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Alteration in Gas Transport: Care of the Patient with Problems of the Respiratory Tract Carol Isaac MacKusick, MSN, RN, CNN Nursing 2903 Fall, 2005 The Nursing Process and Respiration Assessment Client History Why are you here? General overall health Any ‘colds’ or congestion or allergy problems? Smoking history Pack years: number of packs per day times number of years How much time away from work or school have you missed because of this? Assessment Client History Subjective symptoms Dyspnea with ADLs? Childhood diseases Adult illnesses Asthma, pneumonia, allergies, croup Pneumonia, sinusitis, TB, HIV, emphysema, DM, HTN, cardiac disease Vaccine history Flu, pneumonia, BCG Assessment Client History Surgeries of upper or lower respiratory tract Injuries to upper or lower respiratory tract Hospitalizations Date of last CXR, PPD, PFT Recent weight loss Night sweats Assessment Client History Sleep disturbances How many pillows? Family history Recent travel Occupation Leisure activities Assessment Client History Drug use Recreational (marijuana, cocaine, crack) Prescription ACE inhibitors Antihistamines Bronchodilators Chemotherapy OTC Allergy medications Home remedies Herbals: Elecampane, Hyssop, Mullein, Licorice Assessment Client History Allergies Foods, drugs, substances Allergic response? Treatment? Diet history BMI Obese? Malnourished? Body weight in pounds times 703 divided by height in inches squared Food intake related to breathing issues? Assessment Client History Occupation and Home Life Environmental factors and exposure Type of heat used in the home Animals or pets in home Hobbies involving chemicals Pest infestation at home or work Tie to asthma, wheezing related to roaches Assessment Major signs and symptoms Cough Type, duration, length Sputum production Color, consistency, amount Dyspnea Rate of perception ADLs Paroxysmal nocturnal dyspnea Orthopnea Assessment Major signs and symptoms Chest pain Wheezing Clubbing of fingers / nails Hemoptysis Cyanosis Gerontologic Considerations Vital capacity and respiratory muscle strength peak between 2025 and then decrease Age 40 and older – surface area in alveoli is reduced Age 50 – alveoli loses elasticity Loss of chest wall mobility>decrease in vital capacity Gerontologic Considerations Amount of respiratory dead space increases with age Decreased diffusion capacity with age – lower oxygen level in arterial circulation Risk Factors for Respiratory Disease Smoking Personal / family history Occupation Allergens Recreational exposure Physical Assessment Nose and Sinuses External nose Deformities, tumors Nostrils: symmetry of size, shape Nasal flaring Inspect for color, swelling, drainage, bleeding Mucous membranes Nasal septum Bleeding, perforation, deviation Physical Assessment Air movement Occlude one nare Sinuses Via palpation Tenderness, swelling Tapping Penlight Frontal, maxillary Physical Assessment Pharnyx, Trachea, and Larynx Posterior pharynx Tongue depressor One side at a time Observe rise and fall of palate and uvula (ah) Inspect for color, symmetry, discharge, edema, ulceration, tonsillar enlargement Neck Inspect for symmetry, alignment, masses, swelling, bruises, use of accessory neck muscles in breathing Physical Assessment Neck Lymph nodes Tender, movable – inflammation Hard, fixed – suggest malignancy Trachea Palpate for position, mobility, tenderness, masses Larynx laryngoscope Physical Assessment Lungs and Thorax Inspection Palpation Fremitus 99 Crepitus Bubble wrap Chest expansion Movement Physical Assessment Lungs and Thorax Percussion Pulmonary resonance Air, fluid, solid masses Intercostal spaces only Diagphragmatic excursion Normal 1 -2 inches Deep breath / percuss No breath / percuss Normally higher on the right (liver) Physical Assessment Auscultation Upright first Bare chest Open mouth breathing Full respiratory cycle Observe for dizziness Physical Assessment Normal breath sounds Bronchial, bronchovesicular, vesicular Not heard peripherally Adventitious breath sounds Additional sounds superimposed