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Respiratory Fundamentals Linda Winn, RN, MSN Ed., BA Ed. Major Topics • Anatomy http://www.argosymedical.com/Respiratory/samples/animations/Respirat ion/index.html http://www.argosymedical.com/Respiratory/samples/animations/Sherwo od%20Respiration/index.html • Assessment • Labs • Diagnostics • Meds • Common Diagnoses Activity • Each team will be assigned one of the following topics to research and present to the entire group: – Assessment • Normal assessment – what makes up a complete respiratory assessment? • Abnormal findings & significance – Labs • What labs are relative to respioratory status? • Normals • Abnormals & significance – Diagnostics • • • • What diagnostic tests are relative to pulmonary status? Normals Abnormals & significance Any significant patient care measure before, during, or after tests – Meds • Major categories / actions of Respiratory meds • Significant side-effects • Nursing measures specific to meds Respiratory Assessment Assessment • Screening Exam Techniques http://depts.washington.edu/physdx/pulmonary/tec h.html http://depts.washington.edu/physdx/pulmonary/de mo.html Resp Assessment • Breathing Pattern – I:E ratio – Kussmaul – Rate • Dyspnea – Orthopnea – PND – Paroxysmal nocturnal dyspnea • Cough and Sputum – – – – – – – Frequency Dry / moist Amount Color Thickness Odor Hemoptysis Assessment (Cont.) • Inspection – Symmetry – Skin color – lip color / finger clubbing – WOB – accessory muscles • Auscultation – Adventitious sounds • Chest pain • History – Diagnoses – Smoking • Quick, Focused Assessment Breath Sounds Link • Normal and Adventitious breath sounds http://faculty.etsu.edu/arnall/www/public_html/heartlung/breathsounds/conte nts.html Diagnostics & Labs Labs • H/H • Sputum Analysis – – – – C&S Gram Stain Acid-Fast smear (AFB) Cytology • ABG’s • WBC • O2 Sats Diagnostic Tests • CXR • CT Chest • MRI • V/Q Scan • Bronchoscopy http://www.nlm.nih.gov/medlineplus/tutorials/bronchoscopy/htm/_no_50_no_0.htm • Thoracentesis • PFTs – Pulmonary Function Tests –Spirometry Diagnostics • PFR – http://www.argosymedical.com/Respiratory/samples/ animations/Peak%20Flow%20Meter/index.html Diagnostic Tests • Endoscopic Exams – Bronchoscopy: direct inspection of airways • Only __________ ___________ of airways – Purposes: • diagnose diseases • find obstructions • obtain tissue samples • remove mucous plugs, foreign bodies • find bleeding sources Pulmonary Meds Pulmonary Meds • Oxygen (later) • Corticosteroids http://www.argosymedical.com/Respiratory/sample s/animations/Inhaled%20Corticosteroids/index.ht ml • Antibiotics • Beta-Agonists Respiratory Med Delivery Metered Dose Inhalers – deliver constant dose of drug directly to airways – requires hand-lung coordination – propellant based – compact & portable – relatively inexpensive How & Why Is the Spacer Used? Spacer http://www.mayoclinic.com/health/asthma/MM00608 Methods of Delivery Dry Powder Inhalers – no propellants used – breath activated easier to use – delivers more drug to airways than MDIs http://www.mayoclinic.com/health/asthma/MM00405 Methods of Delivery Nebulizers – used at home or hospital – continuous aerosol spray with external energy source (O2) – takes longer to deliver drug – choice if patient unable to use MDIs Respiratory Treatments • Coughing and Deep Breathing (later) • Incentive Spirometry (later) • Oropharngeal Suctioning • Inhaled Medication • Oxygen Therapy (Supplementation) Coughing & Deep Breathing • Position for maximal lung expansion • Splint with hand(s) or pillow • Slow inspiration via nose, hold 3-5 seconds, exhale via mouth. Cough after 2-3 breaths. • Pulmonary disease: exhale via pursed lips & cough after expiration started • More frequent coughing if productive • Coughing contraindicated: