Alterations In Respiratory Function Paper

Alterations in Respiratory Function

1. Define and use the key terms as listed in the assigned readings 2. Using the four adaptive modes of Roy’s Adaptation Model (RAM), recognize human adaptive responses to behavior or stimuli that affect respiratory function. 3. Identify differences, which affect the respiratory system in young, middle, and older adults. 4. Identify signs and symptoms of acute respiratory distress from impaired gas exchange. 5. Incorporate assessment of respiratory risk factors into the nursing history and physical assessment.
6. Identify components of a physical examination for a client with compromised respiratory function. 7. Identify the clinical significance and related nursing implications of laboratory and diagnostic tests and procedures
used for assessment and evaluation of respiratory function.
8. Specify nursing care of patients undergoing diagnostic procedures of the respiratory system.
9. Explain the indications, principles, procedures and nursing management of adults with compromised respiratory status requiring mechanical ventilation and thoracic surgery.

10. Describe stimuli and behaviors, pathophysiology, diagnosis, medical management, complications, & nursing care for clients experiencing respiratory disorders (incl: resp infections, chronic obstructive disorders, environmental lung diseases, respiratory emergencies, pulmonary vasc. disorders, pleural disorders, & neoplastic disorders).

11. Identify properly the medications on the drug list by generic name, classification, mechanism of action, clinically significant side effects, normal dosage, and nursing implications. Be able to correctly calculate IV, IM and PO dosages.

12. Compare and contrast nursing assessment findings, care and evaluation of patients with bacterial, viral, and fungal respiratory illnesses.

13. Develop a teaching/learning plan for adults experiencing compromised respiratory function. 14. Utilize the RAM nursing process to develop a plan of care for clients experiencing compromised respiratory function. 15. Provide culturally sensitive nursing care to the patient with respiratory illness.

Review of Chapter 30 and notes from NURS 115 oxygenation unit Abdominal respiration breathing accomplished mainly by the abdominal muscles and diaphragm Afterload – resistance to left ventricular ejection; the work the heart must overcome to fully eject the blood from the left ventricle Aerobic respiration the oxidative transformation of certain substrates into secretory products, the released energy being used in the process of assimilation Anaerobic respiration respiration in which energy is released from chemical reactions in which free oxygen takes no part Atelectasis – collapse of alveoli, preventing the normal respiratory exchange of oxygen and CO2 Atriventricular node (AV) – portion of the cardiac conduction system located on the floor of the right atrium; it receives electrical impulses from the atrium and transmits them to the bundle of HIS Biot's respiration rapid, short breathing w/pauses of several seconds, indicating ↑ intracranial pressure Cardiac output (CO) – volume of blood expelled by the ventricles of the heart, equal to the amount of blood ejected at each beat, multiplied by the number of beats in the period of time used for computation (usually 1 min) Cardiopulmonary rehabilitation – actively assisting the patient with achieving and maintain an optimal level of health through controlled physical exercise, nutrition counseling, relaxation and stress management techniques, prescribed meds , O2, and compliance Cardiopulmonary resuscitation – basic emergency procedures for life support consisting of artificial respiration and manual external cardiac massage Chest percussion – striking of the chest wall with a cupped hand to promote mobilization & drainage of pulmonary secretions Chest physiotherapy (CPT)– group of therapies used to mobilize pulmonary secretions for expectoration Chest tube – catheter inserted through the thorax into the chest cavity for removing air or fluid, used after chest or heart surgery or pneumothorax Cheyne-Stokes respiration breathing with rhythmic waxing and waning of depth of breaths and regularly recurring apneic periods cogwheel respiration breathing with jerky inhalation Depolarization – the reduction of a membrane potential to a less negative value. It is caused by the influx of cations, such as sodium and calcium, through ion channels in the membrane. In many neurons and muscle cells, depolarization may lead to an electric impulse called an action potential Diaphragmatic breathing – respiration in which the abdomen moves out while the diaphragm descends on inspiration Diffusion – movement of molecules from an area of high concentration to an area of lower concentration Dyspnea – sensation of shortness of breath Dysrhythmias – deviation from the normal pattern of the heartbeat External respiration exchange of gases between the lungs and blood Hemoptysis – coughing up blood from the respiratory tract Hemothorax – accumulation of blood and fluid in the plural cavity between the parietal and visceral pleurae Humidification – process of adding water to gas Hypercapnia – greater-than-normal amounts of CO2 in the blood; also called hypercarbia Hyperventilation – respiratory rate in excess of that required to maintain normal CO2 levels in the body Hypoventilation – respiratory rate insufficient to prevent CO2 retention Hypoxemia – arterial blood oxygen level less than 60 mm Hg; low oxygen level in the blood Hypoxia – inadequate cellular oxygenation that may result from a defieciency in the delivery or use of O2 at the cellular level Internal respiration exchange of gases between the body cells and blood Kussmaul's respiration , Kussmaul-Kien respiration air hunger; deep rapid breathing as seen in respiratory acidosis Myocardial infarction – necrosis of a portion of cardiac muscle caused by obstruction in a coronary artery Myocardial ischemia – condition that results when the supply of blood to the myocardium from the coronary arteries is insufficient to meet the O2 demands of the organ Nebulization – process of adding moisture to inspired air by the addition of water droplets Normal sinus rhythm – wave pattern on an electrocardiogram that indicates normal conduction of an electrical impulse through the myocardium Orthopnea – abnormal condition in which a person must sit or stand up to breath comfortably Oxygen therapy – procedure in which oxygen is administered to a patient to relieve or prevent hypoxia Paradoxical respiration that in which all or part of a lung is deflated during inhalation and inflated during exhalation, such as in flail chest or paralysis of the diaphragm Perfusion – (1) passage of a fluid through a specific organ or an area of the body Pneumothorax – collection of air or gas in the pleural space Postural drainage – use of positioning also w/percussion and vibration to drain secretions from specific segments of the lungs and bronchi into the trachea Preload – volume of blood in the ventricles at the end diastole, immediately before ventricular contraction Productive cough – sudden expulsion of air from the lungs that effectively removes sputum from the respiratory tract and helps clear the airways Pursed lip breathing – deep inspiration followed by prolonged expiration through pursed lips Repolarization –process by which membrane potential of a neuron or muscle cell is restored to cell's resting potential Respiration –exchange of oxygen and carbon dioxide between the atmosphere and the body cells Sinoatrial (SA) node – called the ”pacemaker of the heart” because of the origin of the normal heartbeat begins at the SA node. The SA node is in the right atrium next to the entrance of the superior vena cava Stroke volume (SV)– amount of blood ejected by the ventricles with each contraction. It can be affected by the amount of blood in the left ventricle at the end of diastole (preload), the resistance to left ventricular ejection (afterload), and myocardial contractility Surfactant – chemical produced in the lung by alveolar type 2 cells that maintains the surface tension of the alveoli and keeps them from collapsing Ventilation – respiratory process by which gases are moved into and out of the lungs Vibration – fine, shaking pressure applied by the hands to the chest wall only during exhalation Wheezing – adventitious lung sound caused by a severely narrowed bronchus Oxygenation - basic human need. Heart and lungs supply body with oxygen necessary for carrying out the respiratory & metabolic processes needed to sustain life.

