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Friday, November 9, 2007

Respiratory System :: Medical Surgical Nursing :: Review For Nursing Licensure Examination

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Respiratory System :: Medical Surgical Nursing :: Review For Nursing Licensure Examination Slide Transcript
Slide 1: Medical and Surgical Nursing Review The Respiratory System Nurse Licensure Examination Review

Slide 3: Outline Of Review Concepts:  Review of the relevant respiratory anatomy  Review of the relevant respiratory physiology  The respiratory assessment  Common laboratory examinations

Slide 4: Outline Of Review Concepts:  Review of the common respiratory problems and the nursing management  Review of common respiratory diseases  Upper respiratory conditions  Lower respiratory conditions

Slide 5: Respiratory Anatomy & Physiology  The respiratory system consists of two main parts - the upper and the lower tracts

Slide 6: Respiratory Anatomy & Physiology  The UPPER respiratory system consists of:  1. nose  2. mouth  3. pharynx  4. larynx

Slide 7: Respiratory Anatomy & Physiology  The LOWER respiratory system consists of:  1. Trachea  2. Bronchus  3. Bronchioles  4. Respiratory unit

Slide 8: Upper Respiratory Tract

Slide 9: The Nose  This is the first part of the upper respiratory system that contains nasal bones and cartilages  There are numerous hairs called vibrissae  There are numerous superficial blood vessels in the nasal mucosa

Slide 10: The Nose  The functions of the nose are:  1. To filter the air  2. To humidify the air  3. To aid in phonation  4. Olfaction

Slide 11: The Pharynx  The pharynx is a musculo - membranous tube that is composed of three parts  1. Nasopharynx  2. Oropharynx  3. Laryngopharynx

Slide 12: The Pharynx  The pharynx functions :  1. As passageway for both air and foods (in the oropharynx)  2. To protect the lower airway

Slide 13: The Larynx  Alsocalled the voice box  Made of cartilage and membranes and connects the pharynx to the trachea

Slide 14: The Larynx  Functions of the larynx:  1. Vocalization  2. Keeps the patency of the upper airway  3. Protects the lower airway

Slide 15: The Paranasal sinuses  These are four paired bony cavities that are lined with nasal mucosa and ciliated pseudostratified columnar epithelium  Named after their location - frontal, ethmoidal, sphenoidal and maxillary

Slide 16: The Paranasal sinuses  Thefunction of the sinuses: Resonating chambers in speech

Slide 17: The Lower Respiratory System  The lower respiratory system consists of  1. Trachea  2. Main bronchus  3. Bronchial tree  4. Lungs- 3R/ 2L  The trachea to the terminal bronchioles is called the conducting airway  The respiratory bronchioles to the alveoli is called the respiratory acinus

Slide 18: The Trachea A cartilaginous tube measures 10-12 centimeters  Composed of about 20 C-shaped cartilages, incomplete posteriorly

Slide 19: The Trachea  The function of the trachea is to conduct air towards the lungs  The mucosa is lined up with mucus and cilia to trap particles and carry them towards the upper airway

Slide 20: The Bronchus  The right and left primary bronchi begin at the carina  The function is for air passage

Slide 21: The Primary Bronchus RIGHT BRONCHUS LEFT BRONCHUS   Wider Narrower   Shorter  Longer  More Vertical  More horizontal

Slide 22: The Bronchioles  The primary bronchus further divides into secondary, then tertiary then into bronchioles  The terminal bronchiole is the last part of the conducting airway

Slide 23: The Respiratory Acinus  The respiratory acinus is the chief respiratory unit  It consists of  1. Respiratory bronchiole  2. Alveolar duct  3. alveolar sac

Slide 24: The Respiratory Acinus  The respiratory acinus is the chief respiratory unit  The function of the respiratory acinus is gas exchange through the respiratory membrane

Slide 25: The Respiratory Acinus  The respiratory membrane is composed of two epithelial cells  1.The type 1 pneumocyte - most abundant, thin and flat. This is where gas exchange occurs  2. The type 2 pneumocyte - secretes the lung surfactant

Slide 26: The Respiratory Acinus A type III pneomocyte is just the macrophage that ingests foreign material and acts as an important defense mechanism

Slide 27: Accessory Structures The PLEURA  Epithelial serous membrane lining the lung parenchyma  Composed of two parts- the visceral and parietal pleurae  The space in between is the pleural space containing a minute amount of fluid for lubrication

Slide 28: Accessory Structures The Thoracic cavity  The chest wall composed of the sternum and the rib cage  The cavity is separated by the diaphragm, the most important respiratory muscle

Slide 29: Accessory Structures The Mediastinum  The space between the lungs, which includes the heart and pericardium, the aorta and the vena cavae.

Slide 30: GENERAL FUNCTIONS OF THE Respiratory System  Gas exchange through ventilation, external respiration and cellular respiration  Oxygen and carbon dioxide transport

Slide 31: The Assessment HISTORY  Reason for seeking care  Present illness  Previous illness  Family history  Social history

Slide 32: The Assessment PHYSICAL EXAMINATION  Skin- cyanosis, pallor  Nail clubbing  Cough and sputum production  Inspect - palpate - percuss - auscultate the thorax

Slide 33: The Assessment LABORATORY EXAMINATION  1. ABG analysis  2. Sputum analysis  3. Direct visualization - bronchoscopy  4. Indirect visualization - CXR, CT and MRI  5. Pulmonary function test

Slide 34: ABG Analysis  This test helps to evaluate gas exchange in the lungs by measuring the gas pressures and pH of an arterial sample

Slide 35: ABG Analysis  Pre-test: choose site carefully, perform the Allen’s test, secure equipments- syringe, needle, container with ice  Intra-test: Obtain a 5 mL specimen from the artery (brachial, femoral and radial)  Post-test: Apply firm pressure for 5 minutes, label specimen correctly, place in the container with ice

