Learning Objectives - Respiratory

Learning Objectives - Respiratory Content Chapter 20 1. Understand how to perform a respiratory assessment & differentiate between normal v. abnormal findings. Normal Findings: - AP diameter 2:1 - Clear, even, unlabored breath - Symmetrical chest rise/fall and expansion - Resonance – heard over healthy lung tissue - Tactile fremitus “99” Abnormal Findings - Chest wall deformities: shape/asymmetry  barrel chest (1:1 COPD); traumatic flail chest (paradoxical breathing); funnel chest (pectus excavatum); pigeon chest (pectus carinatum) kyphoscoliosis (s-shaped spine) - Abnormalities in rate and rhythm: tachypnea; bradypnea; apnea; hyperpnea; Kussmaul’s; Cheyne-stokes, etc. - impaired respiratory movement: substernal retractions, use of accessory muscles (i.e. COPD, asthma) - Percussion: ◦ ◦ Dullness (pneumonia, pleural effusions, tumors); Hyperresonance (asthma, COPD, emphysema pneumothorax if on one side) - Adventitious breath sounds: ◦ Wheezing - lower airway obstruction or tissue inflammation (i.e. asthma) ◦ Stridor – upper airway obstruction, heard on INSPIRATION ◦ Ronchi - chest congestion/secretions in large airways. (SNOREEE) ◦ Crackles/Rales - 2 types of crackles Coarse crackles from fluid (i.e. pneumonia, fluid in the lungs in early congestive heart failure, bronchitis) - Harsh, moist sound originating in the large bronchi and heard early in inspiration Fine crackles from atelectasis (Rice Krispy Treats) - Posterior lung assessment very important b/c crackles start in bases of lungs - Sounds like hair rubbing together, originates in alveoli and heard late in inspiration) ◦ Silent chest – absent or markedly decreased breath sounds (i.e. pneumothorax on affected side) ◦ Pleural friction rub – secondary to inflammation (sounds like two pieces of leather being rubbed together) - Decreased or absent fremitus d/t thick chest wall, COPD, pneumothorax, a tumor, obstructed bronchus 2. Understand the concepts of airway resistance and compliance and factors that affect resistance and compliance. Airway Resistance - determined by diameter of airway, lung volumes and velocity of airflow - Any process that changes the bronchial diameter or width affects airway resistance and alters the rate of airflow - ↑ resistance = more effort required to achieve normal levels of ventilation (think of breathing through a straw) - Causes of increased airway resistance: ◦ Contraction of bronchial smooth muscle (i.e. asthma) ◦ Thickening of bronchial mucosa (i.e. chronic bronchitis) ◦ Obstruction of the airway (i.e. mucus or a tumor) ◦ Loss of lung elasticity (i.e. emphysema - alveoli unable to recoil normally) Compliance - elasticity and expandability of the lungs and thoracic structures. - Compliance allows the lung to expand (ease of distensibility). - Factors that determine lung compliance are the surface tension of the alveoli, the connective tissue and water content of the lungs, and the compliance (expansion) of the thoracic cavity. ◦ Increased or High compliance - lungs have lost their elastic recoil & stretch with ease (i.e. emphysema) ◦ Decreased or Low compliance - lungs and the thorax are “stiff ”/difficult to stretch (i.e. sarcoidosis) - Conditions include morbid obesity, pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, and acute respiratory distress syndrome (ARDS). 3. Have a basic understanding of ventilation, perfusion, and gas exchange A. Ventilation: movement of air in and out of the airways (i.e. breathing) B. Perfusion: CV system pumps de-oxygenated blood through the lungs and delivers oxygenated blood to the tissues C. Gas Exchange: diffusion/exchange of respiratory gases in the alveoli and capillaries (i.e. O2 exchanged for CO2) ◦ Effective gas exchange depends on distribution of gas (ventilation) and blood (perfusion) in all portion of the lung (i.e. ventilation–perfusion (Ѵ/Ǫ) ratio)  Airway blockages, local changes in compliance, and gravity may alter ventilation.  Change in pulmonary artery pressure, alveolar pressure, or gravity cause alterations in perfusion. 4. Be able to identify risk factors for hypoventilation and interventions. Hypoventilation – shallow, irregular breathing resulting in poor ventilation in the lungs - PaCO2 ↑ (body can’t adequately remove carbon dioxide) - PaO2 ↓ Risk Factors: - Neuromuscular diseases  cause weakening of muscles that control breathing  Myasthenia gravis, Guillain–Barré syndrome, polio - Chest wall deformities  interfere with the ability to inhale and exhale  Limited thoracic movement (i.e. kyphoscoliosis)  Limited lung movement (i.e. pleural effusion, pneumothorax) - Severe obesity  causes the body to work harder to breathe)  Obesity hypoventilation syndrome (OHS) ▪ Most people with OHS have concurrent obstructive sleep apnea (OSA) - Obstructive sleep apnea (OSA)  collapses airway during sleep - Chronic lung disease  conditions like COPD and cystic fibrosis that lead to blocked airways  Risk for oxygen induced hypoventilation in pts with COPD - -  Alveolar hypoventilation can lead to respiratory acidosis (retention of CO2) Impaired brain function/signaling  Brain injury  spinal cord trauma, cerebrovascular accidents  Depressed respiratory centers in the medulla  anesthesia, sedation, and drug overdose. Medications  Alcohol, barbiturates, sedatives, opioids, benzodiazepines Interventions:  oxygen therapy to support breathing  weight loss (OHS)  CPAP or BiPAP machine to keep your airway open while sleeping (OSA)  surgery to correct a chest deformity  inhaled medications to open airways and treat ongoing lung disease  Monitor/assess  respiratory rate, depth, and effort; auscultate breath sounds; declining level of consciousness; heart rate/rhythm; skin color, temp, moisture; assist with TCDB; monitor ABGs and pulse oximetry reading; maintain hydration 5. Respiratory Diagnostic tests: Pulmonary Function Tests (PFTs)  Determine lung function and breathing difficulties, are often used in pts with chronic respiratory disorders to aid in diagnosis.  