Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Respiratory Alterations Fall 2010 Rev 1
Transcript
Assessment of the Respiratory System Irene Owens MSN, FNP-BC Anatomy and Physiology Review Upper respiratory tract Lower respiratory tract Lungs Accessory muscles of respiration Respiratory changes associated with aging Assessment Techniques Collect history of client data on family, personal, smoking, drug use, allergies, travel, place of residence, dietary history, occupational history, and socioeconomic level. Assess current health problems such as cough, sputum production, chest pain, and dyspnea. Physical Assessment Assessment of the nose and sinuses Assessment of the pharynx, trachea, and larynx Assessment of the lungs and thorax –Inspection –Palpation, check fremitus –Percussion –Auscultation Breath Sounds Normal breath sounds include bronchial, bronchovesicular, and vesicular. Adventitious breath sounds include: –Crackle –Wheeze –Rhonchus –Pleural friction rub Other Assessments Voice sounds Bronchophony Whispered pectoriloquy Egophony Skin and mucous membranes General appearance Endurance Psychosocial Assessment Some respiratory problems may be worsened by stress. Chronic respiratory disease may cause changes in family roles, social isolation, and financial problems due to unemployment or disability. Discuss coping mechanisms and offer access to support systems. Laboratory Tests Blood tests Sputum tests Radiographic examinations including standard chest x-rays, digital chest radiography, CT Ventilation and perfusion scanning Pulse oximetry Pulmonary Function Testing These tests evaluate lung volumes and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, and distribution of ventilation. Client preparation Procedure for performing tests at the bedside Other Testing and Follow-Up Care Exercise testing Skin testing Other Invasive Diagnostic Tests Endoscopic examinations Thoracentesis: aspiration of pleural fluid or air from the pleural space –Client preparation for stinging sensation and feeling of pressure –Correct position –Motionless client –Follow-up assessment for complications Lung Biopsy Performed to obtain tissue for histologic analysis, culture, or cytologic examination Client preparation May be performed in client’s room (Continued) Lung Biopsy (Continued) Follow-up care: –Assess vital signs and breath sounds at least every 4 hours for 24 hours. –Assess for respiratory distress. –Report reduced or absent breath sounds immediately. –Monitor for hemoptysis. Interventions for Clients Requiring Oxygen Therapy Oxygen Therapy Hypoxemia: low levels of oxygen in the blood Hypoxia: decreased tissue oxygenation Goal of oxygen therapy: to use the lowest fraction of inspired oxygen for an acceptable blood oxygen level without causing harmful side effects Hazards and Complications of Oxygen Therapy Combustion Oxygen-induced Oxygen hypoventilation toxicity Absorption atelectasis Drying of mucous membranes Infection Low-Flow Oxygen Delivery Systems Nasal cannula Simple face mask Partial rebreather mask Non-rebreather mask High-Flow Oxygen Delivery Systems Venturi mask Face tent Aerosol mask Tracheostomy collar T-piece Noninvasive Positive-Pressure Ventilation BiPAP cycling machine delivers a set inspiratory positive airway pressure each time the client begins to inspire. At exhalation, it delivers a lower set endexpiratory pressure. Together the two pressures improve tidal volume. Technique uses positive pressure to keep alveoli open and improve gas exchange without airway intubation. Continuous Nasal Positive Airway Pressure Technique delivers a set positive airway pressure throughout each cycle of inhalation and exhalation. Effect is to open collapsed alveoli. Clients who may benefit include those with atelectasis after surgery or cardiacinduced pulmonary edema; it may be used for sleep apnea. Transtracheal Oxygen Delivery Used for long-term delivery of oxygen directly into the lungs Avoids the irritation that nasal prongs cause and is more comfortable Flow rate prescribed for rest and for activity Home Oxygen Therapy Criteria for home oxygen therapy equipment Client education for use –Compressed gas in a tank or cylinder –Liquid oxygen in a reservoir –Oxygen concentrator Interventions for