is type II hypercapnic, or ventilatory failure (eg, chronic obstructive pulmonary disease, myasthenia gravis, flail chest).

acute pancreatitis complications

Acute respiratory distress syndrome

Does kids with CF encourages to do Aerobic exercise?

Aerobic exercise is beneficial to promote removal of airway secretions, improve muscle strength, and increase lung capacity

bronchoscopy

An endoscopic bronchoscopy is a procedure in which the bronchi are visualized with a flexible fiberoptic bronchoscope that is passed down through the nose (or through the mouth, or endotracheal or tracheostomy tube). The client receives mild sedation (eg, midazolam) to provide relaxation and promote comfort. A topical anesthetic (eg, lidocaine, benzocaine) is applied to the nares and throat to suppress the gag and cough reflexes, prevent laryngospasm, and facilitate passage of the scope. The procedure is done to diagnose, obtain tissue samples for biopsy, lavage, and to remove secretions (mucus plugs), foreign objects, or abnormal tissue with a laser. Blood-tinged sputum is common and can occur from inflammation of the airway, but hemoptysis of bright red blood can indicate hemorrhage, especially if a biopsy was performed.

Pneumonia

An inflammation of lung tissue, wherer the alveoli in the affected areas fill w/fluid 1. Infection of the pulmonary tissue, including the interstitial spaces, the alveoli, and the bronchioles. 2. The edema associated with inflammation stiffens the lung, decreases lung compliance and vital capacity, and causes hypoxemia. 3. Pneumonia can be community-acquired or hospital-acquired. 4. The chest x-ray film shows lobar or segmental consolidation, pulmonary infiltrates, or pleural effusions. 5. A sputum culture identifies the organism. 6. The white blood cell count and the erythrocyte sedimentation rate are elevated.

Lung sounds

Bronchial - Tracheal area - Loud high pitch Bronchovesicular - Anterior 1-2nd intercostal space - Posterior between scapula - Medium pitch Vesicular - Peripheral lung fields - Pitch soft & low - Inspiration sound louder than expiration

Ronchi (sonorus wheeza)

Bronchitis Bronchitis is inflammation of the upper airways (bronchi) often precipitated by a viral infection. Rhonchi (ie, sonorous wheeze) are continuous, low-pitched adventitious breath sounds that occur when thick secretions or foreign bodies (eg, tumors) obstruct airflow in the upper airways. The resulting sound resembles moaning or snoring and is heard primarily during expiration but may also be present during inspiration. Rhonchi are commonly heard in bronchitis, cystic fibrosis, or some types of pneumonia, and may clear with coughing or suctioning

COPD and polycythemia

COPD may lead to polycythemia (increased red blood cells), in which the body attempts to compensate for chronic hypoxia by increased proliferation of erythrocytes. This occurs when erythropoietin is released from the kidneys in response to hypoxemia and leads to erythropoiesis. This ultimately has the opposite effect of anemia, making supplementation with iron not necessary and possibly even harmful.

Positive with no symptoms of TB

CXR to do done

Why COPD pt need to get influenza and pneumococcal vaccines?

Clients with COPD are at increased risk for respiratory infections, which can trigger an acute exacerbation of COPD. Therefore, it is vital that clients receive both routine influenza and pneumococcal vaccinations

Who will you see first? 1) "Client with right-sided pleural effusion who has decreased breath sounds at the right lung base" 2) "Client with severe acute pancreatitis who has inspiratory crackles at the lung bases"

Clients with acute pancreatitis can develop respiratory complications including pleural effusions, atelectasis, and acute respiratory distress syndrome (ARDS). These complications are often due to activated pancreatic enzymes and cytokines that are released from the pancreas into the circulation and cause focal or systemic inflammation. ARDS is the most severe form of these complications and can rapidly progress to respiratory failure within a few hours. Therefore, the presence of inspiratory crackles in this client could indicate early ARDS and needs to be assessed further for progression --The lung under the pleural effusion is compressed, and the breath sounds are decreased/absent if auscultated over the area; this is an expected finding. Until the pleural effusion is treated with diuretics or thoracentesis, these findings will remain unchanged.

