Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Metropolitan Community College Fall 2013 Jane Miller, RN MSN Objectives Identify patients at risk for pulmonary embolism (PE) Identify clinical manifestations of pulmonary embolism Identify diagnostic tools for determination of pulmonary embolism Identify treatment of pulmonary embolism to include oxygenation, nonsurgical management, surgical management, and nursing interventions Identify intervention for prevention of pulmonary embolism Identify patient education necessary for management of pulmonary embolism Identify pathophysiology and causes of acute respiratory failure. Define pathophysiology and causes of acute respiratory distress syndrome (ARDS) Identify clinical manifestations, diagnostic assessment, and interventions for patients with ARDS Identify the patient who requires intubation and mechanical ventilation Identify procedure for endotracheal intubation including indications for, verifying tube placement, and nursing care Define goals of mechanical ventilation, including types of, controls and settings, and care of the patient to prevent complications Define the weaning process from the ventilator to extubation Identify pathophysiology, clinical manifestations, diagnostic tests, and interventions for pneumonia, tuberculosis, lung abcess, emphysema, cystic fibrosis, pulmonary hypertension, pulmonary edema Pulmonary System Risk Factors Smoking Pack year = twenty cigarettes smoked every day for one year Inactivity DVT & PE Cardiovascular disease Obesity Sleep apnea Substance abuse Pneumonia, CNS depression, PE Trauma Burns, spinal cord injury, brain injury, blunt and penetrating chest injuries Occupation Construction, farmers, firemen, janitors Culture Testing & treatment Environment Work & home Hand and oral hygiene Nutrition Travel and area of residence SARS, TB Adventitious Breath Sounds Crackles (Rales) Caused by fluid, inflammation, infection, or secretions Pneumonia, bronchitis, CHF, pulmonary edema, fibrosis Fine or course “popping” sound, nonmusical, discontinuous Lounder during inspiration Wheezes (Rhonchi) Caused by narrowing of the airway Bronchospasm, secretions, airway inflammation High-pitched musical sound, continuous Heard during inspiration and expiration equally Stridor Caused by an obstruction High-pitched crowing Heard only during inspiration Requires immediate intervention Pleural Friction Rub Caused by pleural inflammation Rubbing or grating sound, walking on fresh snow Heard during inspiration only http://www.easyauscultation.com/adventitious-breath-sounds.aspx Assessment Patient interview Complaint, symptoms, previous illness & hospitalizations, medications, allergies Physical exam General appearance Mentation Rate, depth, and rhythm of respirations Kussmaul’s: increased rate and depth Cheyne-Stokes: rapid breathing then apnea Thoracic size, shape, & expansion Skill color, temperature, moisture Gerontological Considerations Respiratory function decreases Skeletal changes from osteoporosis Rib cage becomes more rigid Anterior posterior diameter increases Alveolar surface decreases Lung tissue becomes less elastic Comorbidities Upper Airway Disorders Disorders of the head & neck Nasal and facial fractures Result of trauma Deformity, tenderness, edema, bleeding, crepitation, pain, difficulty talking or chewing, diplopia, CSF leak Diagnosed by clinical exam, x-ray, CT scan, CSF halo test Treatment includes rest, ice, head elevation, pain management, closed reduction, spliniting, ORIF, jaw wired shut Nursing Management Elevate HOB Apply ice Provide pain control Liquid diet high in protein and calories Treat N&V, especially if jaw wired shut Oral care Monitor patency of airway Watch for bleeding Educate on risks for nose bleeds Educate about no straining with CSF leak Inflammation & Infection of Nose & Paranasal Sinuses Rhinitis: inflammation of the nasal mucous membrane Sinusitis: inflammation of the paranasal and frontal sinuses Nasal obstruction Polyps Foreign bodies Nursing Management Administer allergy medications Educate regarding avoiding allergens or triggers, signs of allergic reaction, when to seek medical care Assist in foreign body removal Close other nostril, and gently blow through affected nostril Post operative monitoring is required Airway Obstruction Potentially a life threatening emergency Causes Inhalation burns Infection Allergic response Laryngeal trauma Tumor Aspiration Assess for stridor Nursing Management Type of obstruction determines nursing needs Assess their ability to talk Quick visual assessment Patient history