Clients with Noninfectious Problems of the Upper Respiratory Tract Fracture of the Nose Displacement of either the bone or cartilage of the nose can cause airway obstruction or cosmetic deformity and is a potential source of infection. Cerebrospinal fluid could indicate skull fracture. Interventions: –Rhinoplasty –Nasoseptoplasty Epistaxis Nosebleed is a common problem. Interventions if nosebleed does not respond to emergency care: –Affected capillaries are cauterized with silver nitrate or electrocautery and the nose is packed. –Posterior nasal bleeding is an emergency. (Continued) Epistaxis (Continued) –Assess for respiratory distress and for tolerance of packing or tubes. –Administer humidification, oxygen, bedrest, antibiotics, pain medications. Nasal Polyps Benign, grapelike clusters of mucous membranes and connective tissue May obstruct nasal breathing, change character of nasal discharge, and change speech quality Surgery: treatment of choice Cancer of the Nose and Sinuses Cancer of the nose and sinuses is rare and can be benign or malignant. Onset is slow and manifestations resemble sinusitis. Local lymph enlargement often occurs on the side with tumor mass. Radiation therapy is the main treatment; surgery is also used. Facial Trauma Le Fort I nasoethmoid complex fracture Le Fort II maxillary and nasoethmoid complex fracture Le Fort III combination of I and II plus an orbital-zygoma fracture, often called craniofacial disjunction First assessment: airway http://en.wikipedia.org/wiki/Le_Fort_fra cture_of_skull Facial Trauma Interventions Anticipate the need for emergency intubation, tracheotomy, and cricothyroidotomy. Control hemorrhage. Assess for extent of injury. Treat shock. Stabilize the fracture segment. Obstructive Sleep Apnea Breathing disruption during sleep that lasts at least 10 seconds and occurs a minimum of five times in an hour Excessive daytime sleepiness, inability to concentrate, and irritability Nonsurgical management and change of sleep position Surgical management: uvulopalatopharyngoplasty Disorders of the Larynx Vocal cord paralysis Vocal cord nodules and polyps Laryngeal trauma Interventions for Clients with Noninfectious Problems of the Lower Respiratory Tract Chronic Airflow Limitation Chronic lung diseases of chronic airflow limitation include: –Asthma –Chronic bronchitis –Pulmonary emphysema Chronic obstructive pulmonary disease includes emphysema and chronic bronchitis characterized by bronchospasm and dyspnea. Asthma Intermittent and reversible airflow obstruction affects only the airways, not the alveoli. Airway obstruction occurs due to inflammation and airway hyperresponsiveness. Aspirin and Other Nonsteroidal Anti-Inflammatory Drugs Incidence of asthma symptoms after taking aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) However, response not a true allergy Results from increased production of leukotriene when other inflammatory pathways are suppressed Collaborative Management Assessment History Physical assessment and clinical manifestations: –No manifestations between attacks –Audible wheeze and increased respiratory rate –Use of accessory muscles –“Barrel chest” from air trapping Laboratory Assessment Assess arterial blood gas level. Arterial oxygen level may decrease in acute asthma attack. Arterial carbon dioxide level may decrease early in the attack and increase later indicating poor gas exchange. (Continued) Laboratory Assessment Atopic (Continued) asthma with elevated serum eosinophil count and immunoglobulin E levels Sputum with eosinophils and mucous plugs with shed epithelial cells Pulmonary Function Tests The most accurate measures for asthma are pulmonary function tests using spirometry including: –Forced vital capacity (FVC) –Forced expiratory volume in the first second (FEV1) –Peak expiratory rate flow (PERF) –Chest x-rays to rule out other causes Interventions Client education: asthma is often an intermittent disease; with guided selfcare, clients can co-manage this disease, increasing symptom-free periods and decreasing the number and severity of attacks. Peak flow meter can be used twice daily by client. Drug therapy plan is specific. Drug Therapy Pharmacologic management of asthma can involve the use of: Bronchodilators Beta2 agonists