Peritonsillar abscess

Collection of pus or fluid around the tonsil Major complication: Airway obstruction Peritonsillar, or retropharyngeal, abscess is a serious complication that can result from tonsillitis or pharyngitis. The presenting features of peritonsillar abscess, in addition to fever, include a "hot potato" (muffled) voice, trismus (inability to open the mouth), pooling of saliva (drooling), and deviation of the uvula to one side. The abscess can progress to life-threatening airway obstruction (eg, dysphagia, stridor, restlessness). The nurse should immediately assess the client with symptoms of peritonsillar abscess and monitor for signs of airway obstruction

Common symptom of obstructive sleep apnea

Common symptoms include frequent periods of sleep disturbance, snoring, morning headache, daytime sleepiness, difficulty concentrating, forgetfulness, mood changes, and depression.

Discharge instructions for client with pneumonia

Discharge instructions for a client recovering from pneumonia focus on proper medication regimen, lung expansion and coughing techniques, activity level, hydration, nutrition, avoidance of tobacco products, reportable manifestations (eg, respiratory distress, chest pain, fever, cough, change in mucus), follow-up care, influenza and pneumonia vaccinations, and respiratory and hand hygiene o Avoid the use of over-the-counter cough suppressant medicines. Unless prescribed by the HCP, cough suppressants are avoided as they impair secretion clearance, especially in clients with chronic bronchitis. o Schedule a follow-up with the HCP and chest x-ray. Follow-up is needed at about 2 weeks after completion of antibiotic therapy. X-ray may be needed at a later time in certain high-risk clients to make sure the pneumonia is resolved with no underlying cancer. o Use a cool mist humidifier in your bedroom at night. Humidifiers keep mucus membranes moist, maintain effectiveness of the mucociliary escalator, and facilitate expectoration of mucus. A warm bath also loosens the secretions. o Continue using the incentive spirometer at home. Deep breathing and coughing promote lung expansion, ventilation, oxygenation, and airway clearance. o Drink 1-2 liters of water a day, if not contraindicated, to help thin secretions and facilitate mobilization. Limit caffeine and alcohol as they can dry mucus membranes due to diuretic effects. o Notify the HCP of any increase in symptoms (eg, shortness of breath, cough, sputum production, chest pain, fever, confusion). o Avoid all tobacco products and second-hand smoke as these irritate the airways and impair mucociliary clearance and oxygenation. o Eat a balanced diet, increase activity slowly over about 2 weeks, and take rest periods when needed to help maintain resistance to infection. o After a client has IV antibiotic therapy, completing a full course of oral antibiotic therapy is necessary to prevent reoccurrence of disease and antibiotic resistance. o Contracting pneumonia does not provide lifelong immunity to the disease. Yearly influenza vaccination and pneumonia vaccination as directed by the HCP are recommended

T or F Athlete with asthma needs to avoid physical activity.

F Although physical activity is an asthma trigger, athletes with asthma do not need to avoid activity altogether. Rather, they may take an inhaled bronchodilator 20 minutes before activity to help prevent exercise-induced asthma attacks. In addition, this client may be prone to minor musculoskeletal injuries (eg, sprains, strains) due to an active lifestyle; the nurse should teach about alternatives to common over-the-counter nonsteroidal anti-inflammatory medications that may be used for analgesia (eg, acetaminophen [Tylenol]).

hypercapnia respiratory failure

Failure: Inadequate alveolar ventilation Treatment: Give ventilatory support An elevated carbon dioxide (CO2) level (normal: 35-45 mm Hg [4.7-6.0 kPa]) is usually an indicator of hypercapneic respiratory failure. The bilevel positive airway pressure (BIPAP) machine will provide positive pressure oxygen and expel CO2 from the lungs. This client is already showing signs of lethargy and confusion, which is usually a late indicator of respiratory decline. Therefore, the nurse's priority should be to get the client on the BIPAP machine as soon as possible. BIPAP therapy is an effective treatment to decrease CO2 levels in clients with hypercapnic respiratory failure.