PFTs measure the following: - lung volumes and capacities - flow rate - diffusion capacities - airway resistance - gas exchange - distribution of ventilation Arterial Blood Gases (ABGs)  Indicate the acid-base state and how well oxygen is being carried to the body  ABG aid in assessing pts pulmonary gas exchange, control of ventilation, and kidney function - ability of the lungs to provide adequate oxygen and remove carbon dioxide = reflects ventilation - ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal pH = reflects metabolic states  Complications: - Hematoma, arterial occlusion = occurs when blood accumulates under the skin at IV site  observe for changes in temp, swelling, color, loss of pulse, or pain - Air Embolism = air enters the arterial system during catheter insertion  lay flat, Valsalva maneuver, notify provider! Pulse Oximetry (SpO2)  Measurement of the oxygen saturation of hemoglobin (Sa02) or the amount of oxygen carried by hemoglobin  CAUTION inaccurate readings… - pts can have a normal SaO2 d/t anemia, sickle cell crisis, carbon monoxide exposure pts can have a false low SaO2 d/t poor signal, cold extremities, polycythemia, movement, pail polish, edema, poor peripheral circulation Cultures & Sputum Studies  Sputum is obtained for analysis to identify pathogenic organisms and to determine whether malignant cells are present  Cultures can identify pathogens responsible for respiratory infections - Throat cultures useful in detecting streptococcal infection - Nasal/nasopharyngeal detect Staphylococcus aureus or Influenza  ALL CULTURES SHOULD BE OBTAINED PRIOR TO THE INITIATION OF ANTIBIOTIC THERAPY Bronchoscopy/Laryngoscopy  Direct visual examination of the larynx, trachea, and bronchi with fiber-optic bronchoscope  Can be used for diagnostic or therapeutic purposes: - Diagnostic bronchoscopy = visualize tissues and determine the nature, location, and extent of the pathologic process, collect secretions for analysis // tissue sample for diagnosis, etc. - Therapeutic bronchoscopy = remove foreign bodies or secretions, control bleeding, treat postoperative atelectasis  Complications: - Laryngospasm  monitor for signs of respiratory distress - Pneumothorax  assess breath sounds and SaO2, and obtain follow-up chest x-ray - Aspiration  prevent by withholding oral fluids/food until gag reflex returns (usually 2hrs), suction prn  Thoracentesis  surgical perforation of the chest wall with large-bore needle  performed to obtain specimens for diagnostic evaluation or for the removal of fluid (effusion) or air from the pleural space for therapeutic relief of pleural pressure  Complications: - Mediastinal Shift = shift of thoracic structures to one side of the body → Nursing Actions: Monitor VS and auscultate lung sounds for a decrease or absence of breath sounds - Pneumothorax = collapsed lung d/t injury during the procedure → Nursing Actions: monitor for diminished breath sounds, distended neck veins, asymmetry of the chest wall, respiratory distress, cyanosis & monitor post -op CXR results - Bleeding = bleeding can occur if the client is moved during the procedure or if they are at increased risk for bleeding → Nursing Actions: monitor for coughing and hemoptysis; monitor VS and labs for evidence of bleeding (hypotension, reduced Hgb level); assess site for bleeding - Infection = needle puncture can introduce bacteria → Nursing Actions: ensure sterile technique maintained and monitor temp following the procedure 6. Understand how to interpret ABGs 7. Focus on nursing care related to these procedures: Pulse oximeter/oxygen saturation, CXR, sputum culture, thoracentesis, and bronchoscopy **See above** Chapter 21 1. Understand differences between the o2 delivery systems and related nursing care. Related Nursing Care  Nasal (oropharyngeal) catheter: rarely used, should be changed every 8 hrs. alternating nares  Simple masks: be wary of fit, if too tight pt. may feel claustrophobic or may cause skin breakdown  Partial and non-rebreathing masks: make sure the bag is partially inflated (2/3 full), make sure it does not collapse during inspiration  Venturi mask: will mainly be seen with pts with COPD, most accurate/precise noninvasive method. - Make sure the mask is snug enough, so air does not flow into patient’s eyes. - If needed to be removed for patient to eat or take pills use nasal cannula while it is off for supplemental oxygen  The T-piece: is a special adaptor used to deliver oxygen, which connects to the endotracheal or tracheostomy tube and is useful in weaning patients from mechanical ventilation Oxygen Therapy Nursing Considerations  Hypoxemia = inadequate level of O2 in the blood. Hypoventilation, hypovolemia, and interruption of arterial flow can lead to hypoxemia  Hypoxia = decrease in tissue oxygenation - - Early Findings: tachypnea, tachycardia, restlessness, pale skin and mucous membranes, elevated BP, evidence of respiratory distress (use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds) Late Findings: confusion, cyanotic skin and mucous membranes, bradypnea, bradycardia, hypotension, cardiac dysrhythmias  Complications of Oxygen therapy: - Oxygen toxicity Oxygen-induced hypoventilation combustion 2. Be familiar with flow rates and o2 percentages for nasal cannula, simple mask, and