Ineffective gas exchange – lungs Ineffective pump –heart Ventilation – movement of air in and out of the lungs

Diffusion – movement of gases between air spaces & the bloodstream

Respiration –exchange of oxygen & carbon dioxide during cellular metabolism

Perfusion – movement of blood into and out of the lungs to the body’s organs

Structure and Function of the Pulmonary System - consists of 2 lungs, their airways, chest walls, & blood vessels that support them

Right Lung - 3 lobes, upper, lower, middle lobes

Left Lung – 2 lobes, upper & lower lobes

Trachea – enters thorax & bifurcates, or branches out, into the right and left mainstem bronchus

Bronchi – branch into smaller and smaller bronchioles, similar to a tree
Last branch of the airways ends at the exchanging unit of the lung, the alveoli.
With pulmonary surfactant, alveoli expand & contract, allowing for diffusion to occur

Regulation of ventilation – depends on neuroreceptors & chemoreceptors in lungs & central nervous system, muscles that support inspiration & exhalation, and lung elasticity.

Control of ventilation provides for adequate oxygen to meet metabolic demands such as exercise, infection, or pregnancy
~Promotes exhalation of metabolically produced carbon dioxide
~Neural & chemical regulators control ventilation. ~Neural regulation involves the CNS
~CNS sends to chest wall musculature to control ventilation rate, depth, & rhythm.

~ Chemical regulation involves influence of chemicals, such as carbon dioxide & hydrogen ions, which affect rate & depth of ventilation

Oxygen Transport - delivery of oxygen depends on the amount of oxygen entering the lungs (oxygenation) from the atmosphere

~Ventillation – allows for movement of oxygen & carbon dioxide into & out of the lungs.
~Once oxygen has reached alveoli, diffusion occurs
~Oxygen crosses alveolocapillary membrane & is dissolved into plasma
~Then moves into RBCs & binds with hemoglobin molecules
~ Hemoglobin transports most oxygen & serves as a carrier for both oxygen & carbon dioxide
~ Perfusion of oxygenated blood occurs in the capillary beds of organs & tissues

Carbon Dioxide Transport – blood carries CO2 in 3 ways

Dissolved in plasma – at capillary level, carbon dioxide diffuses from cells into the plasma with 7% of CO2 remaining dissolved in the plasma

As carbamino compounds – rest of the CO2 rapidly moves into red blood cells and is hydrated into carbonic acid

As bicarbonate – carbonic acid dissociates into hydrogen and bicarbonate ions.

Factors Affecting Ventilation and Oxygenation Transport

Hypoxia – inadequate tissue oxygenation with a deficiency in oxygen delivery or oxygen utilization at the cellular level/ life threatening condition & if left untreated, will produce cardiac dysrhythmias and death.

* Lowered oxygen-carrying capacity, as in anemia or carbon monoxide poisoning * Diminished concentrations of inspired oxygen, as in high altitudes & airway obstruction * Inability of tissues to extract oxygen from the blood, as in septic shock and cyanide poisoning * Decreasing diffusion of oxygen from the lung (alveoli) into blood, as in pneumonia or atelectasis * Poor tissue perfusion with oxygenated blood, as hypovolemic (↓ B/P less volume ↑HR) shock, cardiogenic shock (inadequate circulation of blood due to primary failure of the ventricles of the heart to function effectively), or cardiomyopathy (heart muscle disease) * Impaired ventilation from multiple rib fractures, chest trauma, spinal cord injury, or head trauma * Obstructive or restrictive diseases, such as chronic obstructive pulmonary disease (COPD) in which airways lose elasticity & become inflamed

Treatment hypoxia includes administration of oxygen and correction of the underlying cause

Hypoventilation when ventilation is inadequate to meet the body’s oxygen demand or eliminate carbon dioxide

* Arterial carbon dioxide (PaCO2) level greater than 45 mm Hg, & respiratory acidosis * Impaired ventilation related to trauma, pain, infection, obstructive diseases, or fluid volume overload

* Alterations in neurological regulation of breathing

* Alterations in chemical regulation of breathing

* Collapse of alveoli related to severe atelectasis (collapse or closure of alveoli)

As ventilation decreases PaCO2 is elevated = respiratory acidosis

Signs & Symptoms * Dizziness * Occipital headache upon waking * Lethargy * Disorientation * Decreased ability to follow instructions * Cardiac dysrhythmias * Electrolyte imbalances * Convulsions * Possible coma or cardiac arrest

~COPD & chronically elevated PaCO2 levels have adapted to higher carbon dioxide level

~ if you administer too much oxygen to pt with COPD this satisfies the body’s oxygen requirement & destroys the stimulus to breathe, resulting in hypoventilation

Treatment - hypoventilation includes correction of the underlying cause, improving tissue oxygenation, restoring ventilation, & achieving acid-base balance

Hyperventilation – increase in respiratory rate, resulting in excess amounts of CO2 elimination results in ↓ PaCO2

Causes or hyperventilation * Severe anxiety * Infection, head injury, medications, acid-base imbalance * Acute anxiety & increased resp. rate may cause loss of consciousness from excess CO2 exhalation * ↑ of 1° F in body temp causes 7% increase in metabolic rate, ↑ CO2 production

Signs and Symptoms * Tachycardia * Shortness of breath * Chest pain * Dizziness * Light-headedness * Decreased concentration * Paresthesia * Circumoral and/or extremity numbness * Tinnitus * Blurred vision * Disorientation * Tetany (involuntary contraction of muscles) (carpopedal spasm)

Hyperventilation → ↓ PCO2 = Respiratory Alkalosis

Treatment hyperventilation includes treating of the underlying cause

improving tissue oxygenation

restoring ventilation

achieving acid-base balance
Factors Affecting Oxygenation
Decreased oxygen-carrying capacity – (anemia, inhalation or toxic substances)

97% of O2 is carried on hemoglobin molecule, any process that decreases or alters hemoglobin, decreases the oxygen-carrying capacity of blood

Decreased Inspired Oxygen Concentration – whe concentration of inspired oxygen declines, oxygen carrying capacity of the blood decreases
~ ↓ environmental oxygen (at high altitudes)
~ ↓ decreased delivery of inspired oxygen, as the result of an incorrect O2 concentration setting on respiratory therapy equipment

Increased Metabolic Rate – (pregnancy, wound healing & exercise- normal) Increases in metabolic activity of the body increases oxygen demand, when the body is unable to meet increased oxygen demand, oxygen levels fall
~ Increases in metabolic activity of the body increases oxygen demand
~ Fever increases tissues need for oxygen as a result CO2 production also increases If fever lasts, and metabolic rate remains high & body begins to break down protein stores, resulting in muscle wasting & decreased muscle mass.
~ Body attempts to adapt to increased CO2 (hypercapnia) levels by ↑ rate & depth of resp. to eliminate excess CO2
~ Pt. work of breathing ↑, & pt. will eventually display early signs & symptoms of

Hypoxemia, decreased arterial oxygen level in the blood

Early signs & symptoms of Hypoxia * Anxiety * Restlessness * Inability to concentrate * Increases in heart rate * Increases resp. rate & blood pressure * Cardiac dysrhythmias, such as premature ventricular contractions, premature atrial contractions, & sinus tachycardia

~ pt assessments often show an ↑ rate & depth of respiration & use of pursed lip breathing & accessory muscles of respiration

Conditions Affecting Chest Wall Movement –
Any condition will decrease ventilation

If diaphragm is unable to fully descend with breathing, volume of inspired air ↓ delivering less O2 to alveoli & subsequently to tissues

Musculoskeletal Abnormalities - abnormal structural shapes & muscle disease contribute to ↓
Oxygenation and ventilation
Rib cage – pectus excavatum
Spinal Column – kyphosis
Muscular dystrophy – decrease diaphragmatic movement, ability to expand & contract chest

Nervous System Diseases – Myasthenia gravis
Hypoventilation Guillain-Barre syndrome Poliomyelitis

~Disease of trauma involving medulla oblongata & spinal cord of the CNS has ability to impair respiration