Refractory hypoxemia

Hallmark condition in ARDS where flooded airspaces allow no inspired gas to enter, so the blood perfusing those alveoli remains at the mixed venous O2 content no matter how high the fractional inspired O2 (Fio2). Refractory hypoxemia is the hallmark of acute respiratory distress syndrome (ARDS), a progressive form of acute respiratory failure that has a high mortality rate. o Causes: It can develop following a pulmonary insult (eg, aspiration, pneumonia, toxic inhalation) or nonpulmonary insult (eg, sepsis, multiple blood transfusions, trauma) to the lung. The insult triggers a massive inflammatory response that causes the lung tissue to release inflammatory mediators (leukotrienes, proteases) that cause damage to the alveolar-capillary (A-C) membrane. As a result of the damage, the A-C membrane becomes more permeable, and intravascular fluid then leaks into the alveolar space, resulting in a noncardiogenic pulmonary edema. o The lungs become stiff and noncompliant, which makes ventilation and oxygenation less than optimal and results in increased work of breathing, tachypnea and alkalosis, atelectasis, and refractory hypoxemia. o Profound hypoxemia despite high concentrations of oxygen is a key sign of ARDS and is the most important assessment finding to report to the HCP.

what is milking chest tube?

Milking chest tubes to maintain patency is performed only if prescribed. It is generally contraindicated due to potential tissue damage from highly increased pressure changes in the pleural space.

Iatrogenic pneumothorax

Iatrogenic pneumothorax can occur due to laceration or puncture of the lung during medical procedures. For example, 1) transthoracic needle aspiration, 2)subclavian catheter insertion, 3)pleural biopsy, and 4) transbronchial lung biopsy all have the potential to injure the lung. 4)Barotrauma 氣壓傷from excessive ventilatory pressure during manual or mechanical ventilation can rupture alveoli or bronchioles. 5) Esophageal procedures may also be involved in the development of a pneumothorax. Tearing during insertion of a gastric tube can allow air from the esophagus to enter the mediastinum and pleural space.

ARDS priotity nursing diagnosis

Impaired gas exchange ARDS involves damage to the alveolar-capillary membrane, resulting in fluid leakage into the alveolar space. Impaired gas exchange related to alveolar-capillary changes and ventilation-perfusion imbalance is an appropriate ND for a client with ARDS.

What is cystic fibrosis?

It is a genetic disorder of the cell membranes. Causes thick, sticky mucus to build up in air passages and pancreas. Cystic fibrosis (CF) is a genetic disorder involving the cells lining the respiratory, gastrointestinal (GI), and reproductive tracts. A defective protein responsible for transporting sodium and chloride causes secretions in these areas to be thicker and stickier than normal.

trach suctioning complications and its associated care

Neer apply suction when inserting the catheter into the airway Risks associated with suctioning include 1) hypoxemia, 2) microatelectasis, and 3) cardiac dysrhythmias. Suctioning removes secretions and oxygen. To minimize both the amount of oxygen removed and mucosal trauma, suction is applied when removing, not inserting, the catheter into the artificial airway. If secretions are thick and difficult to remove, increasing hydration, not suctioning time, is indicated. Aerosols of sterile normal saline or mucolytics such as acetylcysteine (Mucomyst) administered by nebulizer can also be used to thin the thick secretions, but water should not be used. Aerosol therapy may induce bronchospasm in certain individuals and can be relieved by use of a bronchodilator (albuterol).

Pa O2 & SaO2

Pa O2: amount of O2 dissolved in plasma Sa O2: amt of O2 bound to hemoglobin

The nurse is providing care for a client with cancer of the left lung who will undergo video-assisted thoracic surgery in the morning. The client is nervous, jumpy, and short of breath. Pulse is 120/min, respirations are 30/min and shallow, and expiratory wheezing is auscultated in the left upper and lower lung posteriorly. Which of the following is the priority nursing action?

Place HOB in Fowler's or high Fowler's position Elevating the head of the bed to Fowler's or high Fowler's position is the priority nursing action to help relieve shortness of breath, facilitate oxygenation (breathing), and promote lung expansion (airway). Alternate positions to high Fowler's include the following: o Orthopneic position: Sitting in a chair, on the side, or in bed leaning over the bedside table, with one or more pillows under the arms or elbows for support o Tripod position: Sitting in a chair leaning forward with hands or elbows resting on the knees. Sitting upright and leaning forward pulls the scapulae apart, promotes lung expansion, and decreases the diaphragmatic pressure produced by the viscera.

How is the alveoli in pt with pneumonia?

Pneumonia is an inflammatory reaction in the lungs, often due to infection, that causes alveoli to fill with cellular debris and thick, purulent exudate (ie, consolidation), which may cause impaired ventilation and oxygenation.