masknonrebreather. Low- Flow Systems:   Patient breathes some room air (21%) along with the oxygen Variable-performance = do not provide constant or precise concentration of inspired O 2 a. Nasal Cannula  FiO₂: 24% to 44% — Flow: 1 to 6 L  Short term therapy to admin low-to-medium concentrations (1-6 L/min)  Easily dislodged and can cause irritation or drying of nasal and pharyngeal mucosa  Not good for mouth breathers  Nursing Actions: assess patency of nares; ensure prongs fit properly; use watersoluble gel to prevent dry nares; provide humidification for flow rates >4 L/min b. Simple Face Mask  FiO₂: 40% to 60% — Flow: 5 to 8 L  low-to-moderate concentrations of oxygen (5-8 L/min) - flow rates <5 L/min can result in rebreathing of CO2  Nursing Actions: Ensure mask fits properly --> too tight results in claustrophobia & skin breakdown c. Partial Re-breather Mask  FiO₂: 50% to 75% — Flow: 8-11 L/min  Moderate O2 concentration (8-11 L/min)  Reservoir bag (with no valve) remain partially inflated!!! - Complete deflation of reservoir bag during inspiration causes CO2 buildup  Nursing Actions: adjust flow rate to keep bag inflated, assess proper fit and skin breakdown d. Non-re-breather Mask  FiO₂: 80% to 95% — Flow: 10 to 15 L/min  Delivers HIGHEST O2 concentration possible (except for intubation)  Similar to partial rebreathing masks except that they have additional valves - Additional valves close on inspiration to prevent inhalation of room air Important nursing considerations when administering O2 via a non-rebreather mask:  it is almost impossible to ensure 100% oxygen delivery, making it a low-flow oxygen system. High-Flow Systems: (fixed-performance) a. Venturi Mask  FiO₂: 24% to 50% — Flow: 4 to 10 L/min  Delivers fixed amount --> most reliable/accurate method for delivering precise concentrations of O2 through noninvasive means.  Most beneficial for pts. with COPD - accurate FiO₂ is essential to prevent minimal carbon dioxide buildup  Humidifiers usually are not used with this device. 3. Identify and understand care of the patient with a tracheostomy. Bedside equipment  Need to have 2nd trach set-up at bedside  Tracheostomy tube (same size and type), balloon inflator, inner cannula (can be cleaned or replaced), and an obturator  Manual resuscitation bag (Ambu bag)  Working suction  Humidified O2 to keep secretions moist Nursing Management  Patent Airways!!  Continuous monitoring and assessment of respiratory status. If VS are stable, place pt. in semi-flowers to facilitate ventilation, promote drainage, minimize edema, and prevent strain on suture lines  Assess Breath Sounds  Auscultation of lungs best indicator to determine if suction is needed Ronchi/course crackles = secretion in upper airways! Diminished breath sounds could indicate mucous plug  Suction and clean frequently following placement **over suctioning can cause hypoxia**  Suction prior to providing tracheostomy care Oxygenate before and after suctioning Suction 10-15 seconds per pass  Auscultate after suction (Ronchi should go away vs. true wheeze does not go away after suctioning) ** Trach care preformed once a shift if established trach (q8) & Suction PRN (q4)**  Assess skin integrity  Skin breakdown behind the neck from trach collar, sutures at incision site, stoma site, signs of infection (temp & WBC) What findings indicate obstruction of the airway and what are the primary interventions to decrease risk of obstruction? Obstruction findings  Decreased breath sounds  Difficulty inserting suction catheter Mucous plug  Change in respiratory rate  Change in behavior pt. may become anxious due to lack of 02/hypoxia Nursing Interventions  Hydration (oral, IV fluids)  Warmed humidification  Semi-flowers (HOB >30°)  facilitates ventilation, promote drainage, minimize edema, and prevent strain on the suture lines  Administer prescribed O2 and monitor O2 saturation  Monitor for cyanosis Emergency Interventions **First 72 hours highest risk for dislodgment**  Have secondary trach set at  Ambu bag that fits trach  HOB at least 30 degrees bedside  Call rapid response team Potential Complications of tracheostomy: Risk for Infection  Monitor WBC & temperature  Maintain skin integrity - keep dressing gauze clean and dry  Use sterile technique when suctioning and preforming tracheostomy care  Signs/symptoms: erythema, purulence, swelling and signs of inflammation (pain, redness, purulence), WBC (CBC results) Tissue Damage  Maintain cuff pressure at appropriate level (20-25 mm Hg) Too tight = damage to the tissue (necrosis, ischemia) Gurgling sounds indicate cuff leakage Call respiratory therapist - monitor at least q8hrs.  Suction PRN Unnecessary suctioning can initiate bronchospasm and cause mechanical trauma to the tracheal mucosa. Communication Issues  Pt. and family experience can be frustrating  Key Interventions Provide paper or white board for pt. write on to communicate with - providers and families 4. Identify and understand care of the patient after thoracic surgery Thoracotomy - Creation of a surgical opening into the thoracic cavity  May be performed to diagnose lung disease, remove a tumor, or entire/partial lung Risk Factors  Atelectasis & Pneumonia most common (see chart 21.18 above) - Non-modifiable: age, ethnicity, genetics, existing disabilities - Modifiable: obesity, nutritional status, smoking Pre-operative assessment  Objective data  get baseline data → i.e. pt. with COPD may have compensatory mechanisms (adventitious breath sounds) → What finding in a COPD patient would indicate pt. is deteriorating? ▪ Shallow breathing ▪ Impaired ability to cough and clear secretions ▪ Ventilation/perfusion issues ▪ Decrease in inspiratory capacity  Subjective data → Ask pt. about signs and symptoms (cough, sputum, dyspnea) → Smoking history → Cardiopulmonary status (at rest, walking, eating) → Sleeping positions  Labs & Diagnostic tests → chest x-ray, ECG, nutritional assessment, BUN and serum creatinine levels (renal function), blood glucose level (diabetes), serum electrolytes and protein levels, and complete blood cell (CBC) count.  