Slide 36: ABG Analysis ABG normal values  PaO2 80-100 mmHg  PaCO2 35-45 mmHg  pH 7.35- 7.45  HCO3 22- 26 mEq/L  O2 Sat 95-99%

Slide 37: Sputum Analysis  Thistest analyzes the sample of sputum to diagnose respiratory diseases, identify organism, and identify abnormal cells

Slide 38: Sputum Analysis Pre-test: Encourage to increase fluid intake  Intra-test: rinse mouth with WATER only, instruct the patient to take 3 deep breaths and force a deep cough, steam nebulization, collect early morning sputum  Post-test: provide oral hygiene, label specimen correctly

Slide 39: Pulse Oximetry  Non-invasive method of continuously monitoring the oxygen saturation of hemoglobin  A sensor or probe is attached to the earlobe, forehead, fingertip or the bridge of the nose

Slide 40: Bronchoscopy A direct inspection of the trachea and bronchi through a flexible fiber-optic or a rigid bronchoscope  Done to determine location of pathologic lesions, to remove foreign objects, to collect tissue specimen and remove secretions/aspirated materials

Slide 41: Bronchoscopy Pre-test: Consent, NPO x 6h, teaching  Intra-test: position supine or sitting upright in a chair, administer sedative, gag reflex will be abolished, remove dentures  Post-test: NPO until gag reflex returns, position SEMI-fowler’s with head turned to sides, hoarseness is temporary, CXR after the procedure, keep tracheostomy set and suction x 24 hours

Slide 42: Thoracentesis  Pleural fluid aspiration for obtaining a specimen of pleural fluid for analysis, relief of lung compression and biopsy specimen collection

Slide 43: Thoracentesis Pre-test: Consent  Intra-test: position the patient sitting with arms on a table or side-lying fowler’s, instruct not to cough, breathe deeply or move  Post-test: position unaffected side to allow lung expansion of the affected side, CXR obtained, maintain pressure dressing and monitor respiratory status

Slide 44: Pulmonary Function Tests  Volume and capacity tests aid diagnosis in patient with suspected pulmonary dysfunction  Evaluates ventilatory function  Determines whether obstructive or restrictive disease  Can be utilized as screening test

Slide 45: Pulmonary Function Test Lung Volumes  Tidal volume  Inspiratory reserve volume  Expiratory reeve volume  Residual volume

Slide 46: Pulmonary Function Test Lung capacities  Inspiratory capacity  Vital capacity  Functional residual capacity  Total lung capacity

Slide 47: Pulmonary Function Test Pre-test: Teaching, no smoking for 3 days,  only light meal 4 hours before the test  Intra-test: position sitting, bronchodilator, nose-clip and mouthpiece, fatigue and dyspnea during the test  Post-test: adequate rest periods, loosen tight clothing

Slide 48: Common Respiratory Problems and the common interventions

Slide 49: Dyspnea Breathing difficulty Associated with many conditions- CHF, MG, GBS, Muscular dystrophy, obstruction, etc…

Slide 50: Dyspnea General nursing interventions:  1. Fowler’s position to promote maximum lung expansion and promote comfort. An alternative position is the ORTHOPNEIC position  2. O2 usually via nasal cannula  3. Provide comfort and distractions

Slide 51: Cough and sputum production Cough is a protective reflex  Sputum production has many stimuli  Thick, yellow, green or rust-colored bacterial pneumonia  Profuse, Pink, frothy pulmonary edema  Scant, pink-tinged, mucoid Lung tumor

Slide 52: Cough and sputum production General nursing Intervention  1. Provide adequate hydration  2. Administer aerosolized solutions  3. advise smoking cessation  4. oral hygiene

Slide 53: Cyanosis  Bluishdiscoloration of the skin  A LATE indicator of hypoxia  Appears when the unoxygenated hemoglobin is more than 5 grams/dL  Central cyanosis observe color on the undersurface of tongue and lips  Peripheral cyanosis observe the nail beds, earlobes

Slide 54: Cyanosis  Interventions:  Check for airway patency  Oxygen therapy  Positioning  Suctioning  Chest physiotherapy  Check for gas poisoning  Measures to increased hemoglobin

Slide 55: Hemoptysis  Expectoration of blood from the respiratory tract  Common causes: Pulmo infection, Lung CA, Bronchiectasis, Pulmo emboli  Bleeding from stomach  acidic pH, coffee ground material

Slide 56: Hemoptysis Interventions:  Keep patent airway  Determine the cause  Suction and oxygen therapy  Administer Fibrin stabilizers like aminocaproic acid and tranexamic acid

Slide 57: Epistaxis  Bleeding from the nose caused by rupture of tiny, distended vessels in the mucus membrane  Most common site- anterior septum Causes  1. trauma  2. infection  3. Hypertension  4. blood dyscrasias , nasal tumor, cardio diseases

Slide 58: Epistaxis Nursing Interventions  1. Position patient: Upright, leaning forward, tilted prevents swallowing and aspiration  2. Apply direct pressure. Pinch nose against the middle septum x 5-10 minutes  3. If unrelieved, administer topical vasoconstrictors, silver nitrate, gel foams  4. Assist in electrocautery and nasal packing for posterior bleeding

Slide 59: CONDITIONS OF THE UPPER AIRWAY Upper airway infections  1. Rhinitis- allergic, non-allergic and infectious  2. Sinusitis- acute and chronic  3. Pharyngitis- acute and chronic

Slide 60: CONDITIONS OF THE UPPER AIRWAY Upper airway infections 1. Rhinitis- Assessment findings  Rhinorrhea  Nasal congestion  Nasal itchiness  Sneezing  Headache

Slide 61: CONDITIONS OF THE UPPER AIRWAY Upper airway infections 2. sinusitis- Assessment findings  Facial pain  Tenderness over the paranasal sinuses  Purulent nasal discharges  Ear pain, headache, dental pain  Decreased sense of smell