Latent tB

Positive PPD, negative CXR, no symptoms. Receive 9 months INH therapy -no TB transmission -no sputum needed to be collected

Pursed-lip breathing and Co2 trapping

Pursed-lip breathing prolongs exhalation and prevents airway collapse, which alleviates dyspnea relating to air trapping (eg, chronic obstructive pulmonary disease). However, it does not facilitate secretion removal.

SABA

Short-acting beta-2 agonist (albuterol) SABA (short acting bronchodilator agonist) short acting 2 times short acting should not be more than 2 times in a week. short acting 3 times in a day but 20 mins in between

T or F Aspirin can trigger asthma.

T

Why chest tube cannot be clamped?

Tension pneumothorax Clamping the chest tube prevents air or fluid from leaving the pleural space, which may cause a reciprocal tension pneumothorax. The chest tube is clamped only a few hours prior to removal, momentarily to check for an air leak, or if the drainage apparatus needs to be changed.

Fenestrated tube

Used when weaning a patient from a ventilator; allows the patient to speak

The nurse is caring for a client with advanced heart failure on an inpatient hospice unit. The client is having trouble breathing. Which comfort intervention should the nurse implement first?

The client with advanced heart failure on hospice is likely to have dyspnea associated with fluid overload. The first intervention should be to elevate the head of the bed and then assess for fluid overload, which would be treated with IV diuretics. Morphine can alleviate dyspnea associated with heart failure, but it should be used in combination with other nonpharmacologic and pharmacologic interventions.

CF and its associated complication

These abnormal secretions plug smaller airway passages and ducts in the GI tract, which can impair digestive enzymes and result in ineffective absorption of essential nutrients. These sticky respiratory secretions lead to a chronic cough and inability to clear the airway, eventually causing chronic lung disease (bronchiectasis). As a result of these changes, the client's life span is shortened; most affected individuals live only into their 30s.

Cuffed intubation tube

Tracheostomy tubes that are blocked and sealed by what is called a cuff . The cuff blocks any air from flowing around the tube and assures that the patient is well oxygenated. All the air must therefore flow in and out through the tube itself. A pilot tube attached to the cuff stays outside the body and is used to inflate or deflate the cuff. used when pt is on ventilator - Keeps trach in place - Inflate 20-25 cm

Influenza virus

Transmission: airborne droplet, direct contact Onset: 1-4 days Duration: 5-7 days SXS: chills, fever, myalgia, headache, cough, sore throat, fatigue; some dyspneic (crackle in lung) Complications: secondary bacterial pneumonia, bronchitis, dehydration

Cuffless tube

Used for long-term management of patients not on mechanical ventilation or at high risk for aspiration -allow air to pass through the vocal cord from lung so pt can talk

pulmonary edema

accumulation of fluid in the lungs Pulmonary edema is an abnormal accumulation of fluid in the alveoli and interstitial spaces of the lungs. It is a complication of various heart and lung diseases The most common cause of pulmonary edema is left-sided heart failure. overhydration of IV fluid, lack of albumin in the capillary, Hypoalbuminemia:

Croup

an acute respiratory syndrome in children and infants characterized by obstruction of the larynx, hoarseness, and a barking cough -Stridor

Pleurisy

an inflammation of the pleura that produces sharp chest pain with each breath -Pleurisy manifests with pleural friction rub, a loud, rough rubbing or grating sound heard throughout inspiration and expiration that is caused by the pleural surfaces rubbing together. Pleural friction rub sounds similar to crackles, but crackles are typically heard only during inspiration

Which diagnostic tests can best evaluate the client's oxygenation and ventilation status?

arterial blood gases Arterial blood gas (ABG) assessment parameters provide objective data about the efficiency of gas exchange in the lungs and effectively evaluate the following: 1) Acid-base balance (pH, HCO3) 2) Oxygenation status (PaO2, partial pressure of oxygen in the arterial blood) 3) Tissue oxygenation (SaO2, percentage of available hemoglobin saturated with oxygen) 4) Ventilation (PaCO2, partial pressure of carbon dioxide in the arterial blood) Respiratory failure can occur when oxygenation is inadequate (hypoxemic failure) and/or when ventilation is inadequate (hypercapnic failure). The adequacy of oxygenation and ventilation in a client with respiratory failure is best evaluated through ABG analysis.