Education  Turning, coughing, and deep breathing every 2hrs; use of incentive spirometer, and pain control Post-Op Care  Positioning varies depending on surgical procedure - HOB 30-45° (if pt. is stable) - Pneumonectomy - removal of entire lung  Position pt. on side that lung was removed so fluid consolidate, prevent collapse and so the other lung can fully expand → After pneumonectomy, a patient is usually turned every hour from the back to the operative side and should not be completely turned to the unoperated side. This allows the fluid left in the space to consolidate and prevents the remaining lung and the heart from shifting (mediastinal shift) toward the operative side. - Lobectomy - lobe removal (not entire lung)  Pt. can lie on either side unless chest tube is in place, then pt. should not lay directly on the tube  Head-to-toe assessment with focus on cardio and pulmonary systems - Auscultate lung sounds and assess for rate, rhythm, and depth - Monitor oxygenation w pulse oximetry - Monitor EKG for rate and changes - Assess capillary refill, skin color, and status of surgical dressing  Monitor CBC and electrolytes closely (assess for infection & bleeding)  Chest tube drainage to expand lung and remove excess drainage (fluid or blood) 5. Includes care of the patient with a chest tube. 3 Reasons for Chest Tube Placement: 1. Removing air & fluid 2. Preventing drained air/fluid from returning to the pleural space 3. Restoring negative pressure within the pleural space to re-expand the lung EX: pneumothorax (collapsed lung d/t positive pressure entering the pleural space) Chambers of the Traditional Water Seal System 1. Water seal chamber (underwater seal bottle)  Measures the amount of negative pressure within the pts. chest cavity  The water level rises and falls as the pt. breathes (corresponds with breathing)  Neg. pressure increases upon inhalation & returns to baseline upon expiration = TIDALING  Tidaling causes intermittent bubbling, which indicates that the system is functioning properly  CAUTION: continuous bubbling in water seal chamber could indicate an air leak → Air leak in the pleural space can cause pts. to develop crepitus and subcutaneous emphysema → SUBCUTANEOUS EMPHYSEMA escaped air from the lung gets into tissues under the skin. Palpate for crepitus  feels like Rice Krispy's under the skin (clavicular, neck, upper thorax area) 2. Collection chamber  Collects draining fluid from chest tube  Monitor output on hourly basis  notify doc if exceeds >150ml/hr!! 3. Suction control chamber  Helps control the strength of the suction (amt of negative pressure applied to the chest)  Adding more fluids increases strength of suction (amt of suction is determined by the water level)  Typically set at -20 cm of water; can be connected to an outside source MANAGEMENT OF CHEST TUBES (PG. 540) Respiratory Assessment & Cardiovascular Status  Auscultation of lungs (rate, rhythm, depth), adventitious breath sounds, O2 stats, ABGs, signs of resp. distress, cap. refill, skin color  You want to hear BILATERAL EQUAL BREATH SOUNDS (if both lungs present)  Monitor HR and rhythm via auscultation and ECG  dysrhythmias common after thoracic/cardio surgery Assess position of trachea (midline!)  Deviated trachea sign of a mediastinal shift (heart & lungs shift to the operative side) Assess for pain control  Assist with positioning (turn q2 hrs)  PCA pumps (observe for respiratory effect of opioid) Monitor for cardiac shift/compression  fluid accumulation causing the heart to become compressed and stop beating Observe for signs of infection  Fever, WBC, tachypnea  Changes in sputum and drainage - amount, viscosity, color, and odor  Assess incision area q 8hrs. for redness, heat, induration, swelling, separation, and drainage Prevent atelectasis  Educate and assist with turning, coughing, deep breathing  Instruct on use of incentive spirometer, breathing techniques (diaphragmatic and pursed-lip breathing)  Signs/symptoms that may indicate atelectasis = cyanosis, dyspnea, and acute chest pain Assess output Monitor chest tube drainage Amount, color, consistency NOTIFY PROVIDER if drainage >150mL per hour (pt. may be loosing too much blood)  Monitor UOP to assess for fluid balance (0.5mL/kg/hr.) Monitor for crepitus  Rises --> palpate neck, clavicle, upper thorax areas Assess chest tube dressing  Occlusive and air tight dressing should cover chest tube  Sterile Vaseline gauze vs. dry 4x4 (varies per hospital protocol) Chapter 22 1. Focus on identifying and understanding risk factors and care of the patient with obstructive sleep apnea. Obstructive Sleep Apnea (OSA) - recurrent episodes of upper airway obstruction and a reduction in ventilation (lasts 10 seconds & occurs up to 5x per hour) Risk Factors: - Obese individuals, males, postmenopausal women, elderly, individuals with enlarged tonsils, edema in oral-pharyngeal area, decreased muscle tone, large uvula, large neck, smoking Clinical Manifestations: - Frequent and loud snoring - Sleepiness - complain of insomnia and difficulty falling asleep, chronic fatigue, headaches - Decreased oxygenation and elevated CO2 levels --> activation of SNS o Increased risk for hypertension and MI - Impotence/incontinence at nighttime Complication: - Hypertension and cardiac disease (MI) --> stroke - Neurocognitive deficits - Diabetes - Weight gain - Cardiac problems --> dysrhythmias Management - Weight loss, avoidance of alcohol, positional therapy (avoid sleeping on back) - CPAP used to prevent airway collapse - BiPAP makes breathing easier and decreases airway pressure - Surgical Repair: tonsillectomy, uvula-pharyngeal surgery, nasal septoplasty, maxillomandibular surgery, or tracheostomy in severe cases 2. Identify who is at high risk for laryngeal cancer. Risk Factors  Smoking #1  Carcinogens - tobacco, secondhand smoke, paint fumes, wood dust, chemicals, mustard gas, etc.  