Slide 62: CONDITIONS OF THE UPPER AIRWAY Upper airway infections 3. Pharyngitis- Assessment findings  Fiery-red pharyngeal membrane  White-purple flecked exudates  Enlarged and tender cervical lymph nodes  Fever malaise ,sore throat  Difficulty swallowing  Cough may be absent

Slide 63: CONDITIONS OF THE UPPER AIRWAY  Upper airway infections- Laboratory tests  1. CBC  2. Culture

Slide 64: CONDITIONS OF THE UPPER AIRWAY Upper airway infections: Nursing Interventions 1. Maintain Patent Airway  Increase fluid intake to loosen secretions  Utilize room vaporizers or steam inhalation  Administer medications to relieve nasal congestion

Slide 65: CONDITIONS OF THE UPPER AIRWAY Upper airway infections: Nursing Interventions 2. Promote comfort  Administer prescribed analgesics  Administer topical analgesics  Warm gargles for the relief of sore throat  Provide oral hygiene

Slide 66: CONDITIONS OF THE UPPER AIRWAY Upper airway infections: Nursing Interventions 3. Promote communication  Instruct patient to refrain from speaking as much as possible  Provide writing materials

Slide 67: CONDITIONS OF THE UPPER AIRWAY Upper airway infections: Nursing Interventions 4. Administer prescribed antibiotics  Monitor for possible complications like meningitis, otitis media, abscess formation 5. Assist in surgical intervention

Slide 68: CONDITIONS OF THE UPPER AIRWAY Upper airway infection: Tonsillitis  Infection and inflammation of the tonsils  Most common organism- Group A- beta hemolytic streptococcus (GABS)

Slide 69: CONDITIONS OF THE UPPER AIRWAY Upper airway infection: Tonsillitis  ASSESSMENT FINDINGS  Sore throat and mouth breathing  Fever  Difficulty swallowing  Enlarged, reddish tonsils  Foul-smelling breath

Slide 70: CONDITIONS OF THE UPPER AIRWAY Upper airway infection: Tonsillitis  Laboratory test  1. CBC  2. throat culture

Slide 71: CONDITIONS OF THE UPPER AIRWAY Upper airway infection: Tonsillitis  MEDICAL management  1. Antibiotics- penicillin  2. Tonsillectomy for chronic cases and abscess formation

Slide 72: CONDITIONS OF THE UPPER AIRWAY Upper airway infection: Tonsillitis  NURSING INTERVENTION for tonsillectomy  1. Pre-operative care  Consent  Routine pre-op surgical care

Slide 73: CONDITIONS OF THE UPPER AIRWAY Upper airway infection: Tonsillitis  NURSING INTERVENTION for tonsillectomy  2. POST-operative care  Position: Most comfortable is PRONE, with head turned to side  Maintain oral airway, until gag reflex returns

Slide 74: CONDITIONS OF THE UPPER AIRWAY Upper airway infection: Tonsillitis  NURSING INTERVENTION for tonsillectomy  2. POST-operative care  Apply ICE collar to the neck to reduce edema  Advise patient to refrain from talking and coughing  Ice chips are given when there is no bleeding and gag reflex returns

Slide 75: CONDITIONS OF THE UPPER AIRWAY Upper airway infection: Tonsillitis  NURSING INTERVENTION for tonsillectomy  2. POST-operative care  Notify physician if  a. Patient swallows frequently  b. vomiting of large amount of bright red or dark blood  c. PR increased, restless and Temp is increased

Slide 76: Laryngeal Cancer A malignant tumor of the larynx  More frequent in men  50-70 years old RISK FACTORS 1. Smoking 2. Alcohol 3. Exposure to chemicals 4. Straining of voice 5. chronic laryngitis 6. Deficiency of Riboflavin 7. family history

Slide 77: Laryngeal Cancer  Growth can be anywhere in the larynx  1. Supraglottic- above the vocal cords  2. glottic- vocal cord area  3. infraglottic- below the vocal cords  Most tumors are found in the glottic area

Slide 78: Laryngeal Cancer  ASSESSMENT FINDINGS  Hoarseness of more than TWO weeks duration  Cough and sore throat  Burning and pain in the throat especially after consuming HOT liquids and citrus foods  Neck lump  Dysphagia, dyspnea, foul breath, CLAD

Slide 79: Laryngeal Cancer  LABORATORY FINDINGS  1. Indirect laryngoscopy  2. direct laryngoscopy  3. Biopsy  4. CT and MRI  Most commonly- squamos carcinoma

Slide 80: Laryngeal Cancer MEDICAL MANAGEMENT  Radiation therapy  Chemotherapy  Surgery  Partial laryngectomy  Supraglottic laryngectomy  Hemilaryngectomy  Total laryngectomy

Slide 81: Laryngeal Cancer NURSING MANAGEMENT: PRE-operative  1. Provide the patient pre-operative teachings  Clarify misconceptions  Tell that the natural voice will be lost  Teach communication alternatives  Collaborate with other team members

Slide 82: Laryngeal Cancer NURSING MANAGEMENT  2. reduce patient ANXIETY  Provide opportunities for patient and family members to ask questions  Referrals to previous patients with laryngeal cancers and cancer groups

Slide 83: Laryngeal Cancer NURSING MANAGEMENT: POST-op  3. Maintain PATENT Airway  Position patient: Semi or High Fowler’s  Suction secretions  Encourage to deep breath, turn and cough

Slide 84: Laryngeal Cancer NURSING MANAGEMENT: POST-op  4. Administer care of the laryngectomy tube  Suction as needed  Cleanse the stoma with saline  Administer humidified oxygen  Laryngectomy tube is usually removed within 3-6 weeks after surgery

Slide 85: Laryngeal Cancer NURSING MANAGEMENT: POST-op  5. Promote alternative communication methods  Call bell or hand bell  Magic Slate  Hand signals  Collaborate with speech therapist

Slide 86: Laryngeal Cancer NURSING MANAGEMENT: POST-op  6. Promote adequate Nutrition  NPO after operation  No foods or drinks per orem for 10 days  IVF, TPN are alternative nutrition routes  Start oral feedings with thick liquids, avoid sweet foods