The nurse cares for a client who returns from the operating room after a tracheostomy tube placement procedure. Which of the following is the nurse's priority when caring for a client with a new tracheostomy?

checking the tightness of ties and adjusting if necessary, allowing 1 finger to fit under these ties The immediate postoperative priority goal for a client with a new tracheostomy is to prevent accidental dislodgement of the tube and loss of the airway. If dislodgement occurs during the first postoperative week, reinsertion of the tube is difficult as it takes the tract about 1 week to heal. For this reason, dislodgement is a medical emergency. The priority nursing action is to ensure the tube is placed securely by checking the tightness of ties and allowing for 1 finger to fit under these ties.

Pneumonia in older/debilitated pt S/S

confusion, stupor, hypothermia, diaphoresis, anorexia, fatigue, mualgia, headache The older or debilitated patient may not have classic symptoms of pneumonia. Confusion or stupor (possibly related to hypoxia) may be the only finding. Hypothermia, rather than fever, may also be noted with the older patient. Nonspecific clinical manifestations include diaphoresis, anorexia, fatigue, myalgias, and headache.

Active TB

cough, fever, chills, wt loss, anorexia, fatigue, TB can be transmitted, abnormal CXR, positive sputum culture

priority for open chest trauma "open" oneumothorax

cover the wound with petroleum gauze taped on three sides In a traumatic, or "open," pneumothorax, air rushes in through the wound with each inspiration, creating a sucking sound, and fills the pleural space. The lungs cannot expand, so the client develops respiratory distress and air hunger. Tachycardia and hypotension result from impaired venous return, as the heart and great vessels shift with each breath. A tension pneumothorax may also develop if air cannot escape the pleural space. The priority action in this medical emergency is to apply a sterile occlusive dressing (eg, petroleum gauze) taped on three sides, preventing inward air flow while allowing air to escape the pleural space

The nurse assesses a client with a history of cystic fibrosis who is being admitted with a pulmonary exacerbation. Which assessment finding would require immediate action?

current pulse oximetry reading is 90% on room air When addressing the multiple needs of a client with cystic fibrosis, airway and oxygen saturation are the priorities. Pneumothorax can be a complication of cystic fibrosis. In cystic fibrosis (CF), a defective protein responsible for transporting sodium and chloride causes the secretions from the exocrine glands to be thicker and stickier than normal. The sticky respiratory secretions lead to the inability to clear the airway and a chronic cough. The client eventually develops chronic lung disease (bronchiectasis) and is at risk for recurrent lung infections. These clients are also at risk for rupture of the damaged alveoli, which results in sudden-onset pneumothorax. Findings of pneumothorax include sudden worsening of dyspnea, tachypnea, tachycardia, and a drop in oxygen saturation. Because many of these findings can be seen with lung infection, a sudden drop in oxygen saturation could be the only early clue. The client with CF will often have a decreased pulse oximetry (reflects oxygen saturation in the blood) reading due to the chronicity of the disease process and damage to the lungs; however, a reading of 90% requires urgent intervention.

fine crackles

high-pitched, discrete, discontinuous crackling sounds heard during the end of inspiration; not cleared by a cough o Fine crackles are a series of distinct, discontinuous, and high-pitched snapping sounds usually heard on inspiration. o The sound originates as small atelectatic bronchioles quickly reinflate and can be expected in clients who have undergone abdominal surgery due to shallow breathing related to pain. o Although the presence of fine crackles requires treatment (eg, ambulation, deep breathing), this is not the priority assessment.

A student nurse initiates oxygen with a nonrebreather mask for a client with acute respiratory distress. While reassessing the client, the RN notices the reservoir bag is fully deflating on inspiration. What immediate action does the RN take to correct the problem?

increase the O2 flow A nonrebreather mask is an oxygen delivery device used in a medical emergency. It consists of a face mask with an attached reservoir bag and a one-way valve between the bag and mask that prevents exhaled air from entering the bag and diluting the oxygen concentration. The liter flow must be high enough (up to 15 L/min) to keep the reservoir bag at least 2/3 inflated during inhalation and to prevent the buildup of carbon dioxide in the bag.

acute bronchitis

infection and inflammation of bronchial airways -crackles, expiratory wheeze -CXR clear -No abx -if cause by influenza virus, then tamiflu or Relenza -Hallmark: coughing up to 3 wks