on normal sounds Indicate pathology Crackles, wheezes, rhonchi, pleural friction rub Physical Assessment Voice sounds Assessed when abnormalities noted Increased when sound travels through solid or liquid Consolidation of lung, pneumonia, atelectasis, pleural effusion, tumor, abscess Bronchophony: 99 – loud and clear Whispered Pectriloquy: 1, 2, 3 – loud Egophony – ‘E’ – heard as an ‘A’ Physical Assessment Skin and Mucous Membranes General Appearance Pallor, cyanosis, nail beds Muscle development, general body build Muscles of neck, chest Endurance How does the client move in 10 – 20 steps? Speaking exertion Diagnostic Assessment Need to know: Normal / abnormal for: RBC Hgb / Hct WBC / leukocytes / neutrophils Eosinophils Basophils Lymphocytes Monocytes ABGs Sputum studies Skin (PPD) testing Diagnostic Testing Chest xrays Digital Chest Radiography CT V/Q Scan Pulse Oximetry PFTs Diagnostic Testing Pulmonary Function Tests (PFTs) Used generally in chronic conditions Assesses respiratory function Determine extent of dysfunction Measures lung volumes, ventilatory function, and mechanics of breathing, diffusion, and gas exchange Assesses response to therapy Screening test in hazardous industries Diagnostic Testing Arterial Blood Gases (ABGs) Measures blood pH and arterial oxygen and carbon dioxide levels Assesses ability of lungs to provide adequate oxygen and removal of carbon dioxide Assesses ability of kidneys to maintain normal pH Diagnostic Testing Pulse Oximetry Noninvasive method of monitoring oxygen saturation of hemoglobin Unreliable in cardiac arrest and shock, dyes or vasoconstictor meds used, severe anemia, or high carbon monoxide level Diagnostic Testing Cultures Throat or sputum Sputum Best to obtain early AM Rinse mouth, takes deep breaths, coughs, and expectorates Deliver specimen to lab within 2 hours Diagnostic Examination Endoscopy Thoracentesis Bronchoscopy, laryngoscopy, mediastinoscopy Check for patent airway every 15 minutes post procedure for two hours Local anesthetic Patient must remain still Usually at bedside Post procedure: CXR r/o mediastinal shift, monitor VS, auscultate breath sounds Lung biopsy Diagnosis Upper Airway Medical Diagnosis Rhinitis Viral rhinitis Acute sinusitis Chronic sinusitis Acute pharyngitis Chronic pharyngitis Tonsillitis and adenoiditis Diagnosis Upper Airway Medical Diagnosis Peritonsillar abscess Laryngitis Upper Airway Nursing Diagnosis Ineffective airway clearance Acute pain Impaired verbal communication Fluid volume deficit Knowledge deficit Planning and Implementation Upper airway Maintain patent airway Promote comfort Promote communication Encourage fluid intake Teach self care Encourage appropriate hand washing Planning and Implementation Managing potential complications Sepsis Sepsis Meningitis Otitis media Evaluation Maintenance of patent airway Reports feelings of comfort Demonstrates ability to communicate Maintains adequate fluid intake Identifies strategies to prevent infections Becomes free of s/sx of infection Demonstrates adequate knowledge Upper Airway Obstruction and Trauma Medical Diagnosis Sleep apnea Obstructive Central Mixed Epistaxis Nasal Obstruction Fractures of the nose Laryngeal Obstruction Laryngeal Carcinoma Upper Airway Obstruction and Trauma Nursing Diagnosis Knowledge deficit Anxiety Ineffective airway clearance Impaired verbal communication Nutritional imbalance Alteration in body image Self care deficit Sleep deprivation Risk for injury Fatigue Planning and Implementation Sleep apnea Avoid ETOH Decrease body mass CPAP Uvulopalatopharyngoplasty Tracheostomy Pharmacologic Management Low flow O2 Triptil Education Planning and Implementation Epistaxis Dependent on location of site Generally anterior Pinch outer portion / sit upright Silver nitrate / gelfoam / electrocautery Topical vasoconstrictors Monitor VS Estimate amount of blood loss Don’t forget standard precautions Planning and Implementation Nasal Obstruction Deviation of nasal septum Submucous resection Generally outpatient Promote drainage Alleviate discomfort Frequent oral hygiene