Slide 87: Laryngeal Cancer NURSING MANAGEMENT: POST-op  7. Promote positive body image and self- esteem  Encourage verbalization of feelings  Allow independence in self-care

Slide 88: Laryngeal Cancer NURSING MANAGEMENT: POST-op  8. Monitor for COMPLICATIONS  Respiratory Distress  Suction  Coughing and deep breathing  Humidified oxygen  Alert the surgeon

Slide 89: Laryngeal Cancer NURSING MANAGEMENT: POST-op  8. Monitor for Complications  Hemorrhage  Monitor for bleeding  Monitor vital signs  Apply direct pressure over the bleeding artery  Summon assistance and alert the surgeon

Slide 90: Laryngeal Cancer NURSING MANAGEMENT: POST-op  8. Monitor for COMPLICATIONS  Wound infection and breakdown  Monitor for increased temperature, purulent drainage and increased redness/tenderness  Administer antibiotics  Clean and change dressing OD

Slide 91: Laryngeal Cancer NURSING MANAGEMENT: HOME CARE  Humidification system at home is needed  AVOID swimming  Cover the stoma with hands or plastic bib over the opening  Advise beauty salons to avoid hair sprays, powders and loose hair near the opening  Oral hygiene frequently

Slide 92: Acute Respiratory Failure  Sudden and life-threatening deterioration of the gas-exchange function of the lungs  Occurs when the lungs no longer meet the body’s metabolic needs

Slide 93: Acute Respiratory Failure  Defined clinically as:  1. PaO2 of less than 50 mmHg  2. PaCO2 of greater than 5o mmHg  3. Arterial pH of less than 7.35

Slide 94: Acute Respiratory Failure CAUSES  CNS depression- head trauma, sedatives  CVS diseases- MI, CHF, pulmonary emboli  Airway irritants- smoke, fumes  Endocrine and metabolic disorders- myxedema, metabolic alkalosis  Thoracic abnormalities- chest trauma, pneumothorax

Slide 95: Acute Respiratory Failure PATHOPHYSIOLOGY  Decreased Respiratory Drive  Brain injury, sedatives, metabolic disorders  impair the normal response of the brain to normal respiratory stimulation

Slide 96: Acute Respiratory Failure PATHOPHYSIOLOGY  Dysfunction of the chest wall  Dystrophy, MS disorders, peripheral nerve disorders disrupt the impulse transmission from the nerve to the diaphragm abnormal ventilation

Slide 97: Acute Respiratory Failure PATHOPHYSIOLOGY  Dysfunction of the Lung Parenchyma  Pleural effusion, hemothorax, pneumothorax, obstruction interfere ventilation prevent lung expansion

Slide 98: Acute Respiratory Failure ASSESSMENT FINDINGS  Restlessness  dyspnea  Cyanosis  Altered respiration  Altered mentation  Tachycardia  Cardiac arrhythmias  Respiratory arrest

Slide 99: Acute Respiratory Failure  DIAGNOSTIC FINDINGS  Pulmonary function test- pH below 7.35  CXR- pulmonary infiltrates  ECG- arrhythmias

Slide 100: Acute Respiratory Failure  MEDICAL TREATMENT  Intubation  Mechanical ventilation  Antibiotics  Steroids  Bronchodilators

Slide 101: Acute Respiratory Failure  NURSING INTERVENTIONS  1. Maintain patent airway  2. Administer O2 to maintain Pa02 at more than 50 mmHg  3. Suction airways as required  4. Monitor serum electrolyte levels  5. Administer care of patient on mechanical ventilation

Slide 102: COPD  These are group of disorders associated with recurrent or persistent obstruction of air passage and airflow, usually irreversible.

Slide 103: COPD  Themost common cause of COPD is cigarette smoking. Asthma, Chronic bronchitis, Emphysema and Bronchiectasis are the common disorders.

Slide 104: COPD The general pathophysiology:  In COPD there is airflow limitation that is both progressive and associated with abnormal inflammatory response of the lungs to stimuli, usually smoke, particles and dust

Slide 105: ASTHMA  Theacute episode of airway obstruction is characterized by airway hyperactivity to various stimuli that results in recurrent wheezing brought about by edema and bronchospasm

Slide 106: Asthma Pathophysiology  Immunologic/allergic reaction results in histamine release, which produces three main airway responses  a. Edema of mucous membranes  b. Spasm of the smooth muscle of bronchi and bronchioles  c. Accumulation of tenacious secretions

Slide 107: Asthma Assessment Findings Assessment findings  1. Family history of allergies  2. Client history of eczema

Slide 108: Asthma Assessment Findings Assessment findings  3. Pulmonary signs and symptoms- Respiratory distress: slow onset of shortness of breath, expiratory wheeze, prolonged expiratory phase, air trapping (barrel chest if chronic), use of accessory muscles, irritability (from hypoxia), diaphoresis, cough, anxiety, weak pulse, diaphoresis and change in sensorium if severe attack

Slide 109: Asthma Assessment Findings Assessment findings  4. Use of accessory muscles of respiration, inspiratory retractions, prolonged I:E ratio  5. Cardiovascular symptoms: tachycardia, ECG changes, hypertension, decreased cardiac contractility, pulsus paradoxus  6. CNS manifestations: anxiety, restlessness, fear and disorientation

Slide 110: Emphysema  There is progressive and irreversible alveolocapillary destruction with abnormal alveolar enlargement causing alveolar wall destruction. The result is INCREASED lung compliance, DECREASED oxygen diffusion and INCREASED airway resistance!

Slide 111: Emphysema These changes cause a state of carbon dioxide retention, hypoxia, and respiratory acidosis.