Short-acting beta2 agonists Long-acting beta2 agonists Cholinergic antagonists (Continued) Drug Therapy (Continued) Methylxanthines Anti-inflammatory agents Corticosteroids Inhaled anti-inflammatory agents Mast cell stabilizers Monoclonal antibodies Leukotriene agonists Other Treatments for Asthma Exercise and activity is a recommended therapy that promotes ventilation and perfusion. Oxygen therapy is delivered via mask, nasal cannula, or endotracheal tube in acute asthma attack. Emphysema In pulmonary emphysema, loss of lung elasticity and hyperinflation of the lung Dyspnea and the need for an increased respiratory rate Air trapping, loss of elastic recoil in the alveolar walls, overstretching and enlargement of the alveoli into bullae, and collapse of small airways (bronchioles) Classification of Emphysema Panlobular: alveolus destruction of the entire Centrilobular: openings occurring in the bronchioles that allow spaces to develop as tissue walls break down Paraseptal: confined to the alveolar ducts and alveolar sacs Chronic Bronchitis Inflammation of the bronchi and bronchioles caused by chronic exposure to irritants, especially tobacco smoke Inflammation, vasodilation, congestion, mucosal edema, and bronchospasm Affects only the airways, not the alveoli Production of large amounts of thick mucus Complications Chronic bronchitis Hypoxemia and acidosis Respiratory infections Cardiac failure, especially cor pulmonale Cardiac dysrhythmias Physical Assessment and Clinical Manifestations Unplanned weight loss; loss of muscle mass in the extremities; enlarged neck muscles; slow moving, slightly stooped posture; sits with forward-bend Respiratory changes Cardiac changes Laboratory Assessment Status of arterial blood gas values for abnormal oxygenation, ventilation, and acid-base status Sputum samples Hemoglobin and hematocrit blood tests Serum alpha1-antitrypsin levels drawn Chest x-ray Pulmonary function test Impaired Gas Exchange Interventions for chronic obstructive pulmonary disease: –Airway management –Monitoring client at least every 2 hours –Oxygen therapy –Energy management Drug Therapy Beta-adrenergic agents Cholinergic antagonists Methylxanthines Corticosteroids Cromolyn sodium/nedocromil Leukotriene modifiers Mucolytics Surgical Management Lung transplantation for end-stage clients Preoperative care and testing Operative procedure through a large midline incision or a transverse anterior thoracotomy Postoperative care and close monitoring for complications Ineffective Breathing Pattern Interventions for the chronic obstructive pulmonary disease client: –Assessment of client –Assessment of respiratory infection –Pulmonary rehabilitation therapy –Specific breathing techniques –Positioning to help alleviate dyspnea –Exercise conditioning –Energy conservation Ineffective Airway Clearance Assessment of breath sounds before and after interventions Interventions for compromised breathing: –Careful use of drugs –Controlled coughing –Suctioning –Hydration via beverage and humidifier (Continued) Ineffective Airway Clearance (Continued) –Postural drainage in sitting position when possible –Tracheostomy Imbalanced Nutrition Interventions to achieve and maintain body weight: –Prevent protein-calorie malnutrition through dietary consultation. –Monitor weight, skin condition, and serum prealbumin levels. –Address food intolerance, nausea, early satiety, loss of appetite, and meal-related dyspnea Anxiety Interventions for increased anxiety: –Important to have client understand that anxiety will worsen symptoms –Plan ways to deal with anxiety Health Teaching Instruct the client: –Pursed-lip and diaphragmatic breathing –Support of family and friends –Relaxation therapy –Professional counseling access –Complementary and alternative therapy Activity Intolerance Interventions to increase activity level: –Encourage client to pace activities and promote self-care. –Do not rush through morning activities. –Gradually increase activity. –Use supplemental oxygen therapy. Potential for Pneumonia or Other Respiratory Infections Risk is greater for older clients Interventions include: –Avoidance of large crowds –Pneumonia vaccination –Yearly influenza vaccine Sarcoidosis Granulomatous disorder of unknown cause that