if applicable Assess O2 sat & apply oxygen Heimlich maneuver IV Administer IV steroids, antibiotics Oral suctioning Intubation and tracheostomy equipment at the bedside Crash cart Tracheostomy Surgical placement of an artificial airway below the thyroid cartilage (Adam’s apple) Usually temporary but not always Used for Acute airway obstruction Intubation longer than 7-10 days Vigorous pulmonary hygiene Obstructive sleep apnea After Placement Sutured into place to prevent decannulation Also secured with ties The tube remains in place until the tracheal stoma is well established and won’t close back up A post tracheotomy kit is kept at bedside or on the nursing unit if accidental decannulation occurs An obturator is kept at bedside to assist in reinserting the tube if it comes out. TYPES OF TRACHEAL TUBES Made of silicone, plastic, stainless steel, or silver With or without a cuff Mechanical ventilation requires cuffed tubes to seal the airway to maintain pressures for ventilation Cuffed tubes decrease aspiration risk but do not eliminate it Inner cannulas prevent tube obstructions from thick crusted secretions Average adult size are 7 to 8 Shiley or Bivona are most common Assessing a New Trach Tube Auscultate the lungs Monitoring O2 sats Amount of blood in the sputum and around site Crepitis around the neck Respiratory distress Patency of tracheal tube Postoperative pulmonary edema (POPE) Tracheostomy Care Encourage cough and deep breathing Suction as necessary, but keep to a minimum Limit to 5-10 seconds with each pass Pre-oxygenate with 100% Oxygen when suctioning Insert catheter till patient starts to cough or meet slight resistance – do not use force Trach cares should be done every 8 to 12 hours with cleaning or changing the inner cannula Clean under and around the face plate Assess for skin breakdown Lower Airway Disorders Pneumonia Tuberculosis Lung abcess Emphysema Pulmonary embolism Acute respiratory failure Pulmonary edema Acute respiratory distress syndrome Pneumonia Inflammatory process that results in edema of the alveoli and bronchioles Risk factors Advanced age Compromised immune system Lung disease Alcoholism Altered LOC Smoking Intubation Malnutrition Immobility Pneumonia Causes Bacteria Viruses Fungi Protozoa Parasites Radiation therapy Aspiration Inhalation of toxic gases or chemicals Community Acquired Pneumonia Begins outside hospital or is diagnosed w/in 48 hours after admission Patient did not reside in a long-term facility prior to admission Bacterial or viral Incidence of CAP is highest in winter months Smoking an important risk factor Usually treated on an outpatient basis Hospital Acquired Pneumonia Occurs > 48 hours after hospital admission Mortality rate of 20% to 50% 90% of HAP infections are bacterial Compromised immune systems, chronic lung disease, intubation, and mechanical ventilation increase risk Clinical Manifestations Fever Chills Increased respiratory rate, >20 Increased heart rate, >100 Rusty bloody sputum Crackles X-ray abnormalities Chest discomfort Cough Fatigue, muscle aches, headache, nausea Nursing Management Administer antibiotics Fluoroquinolones - recommended Ex: Ciprofloxacin, Levofloxacin Start while still identifying the specific pathogen Maintain airway and O2 saturation above 93% Promote nutrition and hydration Provide small, frequent, high-carb, high-protein meals Elevate the head of bed Pain relief for chest discomfort Provide time for rest Discharge Priorities/Prevention Continue deep breathing and coughing exercises 4x/day, 6-8 weeks Signs and symptoms to report to health care provider Chills, fever, dyspnea, hemoptysis, fatigue Continue and complete antibiotic therapy as directed Continued rest with gradual increase in activity Proper nutrition and fluid intake Avoid others that are ill Pulmonary Tuberculosis Contagious bacterial infection Mycobacterium tuberculosis Transmitted via aerosolization Affects people with repeated close contact with an infected but undiagnosed person Opportunistic infections common with HIV/AIDS The newest form of TB is multidrug-resistant tuberculosis (MDRTB) Resistant TB is difficult and costly to treat and can be fatal Clinical Manifestations Dyspnea Weight loss Cough Sputum production, may be streaked with blood Sleep disturbances Lethargy, exhaustive fatigue, activity intolerance Nausea Low-grade fever may have occurred for weeks or months Night sweats Diagnosis Mantoux tuberculin skin test Chest x-ray Acid-fast bacillus smear Sputum culture Nursing Management Administer drug therapy as ordered by health care provider Keep patient