Slide 112: Emphysema Cigarette smoking Heredity, Bronchial asthma Aging process Disequilibrium between ELASTASE & ANTIELASTASE (alpha-1-antitrypsin) Destruction of distal airways and alveoli Overdistention of ALVEOLI Hyper-inflated and pale lungs Air traping, decreased gas exchange and Retention of CO2 Hypoxia Respiratory acidosis

Slide 113: Emphysema Assessment 1. Anorexia, fatigue, weight loss 2. Feeling of breathlessness, cough, sputum production, flaring of the nostrils, use of accessory muscles of respiration, increased rate and depth of breathing, dyspnea

Slide 114: Emphysema Assessment  3. Decreased respiratory excursion, resonance to hyper- resonance, decreased breath sounds with prolonged expiration, normal or decreased fremitus  4. Diagnostic tests: pCO2 elevated or normal; PO2 normal or slightly decreased

Slide 115: Chronic bronchitis  Chronic inflammation of the bronchial air passageway characterized by the presence of cough and sputum production for at least 3 months in each 2 consecutive years.  Excessive production of mucus in the bronchi with accompanying persistent cough.

Slide 116: Chronic Bronchitis pathophysiology Characteristic changes include  hypertrophy/ hyperplasia of the mucus-secreting glands in the bronchi, decreased ciliary activity, chronic inflammation, and narrowing of the small airways.

Slide 117: Chronic Bronchitis Assessment  I.Productive (copious) cough, dyspnea on exertion, use of accessory muscles of respiration, scattered rales and rhonchi  2. Feeling of epigastric fullness, cyanosis, distended neck veins, ankle edema  3. Diagnostic tests: increased pCO2 decreased PO2

Slide 118: Bronchiectasis  Permanent abnormal dilation of the bronchi with destruction of muscular and elastic structure of the bronchial wall

Slide 119: Bronchiectasis Caused by bacterial infection;  recurrent lower respiratory tract infections; congenital defects (altered bronchial structures); lung tumors

Slide 120: Bronchiectasis  1. Chronic cough with production of mucopurulent sputum, hemoptysis, exertional dyspnea, wheezing  2. Anorexia, fatigue, weight loss  3. Diagnostic tests  a. Bronchoscopy reveals sources and sites of secretions  b. Possible elevation of WBC

Slide 121: COPD Management Independent and Collaborative Management  1. Rest-To reduce oxygen demands of tissues  2. Increase fluid intake-To liquefy mucus secretions  3. Good oral care-To remove sputum and prevent infection

Slide 122: COPD Management Independent and Collaborative Management 4. Diet:  High caloric diet provides source of energy  High protein diet helps maintain integrity of alveolar walls  Moderate fats  Low carbohydrate diet limits carbon dioxide production (natural end product). The client has difficulty exhaling carbon dioxide.

Slide 123: COPD Management  Independent and Collaborative Management 5. O2 therapy 1 to 3 lpm (2 lpm is safest)  Do not give high concentration of oxygen. The drive for breathing may be depressed.

Slide 124: COPD Management  Independent and Collaborative Management  6. Avoid cigarette smoking, alcohol, and environmental pollutants-These inhibit mucociliary function.  7. CPT –percussion, vibration, postural drainage

Slide 125: COPD Management  Independent and Collaborative Management  8. Bronchial hygiene measures  Steam inhalation  Aerosol inhalation  Medimist inhalation

Slide 126: COPD Management Pharmacotherapy  1. Expectorants (guaiafenessin)/ mucolytic (mucomyst/mucosolvan)  2. Antitussives  Dextrometorphan  Codeine  Observe for drowsiness  Avoid activities that involve mental alertness, e.g driving, operating electrical machines  Cause decrease peristalsis thereby constipation

Slide 127: COPD Management  Pharmacotherapy  3.Bronchodilators  Aminophylline (Theophylline)  Ventolin (Salbutamol)  Bricanyl (Terbutaline)  Alupent (Metaproterenol)  Observe for tachycardia

Slide 128: COPD Management  Pharmacotherapy  4. Antihistamine  Benadryl (Diphenhydramine)  Observe for drowsiness  5. Steroids  Anti-inflammatory effect  6. Antimicrobials

Slide 129: Flail Chest Complication of chest trauma occurring when 3 or more adjacent ribs are fractured at two or more sites, resulting in free-floating rib segments.

Slide 130: Flail Chest Chest wall is no longer able to provide the bony structure necessary to maintain adequate ventilation; consequently the flail portion and underlying tissue move paradoxically (in opposition) to the rest of the chest cage and lungs.

Slide 131: Flail Chest  The flail portion is sucked in on inspiration and bulges out on expiration.  Result is hypoxia, hypercarbia, and increased retained secretions.  Caused by trauma (sternal rib fracture with possible costochondral separations).

Slide 132: Flail Chest PATHOPHYSIOLOGY  During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a “paradoxical” manner  The chest is pulled INWARD during inspiration, reducing the amount of air that can be drawn into the lungs  The chest bulges OUTWARD during expiration because the intrathoracic pressure exceeds atmospheric pressure. The patient has impaired exhalation

Slide 133: Flail Chest This paradoxical action will lead to:  Increased dead space  Reduced alveolar ventilation  Decreased lung compliance  Hypoxemia and respiratory acidosis  Hypotension, inadequate tissue perfusion can also follow

Slide 134: Flail Chest Assessment findings  1. Severe dyspnea; rapid, shallow, grunty breathing; paradoxical chest motion. The chest will move INWARDS on inhalation and OUTWARDS on exhalation.  2. Cyanosis, possible neck vein distension, tachycardia, hypotension  3. Diagnostic tests a. PO2 decreased  b. pCO2 elevated  c. pH decreased 

Slide 135: Flail Chest Nursing interventions  1. Maintain an open airway: suction secretions, blood from nose, throat, mouth, and via endotracheal tube; note changes in amount, color, and characteristics.  2. Monitor mechanical ventilation  3. Encourage turning, coughing, and deep breathing.  4. Monitor for signs of shock: HYPOTENSION, TACHYCARDIA

Slide 136: Flail Chest Medical management: SUPPORTIVE  1. Internal stabilization with a volume-cycled ventilator  2. Drug therapy (narcotics, sedatives)

Slide 137: Pneumothorax Partial or complete collapse of the lung due to an accumulation of air or fluid in the pleural space

Slide 138: Pneumothorax Types  a. Spontaneous pneumothorax: the most common type of closed pneumothorax; air accumulates within the pleural space without an obvious cause. Rupture of a small bleb on the visceral pleura most frequently produces this type of pneumothorax.