Planning and Implementation Fractures of the nose Bleeding from site Bruising Clear fluid CSF Glucose positive Surgical reduction ~ one week post injury Ice therapy Control anxiety Oral hygiene Planning and Implementation Laryngeal Obstruction Often fatal Acute laryngitis, urticaria, scarlet fever, anaphylaxis, foreign bodies Edema: SQ Epi 1:1,000 / corticosteroid Abdominal thrust (Heimlich) Emergent tracheotomy Planning and Implementation Laryngeal Cancer Risk factors: chart 22-5 Dependent upon tumor staging (chart 22-6) Laryngectomy Radiation Speech therapy Potential complications: respiratory distress, hemorrhage, infection, wound breakdown Laryngeal Cancer Educate preoperatively Reduce anxiety Maintain patent airway Encourage speech therapy Maintain adequate nutrition Promote positive body image Teach self care Evaluation Adequate level of knowledge Lessened anxiety Clear airway Acquires effective communication Appropriate intake Positive self and body image Complication free Adheres to home therapy Chest and Lower Respiratory Tract Medical Diagnosis Atelectasis Patho: figure 23-1 Acute tracheobronchitis Pneumonia MUST know table 23-1 and charts 23-2, 23-3 Review older adult considerations / risk factors Assess any older adult with AMS for pneumonia May not have cough or fever Nursing Diagnosis Ineffective airway clearance Activity intolerance Fluid volume deficit Altered nutrition Knowledge deficit Impaired gas exchange Pain Fatigue Planning and Implementation Avoid potential complications: Continuing symptoms Shock Respiratory failure Atelectasis Pleural effusion Confusion Superinfection Planning and Implementation Improve airway patency Promote rest Hydration Humidification Oxygen therapy CPT Long recovery periods Conserve energy Promote fluid intake Planning and Implementation Maintain adequate nutrition Determine caloric needs with RD help Educate client Teach self care Evaluation Adequate airway patency Optimal rest patterns Maintains appropriate nutrition and hydration status Knowledgeable of disease and treatment Adheres to treatment strategies Complication free Inhalation Injury – Smoke and Carbon Monoxide Produce local injuries by inflammation, irritation, and damage to pulmonary tissues Systemic injuries S &S of CO poisoning Mild – headache, visual disturbances, irritability, nausea Severe – confusion, hallucinations, ataxia, coma Therapeutic Management 100% oxygen Artificial ventilation Hyberbaric chamber – more rapid Tx of CO poisoning Possible intubation Steroids, antibiotics, bronchodilators Monitor rate and depth of respirations at least every hour Planning and Intervention VS assessment / monitoring Respiratory assessment Pulmonary physiotherapy Mechanical ventilation Psychological care of child and parents Pulmonary Tuberculosis Risk factors (chart 23-4) CDC recommendations (chart 23-5) Classification of disease 0-5; class 3 – clinically active Older adult AMS, fever, anorexia Delayed reactivity or recall phenomenon with PPD Airborne precautions!! Close the door! Nursing Diagnosis Ineffective airway clearance Knowledge deficit Activity intolerance Potential for treatment non adherence Impaired gas exchange Fatigue Alteration in nutrition Social isolation Planning and Implementation Medical Management Drug resistance is major problem Table 23-2 lists current recommended first line drug therapy Therapy lasts up to 12 months HIV infection has increased prevalence Drug therapy should be dispensed in two week intervals Planning and Implementation Potential Complications Malnutrition Medication side effects Drug resistance Determine which clients should participate in directly observed therapy (DOT) Miliary TB Decreased effectiveness with oral contraceptives Planning and Implementation Promote airway clearance Encourage patient adherence Promote adequate nutrition Encourage rest Educate patient regarding routes of transmission and disease manifestations More people are infected than have active TB Teach self care Evaluation Maintain patent airway Adequate level of knowledge Adheres to treatment regimen Participates