Damage to spinal cord
Phrenic nerve if damaged, diaphragm does not descend, ↓ inspiratory lung volumes Causing hypoxemia
Cervical trauma at C3 to C5 lever results in paralysis of phrenic nerve
Spinal cord trauma below 5th cervical vertebra usually leaves intact but damages nerves that
Innervate intercostal muscles, preventing anteroposterior chest expansion

Trauma
Multiple rib fractures sometimes develop flail chest, life threatening condition which fractures cause instability in part of chest wall → paradoxical breathing win which lung underlying injured area contracts on inspiration & expands on expiration, making ventilation ineffective Chest wall or upper abdominal incisions decrease movement due to pain

Developmental Factors * Adolescents – exposed to respiratory infections & respiratory risk factors (secondhand smoke, and beginning to smoke cigarettes) * Young and Middle age Adults – unhealthy diet, lack of exercise, stress & cigarette smoking * Pregnancy

Older Adults – normal changes * Ventricular wall thickens, decrease in elastin → Decreased cardiac output * Arterial vessels in older adult become calcified & also loose elastin → hypertension & rise in systolic BP * Ventilation & transfer of resp. gases decline as a result of changes in alveoli & ↓ surface area for gas exchange * Reduction of functional cilia in airway causes decrease in effectiveness of cough mechanism putting at risk for resp. infections * Increased risk for flu, community acquired pneumonia, RSV

Lifestyle Factors * Nutrition – w/out essential nutrients pt. may experience resp. muscle wasting, resulting in muscle wasting → decreased muscle strength & respiratory excursion * Cough efficiency is reduced secondary to resp. muscle weakness * Pt. w/chronic lung disease requires diet higher in calories because of increased work of breathing * Moderate - carb diet is recommended to prevent increase in CO2 production * Calories from carbs should be no more than 50% of daily allowance Over nutrition * Leads to obesity → decrease in lung expansion & increase in O2 demand to meet metabolic needs * Diets high in fat ↑ cholesterol & development of plaque in coronary arteries, putting at risk for CAD * Patients who have alteration in nutrition are at risk for anemia. If diet does not supply iron * Needed for hemoglobin synthesis, RBC synthesis is reduced & O2 capacity decreases Hydration – essential for cellular health * Overload or hypervolemia may lead to vascular congestion w/heart, kidney or lung disease * Dehydration may result in dizziness, fainting, hypotension, ↓ resp.
secretion production or thickening of resp. secretions, making difficult for patient to expectorate

Exercise – increases body’s metabolic activity & O2 demand * Rate & depth of respiration increase, enabling person to inhale more O2 & exhale less CO2 * People who exercise for 60 min have lower HR, lower BP, ↓ cholesterol, increased blood flow, ↑ O2 extraction by working muscles * Addition of weight training benefit in ↓ work of heart by ↑ efficiency of other muscles in the body * Fully conditioned people are able to increase O2 consumption by 10-20% because of increased cardiac output & increased efficiency of myocardium

Cigarette Smoking - associated with heart disease, COPD and lung cancer. * Inhaled nicotine enable plaque to build up more quickly in blood vessels, increased risks for blood clots, & causes vasoconstriction in coronary & peripheral vessels

Substance abuse – alcohol & other drugs impair tissue
oxygenation * Poor nutrition intake * Decrease intake from iron rich foods → hemoglobin production * Depresses respiratory center, reducing rate & depth or respiration & amount of inhaled oxygenation * Injury to lung tissue → permanent lung damage & impaired oxygenation * IV drug use places at risk for infections of heart (myocarditis or endocarditis), blood clots, * Transmitted diseases (HIV)

Stress – demand that exceeds the patients coping ability, whether physically or emotionally * Continuous state increases body’s metabolic rate & oxygen demand * Increased rate & depth of respiration & increased cardiac output * May alter normal response to illness & pain * At risk for CAD, hypertension, & asthma

Environmental Factors – smoggy areas v. rural areas * Workplace

Nursing History
Risk Factors – family history, environmental risk. Exercise, stress, tobacco use, diet * Environmental conditions that affect breathing at work? * Recent travel to countries or areas of US where you’ve been exposed to uncommon resp. disease

Fatigue – subjective sensation reported as loss of endurance. Early sign of worsening of Chronic underlying cardiopulmonary disease * When did you first notice? What makes it better or worse? * Was onset sudden or gradual? Is it related to any time of day or constant? * Does it prevent you from doing what you want?

Pain – cardiac pain does not occur w/resp. variations. Most often substernal & typically radiates to left arm & jaw in males. * Some women have epigastric pain, indigestion, or choking feeling & dyspnea * Pleuritic is peripheral & usually radiates to scapular regions. * Inspiratory maneuvers, Coughing, yawning, signing, aggravate. * Usually causes chest pain (knifelike, Lasting 1 mi to hours, increasing with inspiration) * Musculoskeletal pain is often present following exercise, rib trauma, prolonged coughing. * Inspiratory movements aggravate pain & are easily confuses w/pleuritic chest pain

* Ever had pain in your chest? Explain * Where & when do you feel the pain? Radiate? Change w/inspiration? Go away when you hold your breath? * Feel like? Sharp, dull, stabbing? * Occur at rest or w/activity? * How long does it last? * What makes it better?

Breathing pattern – dyspnea (subjective sensation of breathlessness) * Clinical sign of hypoxia associated w/symptoms * exaggerated resp. effort * use of accessory muscles of resp. * nasal flaring * marked increases in rate & depth of respirations

Orthopnea (abnormal condition in which patient uses multiple pillows when lying down or has to sit to breathe) * # of pillows quantifies presence & severity

Wheezing (high pitched musical sound caused by high velocity movement of air through a Narrowed airway)

Cough – sudden, audible expulsion of air from lungs. Protective reflex to clear trachea, bronchi, and lungs of irritants & secretions

Hemoptysis – (bloody sputum) determine if associated with coughing & bleeding from upper resp. tract, sinus drainage, or GI tract (hematemesis) * Describe, including amount, color, duration, presence of sputum

Med use –assess pt knowledge & ability to correctly take meds

Nursing Diagnosis * Activity Intolerance * Ineffective Airway Clearance * Ineffective Breathing Pattern * Decreased Cardiac Output * Fatigue * Impaired Gas Exchange * Risk for Infection * Acute Pain

Implementation * Health Promotion * Influenza and Pneumococcal Vaccine * Environmental Modifications
Acute Care * Dyspnea Management * Meds * O2 therapy as indicated * Physical tech – cardiopulmonary recond, breathing tech, cough control * Psychosocial tech – relax tech, biofeedback, mediation

Maintenance & promotion of O2

Maintenance of Pt. airway

Coughing tech
Cascade – pt takes slow, deep breath & holds for 2 sec while contracting expiratory muscles
Huff cough – stimulates a natural cough reflex, generally effective for clearing central airways
Quad cough – without abdominal muscle control, spinal cord injury Restorative and Continuing Care * Breathing Exercises * Pursed-lip Breathing * Diaphragmatic Breathing

Pharmacological Therapy a. tiotropium (Spiriva) b. albuterol sulfate (Proventil) c. ipratropium (Atrovent) d. prednisone (Deltasone) e. fluticasone/salmeterol (Advair) f. fluticasone (flonase) g. budesonide/formoterol (Symbicort) h. azelastine (Astelin) i. diphenhydramine (Benadryl) j. loratadine (Claritin)

Review of Respiratory System
Purposes of breathing
1.) to provide oxygen for tissue perfusion so cells have enough O2 to take part in metabolism
2.) remove CO2, major waste product of metabolism

Upper respiratory track
Nose & Sinuses
Organ of smell
Receptors from cranial nerve I (olfactory) located in upper areas