Other factors - nutritional deficiencies (vitamins), alcohol abuse, genetics, age (>65), gender (males), race (AA), weakened immune system 3. Identify and understand care of the patient after laryngectomy. Chapter 23 1. Identify who is at risk for the following disorders and understand high priority care for each of these disorders. A. B. C. D. E. Atelectasis Pneumonia Aspiration Acute Respiratory failure Pulmonary TB A. Atelectasis - collapse of alveoli (air sacs in the lungs)  Acute or chronic ◦ Acute: occurs most often in the postoperative setting or immobilized pts (shallow, monotonous breathing pattern)  ◦  Post-OP pain makes it more difficult to breathe  splinting, shallow breathing Chronic: pts with chronic airway obstruction Can be segmental, lobar, or whole lung ◦ microatelectasis - not detectable on chest x-ray ◦ macroatelectasis - loss of segmental, lobar, or overall lung volume CAUSES: foreign body, tumor or growth in an airway, altered breathing patterns, retained secretions, pain, alterations in small airway function, prolonged supine positioning, increased abdominal pressure, reduced lung volumes due to musculoskeletal or neurologic disorders, restrictive defects, and specific surgical procedures (e.g., upper abdominal, thoracic, or open heart surgery) ASSESSMENT FINDINGS  What will the patient be exhibiting? ◦ Increased WOB (tachypnea, dyspnea) and mild-to-moderate hypoxemia ◦ Crackles ◦ Asymmetric chest expansion ◦ Decreased breath sounds indicate collapsed alveoli  ◦ Chest x-ray shows an area of density What will the nurse see and hear? ◦ SEE: Asymmetric Chest expansion ◦ HEAR: Decreased breath sounds and crackles (2 types of crackles) 1. Rice Krispy / fine crackles from atelectasis start in the bases of the lungs  Posterior lung assessment very important b/c crackles start 2. Coarse crackles from fluid INTERVENTIONS- PREVENTION IS THE KEY!  TCDB - turn, cough, and deep breathe  Early mobilization - get the pt. up and walking  Incentive spirometry - expand lungs  CPT - chest percussion therapy  Pain management  Monitor opioid use  Listen to lungs q. 2-4 B. Pneumonia What is Pneumonia? Excessive fluid in the lungs usually caused by infectious process  Inflammation of lung parenchyma caused by various microorganisms (bacteria, mycobacteria, fungi, and viruses) Types 1. Community-acquired pneumonia (CAP)  S. pneumoniae (pneumococcus) and H. influenzae most common cause of CAP 2. Health care-associated pneumonia (HCAP)  Multi-drug resistance, immunocompromised, aspiration PNEUMOCOCCAL PNEUMONIA  Provide Patient Education regarding VACCINATION: ◦ pneumococcal conjugate vaccine (PCV13) and a pneumococcal polysaccharide vaccine (PPSV23).  adults 65 years and older & anyone 2 years or older with certain chronic illnesses ◦ Vaccine administered in the deltoid - confined muscle group = greater concentration ASPIRATION PNEUMONIA  Which lung is more likely to be affected? WHY? ◦ Right lung  straight shot (Place stethoscope on the right middle lobe)  Who is at high risk? Dysphasia – pts with difficulty swallowing (fluid may get into lungs) Vocal cord disorders Seizures ◦ ◦ ◦  Prevention is the KEY! Position HOB 30°  if hemodynamically stable… get VS (HR & BP)  NOT TOLERATING = LOW BP (feel dizzy, pallor (pale), diaphoretic (cool, damp, clammy) ◦ Dysphasia  Swallowing study for pts at risk for aspiration  Monitor for coughing and choking when eating  Silent aspiration - don't hear them coughing or showing signs of choking ◦ TESTING/DIAGNOSIS:  HIGH PRIORITY- Sputum and blood cultures     on broad spectrum abx.  Obtain prior to antibiotic therapy THEN start Chest X-ray CBC ABG – determine level of oxygenation Bronchoscopy - biopsy, lavage (cleaning out the lungs/ take fluid out) – VERY uncomfortable for the pt. MANAGEMENT  Specific antibiotic therapy  Oxygenation  Nutritional support: increased WOB requires additional calories, proper nutrition aid in prevention of secondary infection ◦ Small, frequent meals & Nutritional supplements  Hydration-IV or PO: 2-3 L/day to promote hydration and thin secretions Monitor fluid & electrolyte balance PPD to rule out TB Analgesics & Antipyretics Rest Other respiratory support = Suctioning, Chest PT, Bronchodilators ◦     How will the nurse determine the patient is stable and improving?  