Tuberculosis (TB)

infectious disease caused by Mycobacterium tuberculosis; lungs usually are involved, but any organ in the body may be affected

Tuberculosis (TB) skin tests

intradermal test (e.g. Mantoux test) using purified protein derivative (PPD) to test for either dormant or active TB; much more accurate test than the multiple puncture tine test, which has been used for screening purposes -skin is assessed 48-72 hrs post administration of TB -negative: redness w/o induration -Positive 1) >15mm in healthy individual 2) >10 mm in immunocompromised pts (children under 4, IV drug users, recent immigrant from high prevalence TB country, homless) 3) >5mm: HIV, organ transplant pt, recent contact with TB pt

ventilator associated pneumonia

lower respiratory tract infection that develops more than 48 to 72 hours after endotracheal intubation Because it is a nosocomial infection, signs and symptoms associated with VAP usually present within ≥2-3 days after initiation of mechanical ventilation (MV). o Characteristic clinical manifestations of VAP include purulent sputum, positive sputum culture, leukocytosis (12,000 mm3), elevated temperature (>100.4 F [38 C]), and new or progressive pulmonary infiltrates suggestive of pneumonia on chest x-ray.

Common asthma triggers include:

o Allergens: Dander (eg, cat, dog), dust mites, pollen o Drugs: Beta blockers; nonsteroidal anti-inflammatory agents, including aspirin o Environmental: Chemicals, sawdust, soaps/detergents o Infectious: Upper respiratory infections o Intrinsic: Emotional stress, gastrointestinal reflux disease o Irritants: Aerosols/perfumes, cigarette smoke (including secondhand smoke), dry/polluted air

Tonsillectomy Discharge Teaching

o Avoid coughing, clearing the throat, or blowing of the nose o Limit physical activity o Milk products are discouraged due to their coating effect, which can prompt clearing of the throat o Oral mouth rinses, gargling, and vigorous tooth brushing should be avoided to prevent irritation o The presence of slight ear pain, a low-grade fever, and objectionable mouth odor are common findings during the first 5-10 days after the procedure. Persistent moderate-to-severe earache, fever, or cough requires further evaluation.

Postop Tracheostomy

o Changing of the inner cannula and tracheostomy ties is not usually performed until 24 hours after insertion; this is due to the risk of dislodgement with an immature tract. However, the dressing can be changed if it becomes wet or soiled. Suctioning can be performed to remove mucus and maintain the airway. o The cuff is kept inflated to prevent aspiration from secretions and postoperative bleeding. Cuffs are not regularly deflated and re-inflated. The respiratory therapist should monitor the amount of air in the cuff several times a day to prevent excessive pressure and mucosal tissue damage. o Frequent mouth care to help prevent stomal and pulmonary infection is important in a client with an artificial airway, but it is not the priority action immediately following tracheostomy. o Educational objective: The immediate postoperative priority goal for a client with a newly placed tracheostomy is to prevent accidental dislodgement of the tube and loss of the airway.

obstructive sleep apnea NURING INTERVENTION

o Continuous positive airway pressure device at night to keep the structures of the pharynx and tongue from collapsing backward o Limiting alcohol intake at bedtime as it can cause muscles of the oral airway to relax and lead to airway obstruction o Weight loss and exercise can reduce snoring and sleep apnea-associated airway obstruction. Obesity contributes to the development of OSA o Avoiding sedating medications (eg, benzodiazepines, sedating antidepressants, antihistamines, opiates) as they may exacerbate OSA and worsen daytime sleepiness o Eating before bedtime can interfere with sleep and contribute to excess weight. o Sedatives at bedtime can relax the muscles of the oral airway and lead to airway obstruction. (Option 5) Stimulants such as modafinil may be prescribed for daytime sleepiness but should be avoided at bedtime as they can cause insomnia. o Napping during the day can make it more difficult to sleep through the night