Paranasal sinuses – air filled cavities w/in bones that surround nasal passages
Purposes of the sinuses are to provide resonance during speech
Decrease weight of the skull

Pharynx (throat)
Passageway for both respiratory and digestive tracts

Nasopharynx – located behind nose, above soft palate
Contains adenoids – pharyngeal tonsils trap organisms that enter mouth

Opening of Eustachian tube – connects middle ear and nasopharynx, opens during swallowing to equalize pressure in middle ear

Oropharynx – located behind mouth, below nasopharynx
Extends from soft palate to base of the tongue, used for breathing and swallowing

Laryngopharynx – located behind larynx, extending from base of tongue to esophagus
Critical dividing pt where solids and fluids are separated from air

Lower respiratory tract

Airways * Consist of trachea; two mainstem bronchi; lobar, segmental, and subsegmental bronchi; bronchioles; alveolar ducts; and alveoli * Aka tracheobronchial tree * Inververted tree like structure consisting of muscle, cartilage, & elastic tissues * Decrease in size from trachea to repiratory bronchioles, allows gases to move to and from lunch parenchyma * Gas exchange takes place in lung parenchyma between alveoli and lung capillaries

Trachea (windpipe) * Located in front of esophagus * Begins at lower edge of cricoid cartilage of larynx and extends to level of 4th or 5th thoracic vertebra * Branches into right and left mainstem bronchi at junction called corina * Trachea contains 6 to 10 C shaped rings of cartilage * Open portion of the C is back portion of trachea & contains smooth muscle that is shared w/the esophagus

Mainstem bronchi (primary bronchi) * Begin at corina * Similar in structure to trachea * Right slightly wider, shorter, & more vertical than left * Because of more vertical line of right, CAUTION it can be accidentally intubated when ET passes * Also when foreign object is aspirated from the throat, it usually enters right bronchus * Lined with ciliated, mucous secreting membrane * Cilia move mucus up and away from the lower airway to trachea, where spit out or swallowed
Bronchioles
* Branch from secondary bronchi and divide into smaller and smaller tubes * Which are terminal and respiratory bronchioles * Less than 1 mm in diameter * Have no cartilage & depend on elastic recoil of lung to remain patent * Terminal bronchioles do no participate in gas exchange

Alveolar ducts * Branch from respiratory bronchioles and resemble bunches of grapes * Alveolar sacs arise from these ducts * Alveolar sacs contain groups of alveoli, which are basic units of gas exchange * Healthy adult has about 290 million, surrounded by lung capillaries * Share common walls, making large surface area for gas exchange * Acinus – term for structural until consisting of respiratory bronchiole, alveolar duct, and alveolar sac * Walls of alveoli, specific cells called type II pneumocytes secrete surfactant, fatty protein that reduces surface tension in alveoli * Without surfactant, atelectasis (collapse of alveoli) occurs * In atelectasis, gas exchange is ↓ because alveolar surface is ↓
Lungs
* Lungs are spongelike, elastic, cone-shaped organs located in pleural cavity in chest * Apex of each lung extends above clavicle * Base of each lung lies just above diaphragm (major muscle of inspiration) * Right lung, larger than left, divided into 3 lobes; upper, middle, lower * Left, somewhat narrower and smaller to make room for the heart, only 2 lobes * 60-65% of respiratory function occurs in right lung * Any problems w/right lung interferes w/oxygenation to a greater degree than problem in left lung * Hilium – point at which primary bronchus, blood vessels, nerves & lymphatic’s enter each lung * Chest wall innervated by phrenic (diaphragm) and intercostal (pleura, ribs & muscles) nerves * Bronchi are innervated by vagus nerve

Pluerua * continuous smooth membrane composed of 2 surfaces that totally enclose the lungs * parietal pleural lines inside of the chest cavity & upper surface of diaphragm * visceral pleura covers lung surfaces * 2 surfaces are lubricated by thin fluid produced by cells lining pleura * Fluid allows surfaces to glide smoothly & * painlessly during breathing

Blood flow in the lungs occurs through 2 separate systems * Bronchial system carries blood needed to meet metabolic needs of the lungs * Bronchial arteries, which branch from thoracic aorta are part of systemic circulation & do not participate in gas exchange

Pulmonary circulation is highly vascular capillary network * Oxygen poor blood travels from right ventricle of heart into pulmonary artery

* Eventually branches into arterioles that form capillary networks

* Capillaries are meshed around and through alveoli (site of gas exchange)

* Freshly oxygenated blood travels from capillaries & thru smaller veins to pulmonary veins ^ then to left atrium

* From left atrium, oxygenated blood flows into left ventricle, where it is pumped throughout systemic circulation

Accessory Muscles of Respiration * Breathing occurs thru cx in size and pressure w/in chest cavity

* Contraction and relaxation of specific chest muscles (& diaphragm) cause cx in size and pressure of chest cavity

* Accessory muscles that help; scalene muscles, lift 1st 2 ribs * Sternocleidomastoid muscles; raise sternum * Trapezius & pectorals; fix the shoulders * Various back muscles

RESPIRATORY CX ASSOCIATED W/AGING
ALVEOLI
Alveolar surface area decrease
Diffusion capacity decreases
Elastic recoil decreases
Bronchioles and alveolar ducts dilate
Ability to cough ↓
Airways close early Nursing interventions Encourage vigorous pulmonary hygiene (turn, cough, deep breathe) esp. if confined to bed or has had surgery - Potential for mechanical or infectious respiratory comp. is ↑ Encourage upright position – minimizes ventilation-perfusion mismatching

LUNGS
Residual volume ↑
Vital capacity ↓
Efficiency of O2 and CO2 exchanges ↓
Elasticity ↓ Nursing interventions
Include inspection, palpation, percussion, & auscultation in lung assessment – needed to detect normal age-r/t cx
Help pt actively maintain health & fitness – help keep losses in resp. function to a min
Assess pt respirations for abnormal breathing patterns – periodic breathing patterns can occur
Encourage freq. oral hygiene – oral hygiene aids in removal of secretions

PHARYNX AND LARYNX
Muscles atrophy
Vocal cords become slack
Laryngeal muscles lose elasticity and airways lose cartilage Nursing interventions Have face to face conversations w/pt when poss – pt. voice may be soft & diff. to understand

PULMONARY VASCULATURE
Vascular resistance to blood flow thru pulmonary vascular system ↑
Pulmonary capillary blood volume ↓
Risk of hypoxia ↑ Nursing interventions Assess pt. LOC – pt can become confused during acute respiratory conditions

RESPIRATORY CX ASSOCIATED W/AGING

EXERCISE TOLERANCE
Body’s response to hypoxia and hypercarbia ↓ Nursing interventions Assess for subtle manifestations of hypoxia – early assessment helps prevent complications

MUSCLE STRENGTH
Respiratory muscle strength, esp. of diaphragm & intercostals ↓ Nursing interventions
Encourage pulmonary hygiene, & help pt. actively maintain health & fitness – reg pulmonary hygiene & overall fitness help maintain max function of resp. system & prevent illness

SUSCEPTIBILITY TO INFECTION
Effectiveness of cilia ↓
Immunoglobulin A ↓
Alveolar macrophages are altered Nursing interventions
Encourage pulmonary hygiene, & help pt. actively maintain health & fitness – reg pulmonary hygiene & overall fitness help maintain max function of resp. system & prevent illness

CHEST WALL
Anterposterior diameter ↑
Thorax becomes shorter
Progressive kyphoscoliosis occurs
Chest wall compliance (elasticity) ↓
Mobility may ↓
Osteoporosis is possible Nursing interventions Discuss normal cx of aging – pt may be anxious because they must work harder to breathe Discuss need for ↑ rest periods during exercise – older pt have less tolerance for exercise
Encourage adequate Ca intake (esp. women premenopause) – Ca intake helps prevent osteoporosis by building bone in younger pt.