Normal/effective breathing pattern, respiratory rate comes down, less anxiety, clearer lung sounds (adventitious course crackles, rhonchi, secretions in upper airways, wheezes all start to improve) C. Aspiration Risk Factors:  Seizure activity  Brain injury  Decreased level of consciousness (from trauma, drugs/alcohol, excessive sedation, general     anesthesia) Flat body positioning Stroke Swallowing disorders Cardiac arrest Clinical Practice to Prevent Aspiration - - - Maintain head-of-bed elevation at an angle of 30–45 degrees, unless contraindicated Use sedatives as sparingly as possible Before initiating enteral tube feeding, confirm the tip location For patients receiving tube feedings, assess placement of the feeding tube at 4-hour intervals, assess for gastrointestinal residuals (<150 mL before next feeding) to the feedings at 4-hour intervals For patients receiving tube feedings, avoid bolus feedings in those at high risk for aspiration Consult with primary provider about obtaining a swallowing evaluation before oral feedings are started for patients who were recently extubated but were previously intubated for >2 days Maintain endotracheal cuff pressures at an appropriate level, and ensure that secretions are cleared from above the cuff before it is deflated. D.Acute Respiratory failure Occurs when insufficient O2 is transported to the blood or inadequate CO2 is removed from the lungs and the pts compensatory mechanisms fail. - Ventilation or perfusion mechanisms in the lungs are impaired  PaO2 <60 mm Hg  PaCO2 >50 mm Hg  pH < 7.35 = acidemia  SaO2 <90% Causes: - Mechanical abnormality of lungs or chest wall - Defect in the respiratory control center of the brain - Impairment in the function of the respiratory muscles - Postoperative period = high risk for acute respiratory failure  effects of anesthetic, analgesic, and sedative agents  depress respirations or lead to hypoventilation. -   Pain may interfere with deep breathing and coughing. A V/Q mismatch is the usual cause of respiratory failure after major abdominal, cardiac, or thoracic surgery. Assessment - Dyspnea, restlessness, confusion, tachycardia, hypertension, dysrhythmias, decreased LOC, alterations in respirations and breath sounds, headache (less common) Treatment - Identify and treat root cause of the problem - Administer O2 to maintain PaO2 level higher than 60-70 mm Hg - Place client in upright position (fowler’s) - Encourage deep breathing - Administer bronchodilators as prescribed - Prepare client for mechanical ventilation if supplemental O2 cannot maintain acceptable PaO2 and PaCO2 levels E. Pulmonary TB - M. tuberculosis: primary infectious agent, acid-fast aerobic rod that grows slowly and is sensitive to heat and UV light. - - Mode of transmission: AIRBORNE ◦ Spread through talking, coughing, sneezing, etc. and airborne nuclei remain suspended in the air Disease progression: Insidious (gradual/cumulative effect)  Initial infection usually occurs 2-10 weeks after exposure Symptoms: Weight loss Fever / chills Hemoptysis Night sweats Fatigue Persistent cough Anorexia (PRODUCTIVE) What is unique about the symptoms that an aging adult presents? ◦ Atypical manifestation in older adults: show signs of confusion, unusual behavior, altered mental status ◦ May present with less pronounced symptoms than younger patients ◦ TB skin test may produce no reaction (loss of immunologic memory) OR delayed reaction (recall phenomenon) Highest ◦ ◦ ◦ ◦ ◦ ◦ Risk Immunosuppressed  cancer, transplant, HIV/AIDS, pt. on steroids Aging adults (esp. elders in long-term care facilities) Living in a crowded environment Abuse of drugs or/and alcohol Immigrants health care workers  but usually will not get it d/t healthy immune system Testing/Diagnosis Mantoux method ◦ PPD skin test (intracutaneous injection of Purified Protein Derivative) widely used in screening for latent TB  DOES NOT confirm that active TB is present ◦ Testing procedure:  ½ in. 26g or 27g needle, 0.1 mL of PPD is injected, creating a well-demarcated wheal on inner forearm ◦  Test result read 48 to 72 hours after injection. Testing significance:  A significant reaction indicates past exposure to M. tuberculosis or vaccination with BCG - NEGATIVE: 0 to 4 mm not significant (negative) - POSITIVE: >10 mm considered significant in ppl with normal immunity; >5 mm significant in people at risk (HIV+, close contact with someone with active TB, chest x-ray results consistent with TB)  ◦ ◦ ◦ Pts who have received BCG vaccine in last 10 yrs can have false + skin test. ** QuantiFERON-TB Gold® In-Tube and T-SPOT® TB blood tests preferred for patients who have received the BCG vaccine or pts not likely to return for reading The results available within 24 to 36 hours Acid-fast bacilli (AFB) Smear and Sputum Culture Presence of AFB on a sputum smear may indicate disease but does not confirm the diagnosis of active TB  NEED 3 Positive culture confirms ACTIVE TB  collect 3 consecutive sputum samples every morning  Final culture results may take 4 – 6 weeks  Culture should include multi-resistant organisms  False positive – BCG vaccine, incorrect PPD or inaccurate reading  False negative – immunosuppressed and not having a reaction (look for signs of disease in presentation) Latent TB ◦ Exposed to TB bacteria but not sick. Why?  ◦ ◦ ◦ ◦ ◦ Really good immune system response  probably will never develop diseases d/t strong immune response May never develop the disease No transmission Positive PPD indicating exposure to TB Normal CXR and negative sputum Treat for latent TB to prevent active TB disease MEDICATION FOR TREATMENT OF ACTIVE TB ◦ Combination therapy common d/t ↑ resistance against anti-tuberculin medications ◦ MUST take for 6-12 months  noncompliance contributing to the development of resistant strains of TB ◦ COMMON MEDICATIONS:  Isoniazid (INH) - SAE – peripheral neuropathy , risk of hepatotoxicity, kidney disease (assess for jaundice – eyes, skin, urine), no alcohol  Rifampin (Rifadin) - lot of interaction with other meds, decreased effectiveness of cardiac meds BB & coumadin, can stain clothing, women – use additional form of BC  Pyrazinamide (PZA) - Increase fluid consumption to prevent gout and kidney problems  ◦ Ethambutol (Myambutol) - Ocular toxicity – baseline visual acuity tests PATIENT EDUCATION  Nausea /GI distress – can be taken at bedtime to avoid nausea  Taken on empty stomach or one hr. before eating b/c foods and antacids will slow down absorption  Avoid foods w tyramine & histamine (tuna, aged cheeses, red wine, soy sauce) – cause adverse interactions w meds  TB meds ↑ risk for hepatotoxicity and kidney disease - Avoid alcohol d/t risk liver toxicity and assess for Jaundice  Isoniazid (INH) - take multivitamin (Vit. B) with to prevent peripheral neuropathy  Rifampin – Many drug interactions; Body fluids will be orange (can stain clothing & contact lens); ↓ effectiveness of cardiac meds (beta blockers); women should use additional form of BC d/t ↑ risk for birth defects  Compliance EXTREMELY IMPORTANT!!! 