in self care Maintains optimal rest patterns Complication free Lung Abscess Causative factors Bacterial pneumonia Oral aspiration / obstruction Nursing Diagnosis Airway clearance Knowledge deficit Alteration in nutrition Planning and Implementation Administer AB therapy Monitor for adverse effects CPT TCDB Appropriate nutritional intake Emotional support Educate regarding self care Pleural Condition Diagnoses Medical Diagnosis Pleural Conditions Pleurisy Pleural effusion Empyema Nursing Diagnosis Anxiety Pain Knowledge Deficit Self Care Deficit Alteration in Nutrition Airway Clearance Planning and Implementation Pleural friction rub, decreased fremitus, absent breath sounds Pain relief, comfort measures TCDB Thoracentesis Implement medical regimen Monitor chest tube drainage Empyema – long healing process Diagnosis Pulmonary Edema Life threatening Generally, abnormal cardiac function ‘flash’ pulmonary edema post surgery Crackles in bases, increasing throughout Nursing Diagnosis Airway clearance Cardiac function anxiety Planning and Implementation Administer O2 Assist with ventilation as appropriate Medication administration Monitor patient response Educate and prepare patient and family Diagnosis Acute Respiratory Failure Difference between acute and chronic Chronic: COPD / neuromuscular dx Acute: VP mismatch, alveolar hypoventilation, PaO2 < 50 Nursing Diagnosis Similar to other airway constrictive disease states Planning and Implementation Assist with intubation / mechanical ventilation Monitor response Prevent complication Enable communication Educate family and patient Diagnosis Acute Respiratory Distress Syndrome Inflammatory trigger Nursing Diagnosis Airway clearance Anxiety Pain Nutritional alterations Planning and Implementation Close monitoring Ventilator support CPT Frequent assessment Education Rest and comfort measures Pulmonary Hypertension Causes: Chart 23-7 Nursing Management Identify high risk patients Educate regarding s/sx Oxygen therapy Cor Pulmonale Right ventricle enlargement Generally, from COPD S/ Sx generally r/t underlying disease state Treatment related to addressing underlying disorder Pulmonary Embolism Risk factors: Chart 23-8 Home care: Chart 23-9 Diagnosis: CXR, ECG, V/P scan, ABGs Nursing diagnosis Knowledge deficit Anxiety Airway clearance Pain Decreased cardiac output Risk for injury (bleeding) Planning and Intervention Improve respiratory and vascular status Anticoagulation therapy Thrombolytic therapy Surgical intervention Rare Minimizing risk most important step Monitor therapy Manage pain Sarcoidosis Hypersensitivity response Biopsy required for diagnosis Corticosteroid therapy May involve other body systems Occupational Lung Diseases Medical Diagnosis Silicosis Coal workers’ pneumoconiosis Asbestosis Prevention is key Educate clients to wear a mask Consider also hobbies Diagnosis Lung and Chest Carcinoma: to be covered in oncology section Chest Trauma: to be covered during trauma seminar Aspiration: similar to pneumonia and obstructive disorders High risk in patients with altered LOC Do not force feed clients! Chronic Obstructive Pulmonary Disease Airflow limitation Irreversible Chronic bronchitis, emphysema Risk factors: Chart 24-1 Three primary symptoms: Cough Sputum production Dyspnea Assessment Spirometry – evaluation of airflow obstruction Ratio of FEV: FVC Less than 70% Health history overview: chart 24-2 Assessment: chart 24-3 Stages of COPD: table 24-1 Crackles Nursing Diagnosis Impaired gas exchange Ineffective airway clearance Ineffective breathing pattern Activity intolerance Knowledge deficit Ineffective coping Anxiety Alteration in nutrition Fatigue Planning and Implementation Potential complications: Respiratory insufficiency Chronic respiratory failure Acute respiratory failure Atelectasis Pulmonary infection Pneumonia Pneumothorax Pulmonary hypertension Planning and Implementation Promote smoking cessation Improve gas exchange Medication administration Measure improve in flow rates Airway clearance CPT Controlled coughing Huff coughing Increased fluids Planning and