in negative pressure room Wear N-95 mask Maintain isolation until three consecutive sputum cultures have tested negative Focus on preventing the spread of the infection Drug therapy can take as long as 9 months Signs & symptoms to report Discuss pain management, handling fatigue, importance of good nutrition Lung Abcess Localized area of lung destruction caused by liquefaction necrosis Secondary to anaerobic and aerobic organisms that colonize the upper respiratory tract Periodontal disease History of pneumonia Bronchial carcinoma or obstruction TB Fungal infections Clinical Manifestations Spiking temperature Night sweats Chills Cough with foul sputum, may be blood tinged Pleural chest pain Tachycardia Short of breath Diminished lung sounds Dullness on percussion over the abcessed area Oxygen saturation may decrease with larger abcesses Diagnosis Sputum culture Bronchoscopy Pleural or blood cultures CT scan Nursing Management Administer antibiotics Penicillin G or clindamycin Maintain airway and O2 saturation above 93% Elevate the head of bed Pain relief for chest discomfort Diet high in protein Provide time for rest Educate about medication use after discharge Emphysema Identified by alteration of the lung architecture and destruction of alveolar walls Lungs lose their elasticity, air spaces are enlarged which causes limited airflow out of the lungs Form of COPD Primary cause is smoking Diagnosis ABGs CBC X-ray CT scan Pulmonary function test Nursing Management Administer supplemental oxygen Monitor ABGs Support and anxiety reduction Provide time for rest Education Smoking cessation Safe use of oxygen Infection prevention Pulmonary Embolism Complication of a DVT Thrombus breaks loose and blocks a branch of the pulmonary artery Produces widespread pulmonary vasoconstriction Impairs ventilation and perfusion Results in life-threatening hypoxemia, pulmonary ischemia and pulmonary infarction Risk Factors Most common – prior history of DVT or PE Recent surgery Pregnancy Prolonged immbolization Long trips in airplanes, trains and cars Oral contraceptives Pelvic, Hip or femur fractures Trauma Burns Central venous catheters Genetic conditions causing increased clotting Four Types 1. Massive occlusion of the pulmonary circulation 2. Infarction of a portion of lung tissue 3. Embolus without infarction 4. Multiple pulmonary emboli that are chronic or recurrent Clinical Manifestations Depend on the size, location, and amount of obstruction Classic triad: hemoptysis, dyspnea, chest pain Occurs in < 20% of patients May be asymptomatic Massive PE Typically presents with sudden crushing substernal chest pain, shock, loss of consciousness Usually fatal May also present with tachypnea, crackles, tachycardia, diaphoresis, cyanosis Diagnosis Difficult because many diagnostic test used to evaluate lung function may come back normal ABG, Pulse oximetry, CBC only abnormal is some cases Chest x-ray Normal initially, 24-72 hours may show infiltrates D-Dimer test >500 mg/L shows the body is trying to break down clots Pulmonary angiogram Provides 100% certainty that an obstruction exists Spiral CT Nursing Management Prevention Evaluate risk factors on admission and during hospitalization Range of motion, ambulation, leg compression devices Administer anticoagulant medication - heparin drip until coumadin started and PT/INR is therapeutic Administer oxygen Monitor labs for anticoagulant effectiveness Assess for symptoms of bleeding Acute Respiratory Failure Lungs cannot meet the physiological needs of the body due to failure of heart, lungs or both Hallmark of ARF is respiratory difficulty with abnormal ABG’s 3 categories Hypoxemic (failure of oxygenation) Low O2 in blood Hypercapneic (failure of ventilation) high CO2 in blood Failure of the respiratory centers in the CNS Chart 36-2 Pg. 1007 Clinical Manifestations Dyspnea Hypoxemia Tachypnea Adventitious lung sounds Productive cough Agitated Tachycardia Chart 36-3 Pg. 1007 Causes Acute lung injury Pneumothorax Oversedation Obesity Diaphragmatic fatigue Cervical spinal cord injury Guillain-Barre syndrome Diagnosis ABGs Won’t see any compensation because the kidneys have not had time to compensate for the altered pH Chest x-ray Assists in identifying the primary disorder Treatment is aimed at fixing the hypoxemia and treating the underlying cause Acute Pulmonary Edema Abnormal accumulation of fluid in the lungs Caused by dysfunction of the heart, lungs, or both Lungs have no time to compensate Cardiogenic Increased hydrostatic pressure in the capillary bed secondary to increased pulmonary venous