2. Describe pt. education regarding compliance with TB meds - The multiple-medication regimen that the patient must follow can be complex. Understanding of the medications, schedule, and side effects is important. Inform pt. that taking medications is the most effective means of preventing transmission. The major reason treatment fails is that patients do not take their medications regularly and for the prescribed duration. Chapter 24 1. Understand pathophysiology for COPD and Asthma and high priority care COPD - COPD is a group of diseases that cause airflow blockage (chronic bronchitis and emphysema) & breathing related problems Obstruction caused by hyperinflation of the lungs ◦ Pts with COPD have trapped air  hyperinflated problems exhaling/ getting air out of lungs  retain CO2 Risk Factors: Other risk factors include: #1 = Smoking…causes: ◦ Stimulates excess mucus production ◦ Secondhand smoke exposure ◦ Coughing ◦ Air pollution ◦ Destroys ciliary function ◦ Genetics-A1 antitrypsin deficiency ◦ Inflammation damages bronchiolar and ◦ Leads to early onset emphysema alveolar walls ◦ Aging Chronic Obstructive Bronchitis ◦ Chronic coughing ◦ Increased mucus production  increase in number of goblet cells ◦ Scarring of bronchial lining- impairs ciliary function ◦ Symptoms continue for 3 months at time in consecutive 2 years Emphysema ◦ Alveolar walls destroyed ◦ Difficulty with expiration due to….  ◦ Instead of being an involuntary passive act, expiration becomes active and requires muscular effort. Damage causes:  Blebs –pockets of air in alveolar spaces  Bullae- pockets of air in lung parenchyma  Ventilation Dead Space Physical Assessment Findings ◦ SOB, Increased WOB, dyspnea, ◦ Barrel chested (1:1 AP diameter)  caused by ↑ WOB over long period of time and use of accessory muscles  hyperinflated (hyperexpanded) chest ◦ Increased muscle mass in neck  using neck muscles to breathe ◦ May have weight loss & decreased muscle mass in extremities ◦ Wheezes, retractions (sign of severe resp distress | sucking in of muscles)   ◦ ◦ ◦ ◦ ◦ Retractions = sucking in of muscles (around neck muscles, clavicular area, intercostal spaces) Means they are working really hard to breathe and can indicate severe respiratory distress Decreased Breath Sounds  sometimes you don’t hear anything bc they are so hyperinflated (trapped air) Clubbing - caused by long term periods of hypoxia Color changes  Ruddy – face is reddish/purple color  Dusky – purple color = hypoxia Sputum production - thick secretions Cor Pulmonale – R sided heart failure  Pulmonary hypertension leads to RSHF  High pressure in the pulmonary arteries increases pressure in the right ventricle, which leads to the back up of blood in the venous system, resulting in dependent edema, distended neck veins, or pain in the region of the liver. Complications w/ COPD ◦ ↑ risk for respiratory tract infections  Leads to hospitalizations  Respiratory failure – asses for resp distress  Are they worse than baseline!? ◦ Spontaneous pneumothorax d/t trapped air ◦ Dyspnea at night | orthopnea  Orthopnea - can't sleep lying flat = have to be elevated and sleep on many pillows ◦ Hypoventilation & V/Q mismatch leads to chronic hypoxia Goals/Outcomes ◦ Improve ventilation ◦ Facilitate removal of secretions ◦ Treat infection ◦ Reduce complications  keep them out of respiratory distress ◦ ◦ Slow progression of symptoms Promote health maintenance & client management of disease Management of COPD Multidisciplinary Approach ◦ #1: Stop smoking (improves survival) ◦ Breathing techniques – ppl with COPD have shallow, rapid, and inefficient breathing  Diaphragmatic breathing  Pursed lip breathing (forces air out) - slow expiration, prevents collapse of small airways, and helps the patient control the rate and depth of respiration ◦  Huff cough – breathing out and coughing – promote cough effort and EXPAND lungs Upright position/ tripod positioning (helps use accessory muscles to breath) ◦ ◦ ◦ ◦ Effective coughing Airway clearance (CPT) Nutritional support – some pts may need feeding tubes if really malnourished Pulmonary rehab- with the goal to improve QOL, improve physical and emotional health Improve Ventilation ◦ Bronchodilators relieve bronchospasm by improving expiratory flow through widening of the airways and promoting lung emptying with each breath. These medications alter smooth muscle tone and reduce airway obstruction by allowing increased oxygen distribution throughout the lungs and improving alveolar ventilation. Classes of Bronchodilators (See page 642; table 24-3) ◦ Beta 2 adrenergic agonist ◦ Anticholinergic agents ◦ Combination agents ◦ ◦ Inhaled corticosteroids Inhaled corticosteroids w B2 adrenergic agonist Bronchodilators Side Effects:  Tremors    Tachycardia Jittery/nervousness GI distress/Nausea Oxygen Therapy - Pt. lives in a state of CO2 retention = not going to have a normal ABG PaO2 may not be very high Oxygen therapy sufficient to produce a resting PaO2 of at least 60 or SaO2 