Implementation Improving breathing patterns Inspiratory muscle training Diaphragmatic breathing Pursed lip breathing Standing against wall Over bedside table with pillows Improving activity tolerance Determine limitations Determine client preferences Pacing activities Exercise training Planning and Implementation Self care strategies Realistic goal setting Heat / cold extremes Heat increases oxygen demands Cold promotes bronchospasms Lifestyle modification Coping strategies Self care teaching Evaluation Knowledgeable of smoking dangers Improved gas exchange Achieves maximal airway clearance Improves breathing pattern Demonstrates strategies for activity tolerance and self care Effective coping Avoids complications Bronchiectasis Separate from COPD now Management similar to COPD CPT Smoking cessation Postural drainage Energy conservation measures Asthma Chronic inflammatory disease Sxs: cough, chest tightness, wheezing, dyspnea Is reversible Most common chronic disease of childhood Predisposing factors: Allergens Airway irritants Exercise Stress Sinusitis Medications Viral respiratory tract infections GERD Asthma Nursing Diagnosis Anxiety Airway clearance Breathing patterns Fluid volume deficit Knowledge deficit Assessment Health history Comorbid conditions Sputum cultures / serum samples Elevated levels of eosinophils ABG / pulse ox Hypoxemia during attacks Hypocapnia and respiratory alkalosis PaCO2 May rise initially Return to baseline indicative of impending respiratory failure Planning and Intervention Prevention is key Pharmacology Long acting: corticosteroids, antiinflammatory agents Quick relief: relief of acute symptoms, bronchodilators Table 24-4 details medications Oxygen therapy is often indicated during acute attacks Can be mixed with helium (Heliox) to improve delivery to the alveoli Planning and Intervention Peak flow monitoring Monitor respiratory status Thorough history of allergens Medication administration Fluid administration Daily is recommended Intake and output recording Preparation for mechanical ventilation Planning and Intervention Prevention of complications Status asthmaticus Respiratory failure Pneumonia Atelectasis Airway obstruction Dehydration Status Asthmaticus Attack that does not respond to conventional therapy Close monitoring first 12-24 hours Volume status closely monitored Energy conservation No respiratory irritants Nonallergenic pillow Cystic Fibrosis <40% reach adulthood Airflow obstructive disease with genetic component Elevated sweat chloride >60 mEq/L Steatorrhea Control of infections key Nursing interventions similar to other obstructive diseases Lung transplantation – small number End of life care important Respiratory Procedures Inhalation therapy Oxygen therapy Humidification Aerosol therapy Artificial ventilation Continuous positive airway pressure (C-PAP) Oxygen Therapy Nasal cannula / mask / tent Apply to anyone who is hypoxic or with stridor Considerations Avoid open flames and electrical appliances Monitor response Adverse effects to premature infant’s retina Caution with COPD Oxygen toxicity Use humidification Check skin integrity Aerosol Therapy Used to deposit medications directly into airways Types Hand-held nebulizers Metered-dose inhaler (MDI) Spacer device Close the door when administering Chest Physiotherapy (CPT) Postural drainage in conjunction with adjunctive techniques Manual percussion, vibration, squeezing the chest, cough, forceful expiration, and breathing exercises Considerations Percuss over rib cage Used in increased sputum production CPT Contraindications Pulmonary hemorrhage Pulmonary embolus ESRD Increased intracranial pressure Minimal cardiac reserves Artificial Ventilation Nasotracheal Orotracheal Tracheostomy Considerations In children, tubes have more acute angle and are softer to mold to contours of trachea Smoking Cessation Anyone who smokes is an increased risk for pulmonary problems Assist clients interested in smoking cessation programs Teach all clients who smoke the warning signs of lung cancer That’s All, Folks! Any questions or comments?