Chronic bronchitis is characterized by excessive mucus production, chronic cough, and recurrent respiratory tract infections. Interventions to help reduce viscosity of mucus, facilitate secretion removal, and promote comfort include the following:

o Increasing oral fluids to 2-3 L/day if not contraindicated prevents dehydration and keeps secretions thin o Cool mist humidifier increases room humidity of inspired air o Guaifenesin (Robitussin) is an expectorant that reduces the viscosity of thick secretions by increasing respiratory tract fluid; drinking a full glass of water after taking the medication is recommended. o Abdominal breathing with the huff, a forced expiratory cough technique, is effective in mobilizing secretions into the large airways so that they can be expectorated Chest physiotherapy (postural drainage, percussion, vibration) o Airway clearance handheld devices, which use the principle of positive expiratory pressure to help loosen secretions when the client exhales through the mouthpiece

bronchoscopy post procedure

o Maintain the client in a semi-Fowler'sposition. o Assess for the return of the gag reflex. o Maintain NPO status until the gag reflex returns. o Monitor for bloody sputum. o Monitor respiratory status, particularly if sedation has been administered. o Monitor for complications, such as ronchospasm or bronchial perforation, indicated by facial or neck crepitus, dysrhythmias, hemorrhage, hypoxemia, and pneumothorax. Immediately post bronchoscopy, the nurse monitors for associated potential complications, including hemoptysis, hypoxemia, hypercarbia, hypotension, laryngospasm, bradycardia, pneumothorax, and adverse effects from medications used before and during the procedure.

Clinical manifestations indicating impending respiratory failure include:

o PaCO2 ≥45 mm Hg (6.0 kPa): Indicates hypercapnia and hypoventilation resulting from fatigue and labored breathing. As initial tachypnea subsides and respiratory rate returns to normal, PaCO2 rises and respiratory acidosis develops o PaO2 ≤60 mm Hg (8.0 kPa): Indicates hypoxemia resulting from increased work of breathing, decreased gas exchange (hyperinflation and air trapping), and inability of the lungs to meet the body's oxygen demand o Paradoxical breathing (ie, abnormal inward movement of the chest on inspiration and outward movement on expiration): Indicates diaphragm muscle fatigue and use of respiratory accessory muscles o Mental status changes (eg, restlessness, confusion, lethargy, drowsiness): Sensitive indicators of hypoxemia and hypoxia o Absence of wheezing and silent chest (ie, no sound of air movement on auscultation): Ominous signs indicating severe hyperinflation and air trapping in the lungs o Single-word dyspnea: Inability to speak >1 word before pausing to breathe due to shortness of breath

Non-rebreather mask

o Ports (exhalation valves) are located on each side of the mask and are covered with rubber discs that act as flutter valves. The valves close on inhalation to prevent entry of room air and open on exhalation to prevent reinhalation of exhaled air. The ports should be occluded when initiating the device to fill the reservoir with oxygen. o The nonrebreather mask can deliver high concentrations of oxygen if the mask is secured tightly to the face with the head strap to minimize leaks. Tightness of the mask does not affect the filling or deflating of the reservoir bag. o A nonrebreather mask is an oxygen delivery device used in a medical emergency. It can deliver up to 95%-100% oxygen concentration if properly maintained during use. Proper care of the device includes monitoring the reservoir bag to assure continual inflation during inhalation; monitoring the 2 exhalation (flutter) valves that cover the ports on each side of the mask; and keeping the mask secured to the face by adjusting the tightness of the head strap to minimize leaks

Risk factors for developing pneumonia

o advanced age (>65)--coexisting disease, decreased gas & cough reflex, decreased immune response and lung function o young age (<2)...immature immune system o Central nervous system depression o decrease LOC.....aspiration of oropharyngeal contents, decrease cough and epoglottal reflexes o chronic disease o immunosuppresion o inadequate nutrition o prolonged immobility o smoking & air pollution o upper respiratory tract infectin o tracheal intubation

Passy Muir Valve

one way valve attached to a trachestomy tube that allows for vocalization

The nurse receives an obese client in the postanesthesia care unit who underwent a procedure under general anesthesia. The nurse notes an oxygen saturation of 88%. Which is the most appropriate initial intervention?

perform head tilt and chin tilt Head tilt and chin lift is a maneuver used to open the airway. The tongue may fall back and occlude the airway due to muscular flaccidity after general anesthesia. Manifestations associated with airway obstruction include snoring, use of accessory muscles, decreased oxygen saturations, and cyanosis.

obstructive sleep apnea (OSA)

repetitive pharyngeal collapse during sleep, which leads to absence of breathing; can produce daytime drowsiness and elevated blood pressure Obstructive sleep apnea (OSA) is characterized by partial or complete airway obstruction during sleep that occurs from relaxation of the pharyngeal muscles. The result is repeated episodes of apnea (≥10 seconds) and hypopnea (≤50% normal ventilation), which cause hypoxemia and hypercarbia.