Slide 139: Pneumothorax Types  b. Open pneumothorax: air enters the pleural space through an opening in the chest wall; usually caused by stabbing or gunshot wound.

Slide 140: Pneumothorax Types  c. Tension pneumothorax: air enters the pleural space with each inspiration but cannot escape; causes increased intrathoracic pressure and shifting of the mediastinal contents to the unaffected side (mediastinal shift).

Slide 141: Pneumothorax Assessment findings  1. Sudden sharp pain in the chest, dyspnea, diminished or absent breath sounds on affected side, tracheal shift to the opposite side (tension pneumothorax accompanied by mediastinal shift)  2. Weak, rapid pulse; anxiety; diaphoresis

Slide 142: Pneumothorax Assessment findings  3. Diagnostic tests a. Chest x-ray reveals area and degree of  pneumothorax b. pCO2 elevated  c. pH decreased 

Slide 143: Pneumothorax Nursing interventions 1. Provide nursing care for the client with an endotracheal tube: suction secretions, vomitus, blood from nose, mouth, throat, or via endotracheal tube; monitor mechanical ventilation.

Slide 144: Pneumothorax Nursing interventions 2. Restore/promote adequate respiratory function.  a. Assist with thoracentesis and provide appropriate nursing care.  b. Assist with insertion of a chest tube to water- seal drainage and provide appropriate nursing care.  c. Continuously evaluate respiratory patterns and report any changes.

Slide 145: Pneumothorax Nursing interventions 3. Provide relief/control of pain.  a. Administer narcotics/analgesics/sedatives as ordered and monitor effects.  b. Position client in high-Fowler’s position.

Slide 146: Atelectasis  Collapse of part or all of a lung due to bronchial obstruction  May be caused by  intrabronchial obstruction  tumors, bronchospasm  foreign bodies  extrabronchial compression (tumors, enlarged lymph nodes); or  endobronchial disease (bronchogenic carcinoma, inflammatory structures)

Slide 147: Atelectasis Assessment findings  1. Signs and symptoms may be absent depending upon degree of collapse and rapidity with which bronchial obstruction occurs  2. Dyspnea, decreased breath sounds on affected side, decreased respiratory excursion, dullness to flatness upon percussion over affected area

Slide 148: Atelectasis Assessment findings  3. Cyanosis, tachycardia, tachypnea, elevated temperature, weakness, pain over affected area

Slide 149: Atelectasis Assessment findings 4. Diagnostic tests  a. Bronchoscopy: may or may not reveal an obstruction  b. Chest x-ray shows diminished size of affected lung and lack of radiance over atelectatic area  c. pO2 decreased

Slide 150: Pleural Effusion  Defined broadly as a collection of fluid in the pleural space  A symptom, not a disease; may be produced by numerous conditions

Slide 151: Pleural Effusion General Classification Transudative effusion: accumulation of protein-poor, cell-poor fluid Exudativeeffusion: accumulation of protein rich fluid

Slide 152: Pleural Effusion Assessment findings  1. Dyspnea, dullness over affected area upon percussion, absent or decreased breath sounds over affected area, pleural pain, dry cough, pleural friction rub  2. Pallor, fatigue, fever, and night sweats (with empyema)

Slide 153: Pleural Effusion Assessment findings 3. Diagnostic tests  a. Chest x-ray positive if greater than 250 cc pleural fluid  b. Pleural biopsy may reveal bronchogenic carcinoma  c. Thoracentesis may contain blood if cause is cancer, pulmonary infarction, or tuberculosis; positive for specific organism in empyema.

Slide 154: Pleural Effusion Nursing interventions: In general:  1. Assist with repeated thoracentesis.  2. Administer narcotics/sedatives as ordered to decrease pain.  3. Assist with instillation of medication into pleural space (reposition client every 15 minutes to distribute the drug within the pleurae).  4. Place client in high-Fowler’s position to promote ventilation.

Slide 155: Pleural Effusion Medical management  1. Identification and treatment of the Underlying cause  2. Thoracentesis  3. Drug therapy  a. Antibiotics: either systemic or inserted directly into pleural space  b. Fibrinolytic enzymes: trypsin, streptokinase-. streptodornase to decrease thickness of pus and dissolve fibrin clots  4. Closed chest drainage  5. Surgery: open drainage

Slide 156: Pneumonia An inflammation of the alveolar spaces of the lung, resulting in consolidation of lung tissue as the alveoli fill with exudates  The various types of pneumonias are classified according to the offending organism.  Pneumonia can also be classified as COMMUNITY Acquired Pneumonia (CAP) and Hospital acquired pneumonia (HAP)

Slide 157: Pneumonia PATHOPHYSIOLOGIC FINDINGS ARE:  HYPERTROPHY OF MUCOUS MEMBRANE  Increased sputum production  Wheezing  Dyspnea  Cough  Rales  Ronchi

Slide 158: Pneumonia PATHOPHYSIOLOGIC FINDINGS ARE:  INCREASED CAPILLARY PERMEABILITY  Increased Fluid Exudation  Consolidation-tissue that solidifies as a result of collapsed alveoli  Hypoxemia

Slide 159: Pneumonia PATHOPHYSIOLOGIC FINDINGS ARE: INFLAMMATION OF THE PLEURA  Chest pain  Pleural effusion  Dullness  Decreased Breath sounds  Increased tactile fremitus

Slide 160: Pneumonia PATHOPHYSIOLOGIC FINDINGS ARE: HYPOVENTILATION  Decreased Chest expansion  Respiratory acidosis Depressed PROTECTIVE MECHANISM  Increased WBC (leukocytosis)  Increased RR and Fever

Slide 161: Pneumonia Assessment findings  Cough with greenish to rust-colored sputum production  rapid, shallow respirations with an expiratory grunt  nasal flaring; intercostal rib retraction; use of accessory muscles of respiration  rales or crackles (early) progressing to coarse (later).  Tactile fremitus is INCREASED!