Respiratory Assessment
Environmental factors – home, community, workplace * Occupational lung diseases, result from inhalation of dust * Toxic lung injury * Hypersensitivity disease (hypersensitivity to latex)

Work hx includes exact date of employment & brief job description * Exposure to industrial dust of any type or to chemicals found in smoke & fumes * Bakers, coal miners, stone masons, cotton handlers, woodworkers, welders, potters, plastic & rubber manufacturers, printers, popcorn workers, farm workers, & steel foundry workers, asbestos * Teach pt about use of masks & adequate ventilation to protect respiratory system from inhalation agents

Home & living conditions * Type of heat used, exposure to irritants

Hobby, leisure activities * Painting, working w/ceramics, building model airplanes, refinishing furniture, woodworking

Respiratory Hx * Include smoking, drug use, travel & area of residence

Smoking Hx * Use of cigarettes, cigars, pipe tobacco, marijuana, other controlled substances * Current or past * Passive exposure to smoke in home or workplace * How long, how many packs per pay, whether quict smoking (how long ago) * Doc in pack-years (# of packs smoked per day X # yrs pt has smoked)

Drug use * Prescribed and illicit drugs * Drugs taken for breathing problems or other conditions * Cough can be s/e for some antihypertensive drugs (ACE inhibitors) * OTC drugs * Past drug use and why discontinued

Allergies * Any known allergies to substances, foods, dust, molds, pollen, bee stings, trees, grass, animal dander and saliva, or meds
Travel & geographic area of residence * May be relevant for possible exposure to certain diseases * Histoplamosis, fungal disease caused by inhalation of contaminated dust (found in central US & Central America) * Coccidioidomycosis, fungal, western & southwestern US, Mexico, & portions of Central America as well as Hantavirus

Nutritional Status * To determine allergic reactions to certain foods or preservatives * Manifestations range from rhinitis, chest tightness, weakness, dyspnea (short of breath), urticaria, severe wheezing, to loss of consciousness * Usual food intake & whether any breathing problems occur w/eating * Malnutrition may occur if pt has difficulty breathing while eating or preparing food

Family History & Genetic Risks * Respiratory disorders w/genetic component, CF, some lung cancers, alpha1-antitrypsin deficiency * Pt. w/asthma often have family hx of infectious disease, such as TB

Current Health Problems * Whether current health problems is acute or chronic * Usually includes cough, sputum production, chest pain, shortness of breath at rest or on exertion * Onset of problem, how long it lasts, location, how often occurs, has problem become worse over time, what symptoms occur w/it, which actions or interventions provide relief, which ones make it worse, what tx have been used * Cough * Main sign of lung disease * How long present * Does it occur at specific time of day * Or any r/t physical activity * Productive or non-productive * Congested, dry, tickling, hacking * Sputum production * Duration, color, consistency, odor, & amount of sputum * May be clear, white, tan, gray, or if infection yellow or green * Consistency as thin, thick, watery or frothy * Smokers w/chronic bronchitis have mucoid sputum * Pulmonary edema - excessive pink, frothy sputum * Pneumococcal pneumonia – rust colored sputum * Lung abcesses – foul smelling * Hemoptysis (blood in sputum) most often seen in chronic bronchitis or lung cancer
Current Health Problems * TB, pulmonary infarction, bronchial adenoma, lung abscess may have grossly bloody * Quantify by describing volume tsp, Tbsp, c, or factions of cups * Whether production is ↑, from external stimuli or internal cause * Chest pain * Detailed description of chest pain helps distinguish whether pain in pleural, muscoskeletal, cardiac or GI * Continuous or made worse by coughing, deep breathing, or swallowing * Cardiac pain usually intense and “crushing”, may also radiate to arm, shoulder, neck * Pulmonary pain feels like something “rubbing” inside * Varies depending on cause * May appear only on deep inhalation & the end of exhalation * Usually not made worse by touching or pressing over the area * Dyspnea * Subjective perception & varies between people * May not be consistent w/severity of presenting problem * Type of onset (slow or sbrupt) * Duration (number of hours, time of day) * Relieving factors (cx of position, drug use, activity cessation) * Wheezing, crackles or stridor occurs w/breathlessness) * Does it interfere w/ADLs, if so how severely * Paroxysmal nocturnal dyspnea (PND) intermittent dyspnea during sleep, has sudden onset of breathing diff. that is severe enough to awaken from sleep * Orthopnea – shortness of breath that occurs when lying down, but relieved by sitting up * Usually occur w/chronic lung disease & left sided heart failure

Childhood illnesses * Asthma * Pneumonia * Communicable diseases * Hay fever * Allergies * Eczema * Frequent colds * Croup * CF

Adult illnesses * Pneumonia * Sinusitis * TB * HIV and AIDS * Lung disease such as emphysema & sarcoidosis * Diabetes * Hypertension * Heart disease

* Influenza, pneumococcal and BCG vaccines * Surgeries of upper or lower respiratory system * Injuries of upper or lower respiratory system * hospitalizations * Date of last chest x-ray, pulmonary function test, tuberculin test or other dx tests and results * Recent weight loss * Night sweats * Sleep disturbances * Lung disease & condition of family members * Geographic areas of recent travel * Occupation & leisure activities

ADVENTITIOUS BREATH SOUNDS

DISCONTINUOUS
Fine crackles
Fine rales early or late in inspiration
High-pitched rales

Character
Popping, discontinuous sounds caused by air moving into previously deflated airways; sounds like hair being rolled between fingers near ear “Velcro” sounds late in inspiration usually associated w./restrictive disorders Association Asbestosis Interstitial fibrosis Atelectasis Bronchitis Pneumonia Chronic pulmonary diseases

Course crackles more common on expiration but may be
Low pitched crackles present early in inspiration

Character
Lower-pitched, coarse, discontinuous rattling sounds caused by fluid or secretions in large airways; likely to change w/cough or suction Association Bronchitis Tumors Pneumonia Pulmonary Edema

CONTINUOUS
Wheeze audible during either inspiration, expiration, or both

Character
Squeaky, musical, continuous sounds associated w/air rushing thru narrowed airways; may be heard w/out a stethoscope Arise from small airways Usually do not clear w/coughing

Association Inflammation bronchospasm Edema Secretions Pulmonary vessel engorgement (cardiac “asthma”)

ADVENTITIOUS BREATH SOUNDS

Rhonchus (rhonchi) available during both inspiration & expiration - more prom on expiration Character Lower-pitched, coarse, continuous snoring sounds Arise from large airways

Association Thick, tenacious secretions Obstruction by foreign body Sputum production Tumors

PLEURAL FRICTION RUB
Heard during both inspiration & expirations, generally at end of inspiration and beginning of expiration

Heard in lateral lung fields

Association Pleurisy TB Pulmonary Infarction Pneumonia Lung cancer

Other indicators of Respiratory Adequacy
Skin and mucous membrane cx
Pallor or Cyanosis – inadequate, assess nail beds, mucous membranes or oral cavity Fingers for clubbing – indicates hypoxia of long duration

General appearance
Muscle development & general body build
Long term resp problems limit ability to maintain body weigh & lead to loss of muscle mass
Arms & legs may appear thin or poorly muscled
Muscles of neck & chest may be hypertrophied, esp in COPD pt