pressure due to heart failure MI, hypertension, pericarditis, cardiac tamponade Noncardiogenic Injury of the alveolar-capillary membrane Pneumonia, drowning, acute lung injury, ARDS Clinical Manifestations Dyspnea Crackles Wheezes Central cyanosis Cough with pink frothy sputum Cardiogenic Tachycardia, hypotension, and cool diaphoretic skin Noncardiogenic Tachycardia, hypertension, bounding pulses, and dry skin Nursing Management Administer oxygen Prepare for intubation Administer diuretic such as lasix Emotional support Cardiogenic Morphine to decrease venous return Nitroglycerin to decrease preload ARDS Acute Respiratory Distress Syndrome Progressive form of respiratory failure where there is alveolar capillary inflammation and damage Buildup of fluid in the alveoli which prevents oxygen from passing into the bloodstream. Makes the lungs heavy and stiff Hypoxia despite mechanical ventilation Often occurs along with the failure of other organ systems, such as the liver or kidneys = MODS Mortality = 40% Risk Factors Almost any disease process that generates large-scale inflammation and injury can cause ARDS Sepsis Organ transplantation HIV infection Active malignancy More on Pg. 1015 Mechanical ventilation Alcoholism Lung injury Clinical Manifestations Early sign is hyperventilation with respiratory alkalosis As hypoxemia increases Dyspnea, tachypnea, use of accessory muscles, cyanosis, crackles, wheezes, may have pink frothy sputum Eventually the patient will require intubation and ventilation Late findings Hypotension and decreased cardiac output Diagnosis: ABGs, sputum culture, chest x-ray Nursing Management Treatment is aimed at the underlying cause Administration of oxygen Preparation for intubation Careful fluid restriction Limit lung edema while preventing hypotension and renal failure Administer vasopressors ex: dopamine Nutrition Preoxygenate before activity Care for intubated patients Endotracheal Intubation Indications Inadequate oxygenation or ventilation Airway protection Surgery Oral endotracheal intubation Tube placed through mouth Passes through the vocal cords into the trachea Cuff helps to prevent secretions from being aspirated and prevents air from escaping before ventilating the lungs Mechanical Ventilation Most ventilators are positive pressure ventilators because they provide increased pressure on inspiration Monitors rates, pressures, and volumes and delivers set volumes and/or pressures during the inspiratory cycle Goal is to decrease the work of breathing for the patient If the ventilator does all the work it is a mandatory breath If the ventilator provides support during inspiration or expiration it’s an assisted breath Modes Assist control (CMV) The patient can trigger a breath or the breath can be time triggered Preset volume or pressure is delivered each time Synchronized intermittent mandatory ventilation (SIMV) Set rate where a set volume or pressure is delivered The patient can breath between the set rate and receive the volume from their effort Most common mode Pressure support Patient must have a reliable respiratory effort No set rate or tidal volume delivered When patient inspires it delivers a set pressure to assist the inspiration Often used in combination with SIMV Pressure-controlled Full control mode with set rate and pressure Tidal volume varies from breath to breath Used for patients who have restrictive disease such as ARDS Positive end-expiratory pressure (PEEP) Not a mode but rather a ventilator setting Prevents the pressure of the circuit from returning to zero at the end of expiration Prevents alveoli from collapsing and not opening again Usually set at 5 cm of H2O Nursing Management Assessment How they are breathing Assess the tube for size and depth Position of head How is the tube secured Leak around the cuff Oral assessment Amount and color or secretions LOC & agitation Head to toe assessment Listen to their lungs Have an ambu bag at the bedside Provide nutrition Enteral preferred but may need parental Provide for communication Oral care Turning q 2hrs, especially the head Ensure adequate rest Provide emotional support Weaning As soon as the patient is put on mechanical ventilation the nurse should start planning for weaning No “best practice” identified Many tools available for evaluation One method is to put the client on a t-piece with oxygen or 1 hour. If tolerating after 1 hour extubate References Osborn, Wraa, & Watson chapters 33, 34, 35, & 36 Pack years calculator http://smokingpackyears.com/calculate Lung sounds http://www.easyauscultation.com/lung-sounds.aspx