Slide 162: Pneumonia Assessment findings  Fever, chills, chest pain, weakness, generalized malaise  Tachycardia, cyanosis, profuse perspiration, abdominal distension  Rapid shallow breathing

Slide 163: Pneumonia Diagnostic tests  a. Chest x-ray shows consolidation over affected areas  b. WBC increased  c. pO2 decreased  d. Sputum specimen- culture reveal particular causative organism

Slide 164: Pneumonia 1. Facilitate adequate ventilation.  a. Administer oxygen as needed and assess its effectiveness.  b. Place client in Fowler’s position.  c. Turn and reposition frequently clients who are immobilized/obtunded.  d. Administer analgesics as ordered to relieve pain associated with breathing  e. Auscultate breath sounds every 2—4 hours.  f. Monitor ABGs.

Slide 165: Pneumonia GENERAL Nursing interventions 2. Facilitate removal of secretions  general hydration  deep breathing and coughing  Suctioning  Expectorants  aerosol treatments via nebulizer, humidification of inhaled air  chest physical therapy

Slide 166: Pneumonia GENERAL Nursing interventions 3. Observe color, characteristics of sputum and report any changes; encourage client to perform good oral hygiene after expectoration.

Slide 167: Pneumonia GENERAL Nursing interventions 4. Provide adequate rest and relief/control of pain.  a. Provide bed rest with limited physical activity.  b. Limit visits and minimize conversations.  c. Plan for uninterrupted rest periods.  d. Institute nursing care in blocks to ensure periods of rest.  e. Maintain pleasant and restful environment

Slide 168: Pneumonia GENERAL Nursing interventions 5. Administer antibiotics as ordered. Monitor effects and possible toxicity. 6. Prevent transmission (respiratory isolation may be required for clients with staphylococcal pneumonia). 7. Control fever and chills: monitor temperature and administer  antipyretics as ordered, maintain increased fluid intake, provide frequent clothing and linen changes.

Slide 169: Pneumonia GENERAL Nursing interventions 8. Provide client teaching and discharge planning concerning prevention of recurrence. a. Medication regimen/antibiotic therapy  b. Need for adequate rest,  c. Need to continue deep breathing and coughing 

Slide 170: Pneumonia GENERAL Nursing interventions 8. Provide client teaching and discharge planning concerning prevention of recurrence. d. Availability of vaccines  e. Techniques that prevent transmission (use of  tissues when coughing, adequate disposal of secretions) f. Avoidance of persons with known respiratory  infections g. Need to report signs and symptoms of  respiratory infection

Slide 171: Lung Cancer Primary pulmonary tumors arise from the bronchial epithelium and are therefore referred to as bronchogenic carcinomas. FACTORS: Possibly caused by inhaled carcinogens (primarily cigarette smoke but also asbestos, nickel, iron oxides, air silicone pollution; preexisting pulmonary disorders PTB, COPD)

Slide 172: Lung Cancer Assessment findings  Persistent cough (may be productive or blood tinged)  chest pain  dyspnea  unilateral wheezing, friction rub, possible unilateral paralysis of the diaphragm  Fatigue, anorexia, nausea, vomiting, pallor

Slide 173: Lung Cancer Diagnostic tests.  a. Chest x-ray may show presence of tumor or evidence of metastasis to surrounding structures  b. Sputum for cytology reveals malignant cells  c. Bronchoscopy: biopsy reveals malignancy  d. Thoracentesis: pleural fluid contains malignant cells  e. Biopsy of lymph nodes may reveal metastasis

Slide 174: Lung Cancer 1. Provide support and guidance to client as needed. 2. Provide relief/control of pain. 3. Administer medications as ordered and monitor effects/side effects. 4. Control nausea: administer medications as ordered, provide good oral hygiene, provide small and more frequent feedings.

Slide 175: Lung Cancer 5. Provide nursing care for a client with a thoracotomy. 6. Provide client teaching and discharge planning concerning  a. Disease process, diagnostic and therapeutic interventions  b. Side effects of radiation and chemotherapy  c. Realistic information about prognosis

Slide 176: Lung Cancer Medical management  1. Radiation therapy  2. Chemotherapy: usually includes cyclophosphamide, methotrexate, vincristine, doxorubicin, and procarbazine; concurrently in some combination  3. Surgery: when entire tumor can be removed

Slide 177: Lung Cancer Quick Notes on Bronchogenic Cancer Predisposing factors  Cigarette smoking  Asbestosis  Emphysema  Smoke from burnt wood Types  Squamous cell Ca- with good prognosis  Adenocarcinoma- with good prognosis  Oat cell Ca- with good prognosis  Undifferentiated Ca- with poor prognosis

Slide 178: Lung Cancer Quick Notes on Bronchogenic Cancer Nursing Interventions  Patent airway  O2 / Aerosol therapy  Deep breathing exercises  Relief of pain  Protection from infection  Adequate nutrition  Chest tube management

Slide 179: Lung Cancer Quick Notes on Bronchogenic Cancer Surgery  Pneumonectomy=Removal of a lung (either left or right)  Lobectomy=Removal of a lobe.  Segmentectomy=Removal of a segment.  Wedge resection=Removal of the entire tumor regardless of the segment.  Decortication=Stripping off of fibrinous membrane enclosing the lung  Thoracoplasty=Removal of rib/s. Usually done after pneumonectomy, to reduce the size of the empty thorax thereby prevent mediastinal shift.

Slide 180: Pulmonary Embolism This refers to the obstruction of the pulmonary artery or one of its branches by a blood clot (thrombus) that originates somewhere in the venous system or in the right side of the heart.  Most commonly, pulmonary embolism is due to a clot or thrombus from the deep veins of the lower legs.