Endurance
Decreases w/inadequate breathing for gas exchange
Observe how easily pt moves
Short of breath while resting or short of breath w/10 to 20 steps
As pt speaks, not how often pt pauses for breath
Phychosocial Assessment
Anxiety because of reduced oxygen to the brain or sensation of not getting enough air is frightening

Diagnostic Assessment
Labs
Red blood cell count (RBC) – provides data about transport of O2, deficiency could cause hypoxemia

Arterial blood gases (ABGs) – assess oxygenation (PAO2), alveolar ventilation (PACO2) & acid base balance Provides info for monitoring tx results, adjusting O2, evaluating pt responses

Sputum – id bacterial infection & determine which specific antibiotics will be most effective Helps dx malignant lesions by id cancers cells

Imaging
Chest X-Rays – used for pt w/resp tract disorders to evaluate status of chest and provide base-line for comparison Posteroanterior – back to front Left Lateral Can be used to detect presence of pleural fluid, position of ET tube

CT scan – useful when x-ray reveals suspicious lesion Contrast enhances visibility of structures such as tumors, blood vessels & chambers of heart

Ventilation & perfusion scan (V/Q scan) – can ID areas of lung being ventilated & distribution of blood w/in lungs Used to rule out dx of PE Uses injected or inhaled radionuclide followed by scan Pulse oximetry – IDs hemoglobin saturation Ideal 95-100% Can detect desats before manifestations occur Causes for low readings include movement, hypothermia, ↓ peripheral blood flow, ambiet light, nail polish
Results lower than 91% are emergency

Capnometry & Capnography- methods to measure amount of CO2 present in exhaled air, indirect measurement of arterial CO2 levels Measure end tidal CO2 levels in intubated & those breathing spontaneously (ETCO2) Normal pressure of PETCO2 ranges between 20-40 mm Hg
Factors that ↑ - inadequate O2; fever, hypoventilation, partial airway obstruction, rebreathed exhaled air
Factors that ↓ - poor ventilation; hypothermia, poor cardiac output, hypotension, hypovolemia, PE, apnea, total airway obstruction, tracheal extubation

Pulmonary Function tests – evaluate lung function & breathing problems Useful in screening pt for lung disease before onset of manifestations

Prep
Explain purpose of test
Advise not to smoke 6-8hrs before test
Bronchodilators may be w/held for 4-6hrs before test
Help reduce anxiety and explain what will happen during test
Procedure
Bedside or respiratory lab
Breathe through mouth only
Follow up
Observe for increased dyspnea or bronchospasm

Characteristic & Purposes of Pulmonary Function Tests
FVC (forced vital capacity) – records max amount of air that can be exhaled as quick as pos. after max inspiration
Purpose – gives indication of resp muscle strength and ventilatory reserve. Often ↓ in obstructive disease (due to air trapping) & in restrictive disease

FEV1 (forced expiratory vol in 1 sec) – records max amount of air that can be exhaled in 1st second of expiration Purpose – effort dependent & ↓ normally w/age. ↓ in certain obstructive & restrictive diseases

FEV1/FVC – ratio of expiratory volume in sec to FVC
Purpose- provides much more sensitive indication of obstruction to airflow. Hallmark of obstructive pulmonary disease. Normal or ↑ in restrictive disease

FEF 25%-75% - records forced expirary flow over 25-75% volume (middle half) of FVC Purpose – more sensitive index of obstruction in smaller airways

FRC (functional residual capacity) – amount of air remaining in lungs after normal expiration. Requires use of helium dilution, nitrogen washout, or body plethysmography tech.
Purpose – indicates hyperinflation or air trapping, may result from obstructive pulmonary disease. Normal or ↓ in restrictive pulmonary diseases

TLC (total lung capacity) – amount of air in lungs at end of max inhalation
Purpose - ↑ indicates air trapping associated w/obstructive pulmonary disease. ↓ indicates restrictive disease

RV (residual volume) – amount of air remaining in lungs at end of full, forced exhalation Purpose - ↑ in obstructive pulmonary disease such as emphysema

DLCO (diffusion capacity of carbon monoxide) –reflects surface are of alveolocapillary membrane. Pt inhales small amount of CO2, holds 10 sec, then exhales. Amount inhaled is compared to amount exhaled
Purpose - ↓ whenever alveolocapillary membrane is diminished, emphysema, pulmonary htn, pulmonary fibrosis. ↑ w/exercise & in conditions such as polycythemia & Congestive heart disease Exercise testing * Exercising ↑ metabolism & ↑ gas transport because energy is used * Assesses ability to work or preform ADLs * Differentiates reasons for exercise limitation * Evaluates disease influence on exercise capacity * Determines whether supplemental O2 is needed during exercise * Performed on treadmill or self-paced 12 min walking test * Normal pt exercise limited by circulatory factors * Pulmonary pt is limited by breathing capacity, gas exchange compromise or both
Skin tests * Used w. other dx date to id various infectious disease (TB), viral disease (mononucleosis, mumps), fungal disease (coccidioidomycosis, hisptoplasmosis) * Allergies and status of immune system can be ck through skin testing

Invasive Diagnostic assessments
Endoscopic
Assess breathing problems, bronchoscopy, laryngoscopy, mediastinoscopy
Laryngoscopy – tube for visualization inserted in larynx * access function of vocal cords * remove foreign bodies caught in larynx * obtain tissue samples for biopsy
Mediastinoscopy – insertion of flexible tube through vest wall just above sternum into area of upper chest between lungs * Performed in OR – under general * Examine local structures for presence of tumors * Obtain tissues for biopsy or culture
Bronchoscopy – insertion of tube in airways, usually as far as 2nd bronchi * Viewing airway structures * Obtaining samples for biopsy or culture * Used to dx and manage pulmonary diseases * Performed in ICU – low dose sedation * Assist in placing ET tube * Collecting specimens & dx infections * Most useful in cancer staging * Removal of secretions that are not clearing thru normal suctioning
Pre- verify consent * Assess allergies * “time out” called for verification * NPO 4-8 hours prior * Premed w/benzodiazepines * Benzocaine spray used as topical – can cause methemoglobinemia – conversion of norm hemoglobin to methemoglobin – altered iron state, does not carry O2 – result hypoxia * Normal level ↓ 1% - cyanosis at 10% - death at 50% * Post – monitor V/S q15nin for 1st 2 hours
Thoracentesis
* Aspiration of pleural fluid or air from pleural space * Can be used for dx or treatment * Pleural fluid may be drained to relieve blood vessel or lung compression & resp distress caused by cancer, empyema, pleurisy or TB * Drugs can be instilled into pleural space
Prep
* Expect stinging sensation from local anesthetic * Feeling of pressure when needle is inserted * Stress importance of not moving during procedure to avoid puncture of pleura or lung * Ask about allergy to local anesthetic * Verify informed consent * Entire chest or back exposed, and site shaved if necessary * Actual site depends on volume & location of effusion (x-ray, percussion & sonography)
Procedure
* Usually at bedside * Person performing & assisting wears goggles & masks * After draping pt & cleaning skin, local is injected * Keep pt informed of procedure, while observing for signs of shock, pain, nausea, pallor, diaphoresis, cyanosis, tachypnea, & dyspnea * 18-25 gauge Thoracentesis needle (w/attached syringe) is advanced into pleural space * Gentle suction is applies as fluid in pleural space is slowly aspirated * A vacuum collection bottle sometimes needed for large amounts of fluid * To prevent re-expansion usually no more than 1000mL is removed at one time * After needle w/drawn pressure applied to site, small sterile dressing applied