90 Oxygen administration- Start low and go slow Teach safety with O2 ◦ No smoking ◦ Safe storage Don’t expect the PaO2 to get very high Not going to have a nl ABG Airway Clearance ◦ Bronchodilators ◦ Pulmonary hygiene ◦ Huff cough ◦ Chest PT with postural drainage Reduce Complications ◦ Monitor for sign of acute respiratory failure, and/or pneumothorax ◦ DVT prophylaxis for clients who are immobile, polycythemia or dehydrated ◦ ◦ - - Vaccinations  Influenza & pneumococcal Promote Activity Tolerance ◦ Strengthen resp. muscles ◦ Increased exercise tolerance may decrease dyspnea & fatigue ◦ Breathing exercises  Practice diaphragmatic breathing & Pursed lip breathing  helps get air OUT Improve General Health ◦ Stop smoking or exposure to 2nd hand smoke ◦ Avoid high altitudes ◦ Avoid allergens or triggers causing exacerbation ◦ Nutrition  Frequent small meals  Supplements ◦ Asthma - A life-long chronic inflammatory disorder of the airway - It is associated with: ◦ Airway hyperresponsiveness ◦ Reversible airway obstruction  leads to long-term airway narrowing ◦ These make it different from emphysema and chronic bronchitis What happens to the lungs: - Muscle constriction, airway inflammation, thick tenacious secretions @ Risk Factors:  FH  Hx of eczema or allergies  exposure to either 1st or 2nd hand smoke  Hx of severe resp infections  prematurity/BPD  occupational exposure  air pollution  obesity Causes of Asthma: - Exact cause is unknown - These can all play a part: heredity, environment, chemicals, infections Triggers: - Virus/cold, exercise, irritants, allergens (dust, molds, pollens), cold air/weather changes, emotions, psychogenic, GERD, menses - During acute exacerbations of asthma, bronchoconstriction occurs quickly to narrow the airway in response to an exposure Making a Diagnosis - Hx, PFT’s (gold standard), pulse ox, chest x-ray, PEFR, allergy testing Management Goals: - Avoidance of triggers, reduction of episodes - Restoring a clear airway, effective breathing pattern, adequate oxygenation and ventilation, patient/family education, promoting patient self-esteem, promoting patient/family coping, medication compliance Symptoms:  Coughing  Nasal flaring  Noisy breathing  Wheezing  Retracting  Irritability/anxious  SOB  Fatigue  Stooped body position  Chest tightness  Nighttime cough Complications: - Poor work performance due to lack of sleep, Self-esteem issues, Patient/family stressors, Restrictive lifestyle, Status asthmatics, Respiratory failure, Death High priority care for asthma 1. PREVENTION Patients with recurrent asthma should undergo testing to identify substances that precipitate the symptoms Educate pts to avoid situations that put them at risk (knowledge is key!) 2. MEDICAL MANAGEMENT Pharmacologic Therapy A. Quick relief medications - SABA (albuterol)  med of choice for relief of acute symptoms and exercise induced asthma B. Long acting medications - inhaled corticosteroids and LABA  help manage severe, persistent asthma and prevent recurrence of symptoms. LABA are for patients who have persistent issues for which inhaled steroids (ICS) alone are not effective in managing symptoms. LABA’s should never be given “alone” but always as a combination medication with an ICS as there is a significant increased risk for death Airway inflammation which is what the corticosteroids fix (either inhaled, oral or IV depending on the severity of symptoms). Corticosteroids do not fix bronchoconstriction but work to decrease airway inflammation.  Step approach is taken, starting with a SABA prn, and then advancing to additional treatments if needed.  Patient education is important so they can self-manage symptoms Asthma action plan  know when to seek medical help!  Daily peak flow meter monitoring recommended for certain patients - Describe Pt. education regarding metered dose inhaler  important to teach on proper use of MDI so patient uses it correctly. → Many different types of MDI with different delivery systems (powder, aerosol)  Patient should know how to use the specific one they are prescribed  Reteach if patient is switched to a different type → A spacer can be used with the aerosol type if the patient has trouble coordinating breathing in and actuating the device at the same time → Important to try to hold breath for 10 seconds to let the medication disperse into the lungs → Important to rinse mouth after inhaling corticosteroids in order to avoid thrush Describe Pt. education regarding Peak flow meters PURPOSE: Peak flow meters measure the highest volume of airflow during a forced expiration  Peak flow meter measurements alert the patient when asthma symptoms are worsening and what treatments should be done. → will indicate the current degree of asthma control  Help healthcare providers decide about treatment options → can help identify patterns in symptoms to come up with better treatment options  ASTHMA ACTION PLAN:  GREEN ZONE: 80%-100% of personal best ◦ Doing Well - All is as it should be!  YELLOW ZONE: 50%-80% of personal best ◦ Asthma is getting worse and need to be cautious and limit some activities ◦ May add some meds as prescribed in action plan  RED ZONE: less than 50% of personal best ◦ Possibly dangerous  need to call provider to discuss treatments (probably course of oral steroids). ◦ Need to call 911 if any trouble walking or talking, lips/fingernails blue, or not able to talk in full sentences HOW TO USE A PEAK FLOW METER: 1. Take as deep breath as possible 2. Place meter in mouth and close lips around mouthpiece 3. Blow out as hard and fast as possible into the peak flow meter (1-2 seconds) 4. Do not cough, spit, or let tongue block the mouthpiece