can affect any organ, but the lung is involved most often Autoimmune responses in which the normally protective T-lymphocytes increase and damage lung tissue Interventions (corticosteroids): lessen symptoms and prevent fibrosis Occupational Pulmonary Disease Can be caused by exposure to occupational or environmental fumes, dust, vapors, gases, bacterial or fungal antigens, or allergens Worsened by cigarette smoke Interventions: special respirators that ensure adequate ventilation See page 640 Iggy BOOP Patho: inflammatory process that allows connective tissue plugs to form in the lower airways and in the tissue between the alveoli. Inflammation triggers WBC’s with connective cell growth that occludes and obliterates these airways and leads to restricted lung volume with decreased VC. Not a true pneumonia. No known cause BOOP cont Triggers Infectious organisims, drugs antiseizure medications cocaine, RA, SLE, also related to chest radiation therapy for cancer. Solid organ transplant patients Usually S?S present for months and do not improve with standard ABX. CT will suggest BOOP not confirm it Biopsy needed to confirm BOOP Treatment Corticosteroids Interventions for Clients with Infectious Problems of the Respiratory Tract Rhinitis Inflammation of the nasal mucosa Often called “hay fever” or “allergies” Interventions include: –Drug therapy: antihistamines and decongestants, antipyretics, antibiotics –Complementary and alternative therapy –Supportive therapy Sinusitis Inflammation of the mucous membranes of the sinuses (Continued) Sinusitis Nonsurgical (Continued) management –Broad-spectrum antibiotics –Analgesics –Decongestants –Steam humidification –Hot and wet packs over the sinus area –Nasal saline irrigations Surgical Management Antral irrigation Caldwell-Luc procedure Nasal antral window procedure Endoscopic sinus surgery Pharyngitis Sore throat is common inflammation of the mucous membranes of the pharynx. Assess for odynophagia, dysphagia, fever, and hyperemia. Strep throat can lead to serious medical complications. Epiglottitis is a rare complication of pharyngitis. Tonsillitis Inflammation and infection of the tonsils and lymphatic tissues located on each side of the throat Contagious airborne infection, usually bacterial Antibiotics Surgical intervention Peritonsillar Abscess Complication of acute tonsillitis Pus behind the tonsil, causing one-sided swelling with deviation of the uvula Trismus and difficulty breathing Percutaneous needle aspiration of the abscess Completion of antibiotic regimen Laryngitis Inflammation of the mucous membranes lining the larynx, possibly including edema of the vocal cords Acute hoarseness, dry cough, difficulty swallowing, temporary voice loss (aphonia) Voice rest, steam inhalation, increased fluid intake, throat lozenges Therapy: relief and prevention Influenza “Flu” is a highly contagious acute viral respiratory infection. Manifestations include severe headache, muscle ache, fever, chills, fatigue, weakness, and anorexia. Vaccination is advisable. Antiviral agents may be effective. Pneumonia Excess of fluid in the lungs resulting from an inflammatory process Inflammation triggered by infectious organisms and inhalation of irritants Community-acquired infectious pneumonia Nosocomial or hospital-acquired Atelectasis Hypoxemia Laboratory Assessment Gram stain, culture, and sensitivity testing of sputum Complete blood count Arterial blood gas level Serum blood, urea nitrogen level Electrolytes Creatinine Impaired Gas Exchange Interventions include: –Cough enhancement –Oxygen therapy –Respiratory monitoring Ineffective Airway Clearance Interventions include: –Help client to cough and deep breathe at least every 2 hours. –Administer incentive spirometer— chest physiotherapy if complicated. –Prevent dehydration. (Continued) Ineffective Airway Clearance (Continued) –Monitor intake and output of fluids. –Use bronchodilators, especially beta2 agonists. –Inhaled steroids are rarely used. Potential for Sepsis Primary intervention is prescription of anti-infectives for eradication of organism causing the infection. Drug resistance is a problem, especially among older people. Interventions for aspiration pneumonia aimed at preventing lung damage and treating infection.