Follow up * Chest X-Ray to rule out possible pneumothorax and mediastinal shift (shift of central thoracic structures to one side) * Monitor V/S, auscultate breath sounds for absent or reduced sounds on affected side * Ck puncture site & dressing for leakage or bleeding * Assess for complications (re-accumulation of fluid, subcutaneous emphysema, infection & tension pneumothorax) * Urge pt to breathe deeply to promote expansion of lung * Teach pt about manifestations of pneumothorax (partial or complete collapse of lung) * Pain on affected side that is worse at end of inhalation & end of exhalation * Rapid HR * Rapid, shallow respirations * Feeling of hunger * Prominence of affected side that does not move in & out w/respiratory effort * Trachea slanted more to unaffected side instead of being in center of neack
Lung Biopsy
Performed to obtain tissue for histologic analysis, culture, or cytological exam * Tissue samples used to make definite dx about type of cancer, infection, inflammation or lung disease * Performed during bronchoscopy
Performed during bronchoscopy
Transbronchial biopsy (TBB) * Transbronchial needle aspiration (TBNA) * transthoracic needle aspiration is approach thru skin (percutaneous) for areas that cannot be reached by bronchoscopy * Open lung biopsy performed in OR

Prep * Explain what to expect before and after * Explore pt feelings and fears * To reduce discomfort & anxiety – analgesic or sedative * Pt undergoing percutaneous – discomfort is ↓ w/local but pressure may be felt during needle insertion and tissue aspiration

Procedure * Percutaneous - Positioning similar to Thoracentesis * Skin cleansed w/antiseptic, local given * Under sterile conditions 18-22 gauge needle inserted thru skin into desired area * Tissue needed for microscopic exam obtained * Apply dressing after procedure

Follow up * Monitor V/S and breath sounds q4hrs for 24 hours * Assess for signs of respiratory distress * Pneumothorax – serious complication of needle biopsy & open lung biopsy * Report reduced or absent breath sound immediately * Monitor for hemoptysis (may be scant or transient) * Rare cases, for frank bleeding from vascular or lung trauma

LAB PROFILE – RESPIRATORY ASSESSMENT
BLOOD STUDIES – CBC
Red blood cells females: 4.2—5.4 Males: 4.7 - 6.1
↑ - may be due to excessive prod of erythroprotein, occurs in response to hypoxic stimulus, COPD and from living at high altitude
↓ - possible anemia, hemorrhage or hemolysis

Hemoglobin, total females: 12-16 Males: 14-16
↑ - may be due to excessive prod of erythroprotein, occurs in response to hypoxic stimulus, COPD and from living at high altitude
↓ - possible anemia, hemorrhage or hemolysis

Hematocrit females: 37-47% Males: 42-52%
↑ - may be due to excessive prod of erythroprotein, occurs in response to hypoxic stimulus, COPD and from living at high altitude
↓ - possible anemia, hemorrhage or hemolysis

WBC (leukocyte count) total: 5,000-10,000
↑ - possible acute infections or inflammations, pneumonia, meningitis, tonsillitis, emphysema
↓ - overwhelming infection, autoimmune disorder, immunosuppressant therapy

DIFFERENTIAL WBC (LEUKOCYTE) COUNT
Neutrophils 2500-8000 or 55-70%
↑ - possible acute bacterial infect (pneumonia), COPD or inflammatory conditions (smoking)
↓ - possible viral disease (influenza)

Eosinophil 50-500 or 1-4%
↑ - possible COPD, asthma, or allergies
↓ - pyogenic infections

Basophil 25-100 or 0.5-1%
↑ - possible inflammation; seen in chronic sinusitis, hypersensitivity reactions
↓ - acute infection

Lymphocytes 1000-4000 or 20-40%
↑ - possible viral infection, pertussis, & infectious mononucleosis
↓ - during corticosteroid therapy

Monocytes 100-700 or 2-8%
↑ - possible viral infection, pertussis, & infectious mononucleosis; also may indicate active TB
↓ - during corticosteroid therapy

ABGs

PaO2 80-100 mm Hg
↑ - possible excessive O2 administration
↓ - possible COPD, asthma, chronic bronchitis, cancer of bronchi & lungs, cystic fibrosis, respiratory distress syndrome, anemias, atelectasis, or any other cause of hypoxemia
PaCO2 35-45 mm Hg
↑ - possible COPD, asthma, pneumonia, anesthesia effects, use of opioids (respir. acidosis)
↓ - hyperventilation/respiratory alkalosis

pH up to 60yr: 7.35-7.45
↑ - respiratory or metabolic alkalosis
↓ - respiratory or metabolic acidosis

HCO3 21-28 mEq/L
↑ - respiratory acidosis as compensation for primary metabolic alkalosis
↓ - respiratory alkalosis as compensation for primary metabolic acidosis

SpO2 95-100%
↓ - possible impaired ability of hemoglobin to release O2 to tissues

ROME:

Respiratory= Opposite:
· pH is high, PCO2 is down (Alkalosis).
· pH is low, PCO2 is up (Acidosis).

Metabolic= Equal:
· pH is high, HCO3 is high (Alkalosis).
· pH is low, HCO3 is low (Acidosis).

Nursing Care of Adults With a Tracheostomy (ch 30)
Tracheostomy
* Surgical incision into trachea to create an airway * Tracheostomy – tracheal stoma, opening that results from tracheotomy * indications for trach include acute airway obstruction, need for airway protection, laryngeal trauma & airway involvement during head or neck surgery
Nursing Dx * Impaired gas exchange r/t weak chest muscles, obstruction, or other physical problems * Impaired verbal communication r/t physical barrier (trach, intubation) * Imbalance nutrition: Less than body requirements r/t presence of ET tube * Risk for infection r/t invasive procedures * Impaired oral mucous membrane r/t mechanical factors (ET tube) * Impaired social Interaction r/t communication barriers

Pre-op * Explain about self-care of airway * Alternative methods of communications * Suctioning * Pain control methods * Critical Care Environment (incl. ventilators & routines) * Nutritional support * Feeding tubes * Goals for discharge * Pt will need to learn new methods of speech (pen & pencil, magic slate, pict or alphabet board, or computer generated word generator) * Team approach for planning care & rehab is critical for best outcome

Operative * Initially neck is extended and ET placed to maintain airway * Incision is made through anterior skin of neck * Exposing tracheal rings & moving other tissue out of surgical path * Second incision made through tracheal rings to enter trachea * After trachea entered trach tube inserted * Trach tube is secured in place w/sutures & trach ties * Chest X-Ray is obtained to ensure proper placement of tube

Post-op * Immediately post op, focus care on ensuring patent airway * Confirm presence of bilateral breath sounds * Conduct thorough resp assessment q2hr * Assess pt for complication from procedure
Complications
Tube obstruction – can occur as a result secretions or by cuff displacement * Difficulty breathing * Noisy respirations * Difficultly inserting suction catheter * Thick dry secretions * Unexplained peak pressures (if vent in use)
Assess pt hourly for tube patency
Prevent obstruction by helping pt cough, & deep breathe
Provide inner cannula care
Humidify O2 source
Suction

Tube dislodgement and accidental decannulation – can occur when tube system is not secure * Can be prevented by securing tube in place - ↓ move & traction on tube or accidental pulling * Tube dislodgement in first 72 post op is an emergency-trach tract has not matured & replacement difficult * Tube may end up in subcutaneous tissue instead of trachea * If this occurs, 1st vent pt using mechanical resuscitation bag & facemask while another nurse calls for help * Ensure trach tube of same type (including obturator) and size (or 1 size smaller) is at bedside at all times, along w/trach insertion tray * If occurs after 72 hours, extend pt neck & open tissues of stoma to secure airway * With obturator inserted in trach tube, quickly & gently replace tube & remove obturator * Check for airflow thru tube & for bilateral breath sounds * If you cannot secure airway, get more experience nurse, resp therapist or physician * Ventilate via bag-valve mask * If pt is in distress call Rapid response team