Rib fracture

sharp stabbing pleuritic CP, made worse by inspiration may have an abrasion or contusion (seatbelt) patient will attempt the splint his own arm may be hypoventilating due to pain Rib fractures are often the result of blunt thoracic trauma (eg, motor vehicle collision). In the absence of significant internal injuries (eg, pneumothorax, pulmonary contusion, spleen laceration), interventions focus on pain management and pulmonary hygiene techniques (eg, coughing, deep breathing, incentive spirometry). Breaths may become shallow as the client experiences pain with inspiration, which can result in a buildup of secretions, atelectasis, and pneumonia. The nurse should ensure adequate pain control prior to encouraging pulmonary hygiene techniques

TB skin test positive with symptoms

sputum culture to be collected

Splinting the incision

supporting incision decrease suture stress and pain and increase cough effectiveness

tracheostomy

surgical creation of an opening into the trachea through the neck

tonsillectomy

the surgical removal of the tonsils. Tonsillectomy is usually performed as an outpatient procedure. Postoperative bleeding is an uncommon but important complication and it can last up to 2 weeks. It manifests with frequent or continuous swallowing and/or cough from the trickling blood; some clients may also develop restlessness Postoperative bleeding after a tonsillectomy is uncommon but can last up to 14 days after surgery. Continuous swallowing, restlessness, and frequent coughing are early indicators of bleeding. To prevent hemorrhage, the client should avoid clearing the throat, blowing the nose, and coughing.

ARF

the thorax and abdomen surgery ARF is a potential complication of major surgical procedures, especially those involving the thorax and abdomen, as in this client. ABG values that indicate the presence of ARF are PaO2 ≤60 mm Hg (8.0 kPa) or PaCO2 ≥50 mm Hg (6.67 kPa). ARF occurs quickly over time (minutes to hours), and so there is no physiologic compensation and pH is ≤7.30. Immediate intervention with high O2 concentrations is indicated, and noninvasive or invasive, positive-pressure mechanical ventilation may be necessary.

Ronchi

too much mucus on bronchi

acute otitis media

usually associated with an upper respiratory infection and is most commonly seen in young children infection of middle ear Acute otitis media (ie, infection of the middle ear) may develop secondary to rhinitis (eg, common cold, seasonal allergies) due to inflammation of the Eustachian tube. This client with otitis media will likely require antibiotics and pain management but is not the priority.

Short term asthma medications

• Bronchodilators - Albuterol (proventil), ipratropium (atrovent HFA) • Anti-inflammatory - Corticosteroids (prednisone)

Long term Asthma Medications

• Bronchodilators - Β 2 agonists [salmeterol (serevent diskus)] - Β 2 agonist & steroid [advair, dulera, symbicort] - Anticholinergic [ipratropium (atrovent & albuterol), tiotropium(spiriva)] - Theophylline • Anti-inflammatory - Corticosteroids [flovent, prednisone, montelukast (singular)]

pertusis (whooping cough)

• Caused by Bordetella pertussis - aerobic Gr- coccobacili • Bacteria affect the ciliated escalator system (prevent the movement of mucus) - mucus accumulates in trachea • Infants can suffer from the brain damage caused by severe coughing • Transmitted by droplets • Treatment: Combination antibiotic therapy • Vaccine is available - DTap (young childre <6); Tdap: adult -Tdap tetanus, diphteria, pertussis -TX: The primary treatment for pertussis is antibiotics, usually macrolides (erythromycin, azithromycin [Zithromax]), to minimize symptoms and prevent spread of the disease. The patient is infectious from the beginning of the catarrhal stage through the third week after onset of symptoms or until 5 days after antibiotic therapy has been initiated. Cough suppressants and antihistamines should not be used, since they are ineffective and may induce coughing episodes. Corticosteroids and bronchodilators are also not useful.

influenza (flu)

• Flu season September to April • Type A, B, C • Type A most common - affects animals, human - Can cause worldwide pandemic • Type B & C - affects humans - Mild flu