post-eye, ear, brain or neck surgery Incentive Spirometry • Prevents atelectasis & PNA – Position for maximal lung expansion – Exhale completely – Close mouth around mouthpiece – Inhale slow & deep, watching meter for flow rate – Make inspiration last for 3-5 seconds – 10 X Q/hr WA Respiratory Diagnoses • Asthma • COPD – Chronic Bronchitis – Emphysema • Pneumonia Major Pulmonary Diagnoses • COPD – http://video.about.com/copd/Emphysema.htm – http://video.about.com/copd/COPD.htm • Pneumonia – CAP vs HAP Major Pulmonary Diagnoses • Asthma – http://www.argosymedical.com/Respiratory/samples/animation s/Asthma%20TLC_AZ/index.html – http://www.argosymedical.com/Respiratory/samples/animation s/Asthma/index.html • Sleep Apnea – http://www.argosymedical.com/Respiratory/samples/animation s/CPAP%20Sleep%20Apnea/index.html Pneumonia Collaborative Care • Appropriate antibiotic therapy • Reduced activity and rest • Increased fluid-- 3 liters/day • Antipyretics • Supplemental oxygen • Good nutrition--1500 cal/day • Vaccine prophylaxis • analgesics • CORE Measure Assessment Findings • Fever, restlessness, fatigue, splinting painful chest • (New) cough with or without sputum • Shortness of breath, RR & HR • Pleuritic chest pain • Infiltrates on CXR • Crackles or bronchial sounds in the peripheral lung fields Collaborative Care • Appropriate antibiotic therapy • Reduced activity and rest • Increased fluid-- 3 liters/day • Antipyretics • Supplemental oxygen • Good nutrition--1500 cal/day • Vaccine prophylaxis • Analgesics • Oxygen • CORE Measure Oxygen • Medication – Requires MD order – Side Effects • Highly combustible gas – Clear – Odorless • Set-up is part of initial room check Indications for O2 therapy • Goal – Prevent or relieve hypoxia • Keep SaO2 > 90% – Reduce work of breathing – Room Air / FIO2 = 21% • Used with hypoxia due to: – Respiratory Disorders – Cardiovascular disorders – Central nervous system disorders Safety Precautions • O2 sign posted • No smoking or flames • Electrical equipment grounded • Check tank level before transport • No oil-based lubricants / lotions Delivery Devices • Nasal Cannula • Masks – – – – Simple face Partial rebreathing Non-rebreathing Venturi (Venti Mask) • Tracheostomy – Collar • Ventilator • Flow Meter • Humidification Oxygen Safety Nasal Cannula • Advantages – Safe, simple, tolerated well – Allows eating and drinking – Can humidify • Disadvantages – Easily dislodged • Check regularly – Skin breakdown • Check regularly • O2 Concentrations – 1L/min = 24% – 2L/min = 28% – 3L/min = 32% Simple Face Mask • RA enters via side holes • Advantages – Humidified • Disadvantages – Imprecise FIO2 – High FIO2 needed to prevent rebreathing CO2 • Concentrations – 5-6L/min = 40% – 6-7L/min = 50% – >7L/min = 60% Non-rebreather Mask • Use – Valve prevents air from flowing back into bag – Last step, usually, before intubation • Advantages – High O2 concentrations – Accurate • Disadvantages – Can’t use high humidity – uncomfortable Venturi Mask • Venti-mask – High flow – Adjustable • Advantages – Very precise – Mask of choice for COPD • Disadvantages – uncomfortable O2 and COPD • Historically… – Never give O2 >2L/min to COPD pts. • However… “There has been concern regarding the dangers of administering O2 to COPD pts and reducing their drive to breath.” “This has been a pervasive myth but is not a serious threat.” “In fact, not providing adequate O2 to these patients is much more detrimental.” Lewis, p. 643 (7th ed.) Patient Education • Monitor color of sputum • Self care: at-home meds & treatments; avoid triggers • Prevention – Pneumococcal vaccine, flu shot • Frequent oral hygiene • Encourage fluids • Environmental hazards – altitude, smog, allergies, smoke • Follow up medical care • American Lung Association – www.lungusa.org