Slide 181: Pulmonary Embolism Causes  Fat embolism. Air embolism  Multiple trauma  PVD’s  Abdominal surgery  Immobility  Hypercoagulability

Slide 182: Pulmonary Embolism PATHOPHYSIOLOGY  The thrombus that travels from any part of the venous system obstructs either completely or partially. Then the lungs will have inadequate blood supply, with resultant increase in dead space in the lungs  Gas exchange will be impaired or absent in the involved area

Slide 183: Pulmonary Embolism PATHOPHYSIOLOGY  The regional pulmonary vasculature will constrict causing increased resistance, increased pulmonary arterial pressure and then increase workload of the right side of the heart.

Slide 184: Pulmonary Embolism PATHOPHYSIOLOGY  When the work of the right side of the heart exceeds its capacity, right ventricular failure will result, leading to a decrease in cardiac output followed by decreased systemic perfusion and eventually, SHOCK

Slide 185: Pulmonary Embolism Assessment  Restlessness (cardinal initial sign)  Dyspnea  Stabbing chest pain  Cyanosis  Tachycardia  Dilated pupils  Apprehension/ fear  Diaphoresis  Dysrhythmias  Hypoxia

Slide 186: Pulmonary Embolism Diagnostic Tests: Ventilation-perfusion scan Pulmonary arteriography CXR ECG ABG

Slide 187: Pulmonary Embolism Nursing Interventions  Oxygen therapy STAT  Early ambulation postop  Monitor obese patient  Do not massage legs  Relieve pain- analgesics  HOB elevated  Heparin (2 weeks) then Coumadin (3-6 months)

Slide 188: Pulmonary Embolism Patient Teaching for prevention of Pulmonary Embolism  Active leg exercises to avoid venous stasis  Early ambulation  Use of elastic compression stockings  Avoidance of leg-crossing and sitting for prolonged periods  Drink fluids

Slide 189: Surgical Aspect of Respiratory Care Thoracic Surgery  a. Exploratory thoracotomy: anterior or posterolateral incision through the fourth, fifth, sixth, or seventh intercostal spaces to expose and examine the pleura and lung

Slide 190: Surgical Aspect of Respiratory Care Thoracic Surgery  b. Lobectomy: removal of one lobe of a lung; treatment for bronchiectasis, bronchogenic carcinoma, emphysematous blebs, lung abscesses

Slide 191: Surgical Aspect of Respiratory Care Thoracic Surgery  c. Pneumonectomy: removal of an entire lung; most commonly done as treatment for bronchogenic carcinoma

Slide 192: Surgical Aspect of Respiratory Care Thoracic Surgery  d. Segmental resection: removal of one or more segments of lung; most often done as treatment for bronchiectasis

Slide 193: Surgical Aspect of Respiratory Care Thoracic Surgery  e. Wedge resection: removal of lesions that occupy only part of a segment of lung tissue; for excision of small nodules or to obtain a biopsy

Slide 194: Surgical Aspect of Respiratory Care Nursing interventions: PREOPERATIVE  1. Provide routine pre-op care.  2. Perform a complete physical assessment of the lungs to obtain baseline data.  3. Explain expected post-op measures: care of incision site, oxygen, suctioning, chest tubes (except if pneumonectomy performed)

Slide 195: Surgical Aspect of Respiratory Care Nursing interventions: PREOPERATIVE  4. Teach client adequate splinting of incision with hands or pillow for turning, coughing, and deep breathing.  5. Demonstrate ROM exercises for affected side.  6. Provide chest physical therapy to help remove secretions.

Slide 196: Surgical Aspect of Respiratory Care Nursing interventions: POSTOPERATIVE  1. Provide routine post-op care.  2. Promote adequate ventilation.  a. Perform complete physical assessment of lungs and compare with pre-op findings.  b. Auscultate lung fields every 1—2 hours.  c. Encourage turning, coughing, and deep breathing every 1—2 hours after pain relief obtained.

Slide 197: Surgical Aspect of Respiratory Care Nursing interventions: POSTOPERATIVE  2. Promote adequate ventilation.  d. Perform tracheobronchial suctioning if needed.  e. Assess for proper maintenance of chest drainage system (except after pneumonectomy).  f. Monitor ABGs and report significant changes.  g. Place client in semi-Fowler’s position

Slide 198: Surgical Aspect of Respiratory Care Nursing interventions: POSTOPERATIVE If pneumonectomy is performed, follow surgeon’s orders about positioning, often on back or OPERATIVE SIDE If Lobectomy, patient is usually positioned on the UNOPERATIVE SIDE

Slide 199: Surgical Aspect of Respiratory Care Nursing interventions: POSTOPERATIVE 3. Provide pain relief.  a. Administer narcotics/analgesics prior to turning, coughing, and deep breathing.  b. Assist with splinting while turning, coughing, deep breathing.

Slide 200: Surgical Aspect of Respiratory Care Nursing interventions: POSTOPERATIVE 4. Provide client teaching and discharge planning concerning  a. Need to continue with coughing/deep breathing for 6—8 weeks post-op and to continue ROM exercises  b. Importance of adequate rest with gradual increases in activity levels

Slide 201: Surgical Aspect of Respiratory Care Nursing interventions: POSTOPERATIVE 4. Provide client teaching and discharge planning concerning  c. High-protein diet with inclusion of adequate fluids  d. Chest physical therapy  e. Good oral hygiene  f. Need to avoid persons with known upper respiratory infection  g. Adverse signs and symptoms  h. Avoidance of crowds and poorly ventilated areas.

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Anonymous said...

thanks for posting, it really help me a lot...can u also post MCN ang Communicables Disease...please!!!

Myk said...

I will try to look for MCN and Communicable Diseases questions. If you have stuff that you would like to share with other nurses, please do contact me through email. LETS HELP EACH OTHER!

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