Pneumothorax (air in chest cavity) can develop during trach procedure if the chest cavity is entered * Occurs at apex of lung, when occurs during tracheotomy * Chest x-ray after placement are used to assess for pneumothorax

Subcutaneous emphysema – occurs when there is opening or tear in trachea & air escapes into fresh tissue planes of neck * Inspect and palpate for air under skin around new trach * If skin is puffy & feel a crackling sensation, notify physician immediately
Bleeding
* Small amounts expected for first few days * Constant oozing is abnormal * Wrap gauze around tube & pack gauze gently into wound to apply pressure to bleeding sites

Infection – can occur anytime * In hospital, use sterile technique to prevent infection during suction & trach care * Assess stoma site at least once per shift for purulent drainage, redness, pain, swelling * Trach dressings may be used to keep stoma clean and dry * If not available fold standard 4x4s to fit around tube, DO NOT cut dressing, small bits of gauge could be aspirated thru tube * Change often – moist dressing provide medium for bacterial infections

Tracheomalacia: constant pressure exerted by cuff causes tracheal dilation & erosion of cartilage Manifestations ↑ amount of air is required in cuff to maintain seal Larger tracheostomy tube is required to prevent air leak at stoma Food particles are seen in tracheal secretions Pt does not receive set tidal volume on vent Management No special management unless bleeding occurs Prevention Use uncuffed tube as soon as possible Monitor cuff pressure & air volumes closely and detect cx

Tracheal stenosis: narrowed tracheal lumen, due to scar formation from irritation of tracheal mucosa by the cuff Manifestations Usually seen after cuff is deflated or trach tube is removed ↑ coughing, inability to expectorate secretions or difficultly in breathing or talking Management Tracheal dilation or surgical intervention used Prevention Prevent pulling of & traction on trach tube Properly secure tube in midline position Maintain proper cuff pressure Minimize oronasal intubation time

Tracheosophageal fistula (TEF): excessive cuff pressure causes erosion of posterior wall of trachea. A hole is created between trachea and the anterior esophagus. Pt at highest risk also has NG tube Manifestations Similar to tracheomalacia ↑ amount of air is required in cuff to maintain seal Larger tracheostomy tube is required to prevent air leak at stoma Food particles are seen in tracheal secretions Pt does not receive set tidal volume on vent ↑ choking & coughing while eating Management Manually admin O2 by mask to prevent hypoxemia Use small, soft feed tube instead of NG. Gastrostomy or jujunostomy may be preform Monitor pt w/NG tube closely; assess for TEF & aspiration Prevention Maintain cuff pressure Monitor amount of air need for inflation, & detect cx Progress to deflated cuff or cuffless tube as soon as possible

Trachea-innominate artery fistula: malpositioned tube causes distal tip to push against lateral wall of trach. Continued pressure causes necrosis & erosion of innominate artery. This is med emergency! Manifestations Trach tube pulsates in synchrony w/heartbeat Heavy bleeding from stoma Life threatening complication Management Remove trach tube immediately Apply direct pressure to innominate artery at stoma site Prepare pt for immediate repair surgery Prevention Correct tube size, length and midline position Prevent pulling or tugging on trach tube Immediately notify physician of pulsating tube

Non-cuffed trach used for airway maintenance when mechanical vent is not needed

breathing and swallowing move tube, cuffed tube does not protect against aspiration

fenestrated tube when inner cannula is in plave, fenestration is covered over, closed, works like double lumen tube

With inner cannula removed and plug or red stopper locked in place, air can pass thru fenestration, around tube, & up thru natural airway. Pt can cough and speak

Prevention of Tissue damage * Can occur at point where inflated cuff presses against tracheal mucosa * Inflate cuff to form seal between trachea & cuff while creating least amount of pressure * Check pressure at least once during each shift, keep pressure at 14-20 mm Hg or 20-28 cm H2O * Pt who is malnourished, dehydrated, hypoxic, older or receiving corticosteroids has poor tissue healing and is at risk for greater tissue damage

Air warming & Humidification * Bypasses nose & mouth, which normally humidify, warm & filter air * If humidification & warming are not adequate, tracheal damage can occur * Thick, dried secretions can occlude airway * Assess for fine mist emerging from trach collar or T-piece during inspiration & expiration * Keep temp between 98.6 and 100.4. Should never exceed 104.

Suctioning * Maintains patent airway & promotes gas exchange by removing secretions from pt who cannot cough adequately * Suction is need when audible or noisy secretions, crackles, or wheezes are heard on auscultation * When restlessness, increased pulse or resp. rates * Mucous in artificial airway is present * Patient request * Increase in peak airway pressure on vent

1. Assess need for suctioning 2. Wash hands. Don protective eyewear. Maintain standard precautions 3. Explain to pt that sensations such as shortness of breath and coughing are to be expected but discomfort will be brief 4. Check suction source. Occlude suction source, adjust pressure dial to between 80-129 to prevent hypoxemia and trauma to mucosa 5. Set up sterile field 6. Preoxygenate pt w/100% for 30 sec to 3min to prevent hypoxemia. Keep hyperinflations synchronized w/inhalation 7. Quickly insert suction catheter until resistance is met. Do not apply suction during insertion 8. Withdraw catheter 1-2 com & begin to apply suction and twirling motion of catheter during w/drawal. Never suction longer than 10-15 sec. 9. Hyperoxygenate for 1-5 min or until pt baseline HR and O2 are w/in norm 10. Repeat as needed for up to 3 total suction passes 11. Suction mouth as needed, provide mouth care. 12. Wash hands

Suctioning can cause hypoxia, tissue trauma, infection, vagal stimulation, bronchospasm, & cardiac dysrhythmias * Hypoxia can be cause by these factors in pt w/trach * Ineffective O2 before, during, after suctioning * Use of catheter that is too large for artificial airway * Prolonged suctioning time * Excessive suction pressure * Too frequent suctioning

Vagal stimulation & bronchospasm * Results in severe Bradycardia, hypotension, heart block, ventricular tachycardia, asystole or other dysrhythmias * If vagal stimulation occurs, stop suctioning immediately oxygenate pt manually w/100% O2 * Bronchospasms occur sometimes when catheter passes into airway * May need bronchodilator to relieve spasm and respiratory distress

Non-infectious Upper Respiratory Problems (ch 31)
Epistaxis
Nosebleed – common problem because of many capillaries w/in nose

Occur as a result of: * Trauma * Hypertension * Blood dyscrasias (leukemia) * Inflammation * Tumor * Decreased humidity * Nose blowing * Nose picking * Chronic cocaine use
Procedures such as NG suctioning
Men affected more than women
Older adults tend to bleed most often from posterior portion of nose

Care * Often reports bleeding started after sneezing or blowing nose. * Document amount & color of blood then take vitals * Ask pt about number, duration, & causes of previous episodes

Interventions * Position pt upright & leaning forward to prevent blood from entering stomach and possible aspiration * Reassure pt and attempt to keep quiet to reduce anxiety and BP
Apply direct lateral pressure to nose for 5 min, & apply ice or cool compress to nose and face if possible * Maintain standard precautions * If nasal packing necessary, loosely pack both nares w/gauze or gel tampons * To prevent rebleeding from dislodged clots, instruct not to blow nose for several hours after stopped
Medical attention is needed if nosebleed does not respond to interventions
Affected capillaries may be cauterized w/silver nitrate or electrocautery and nose packed
Anterior packing controls bleed from anterior nasal cavity

Posterior bleeding is emergency because it cannot be easily reached & pt may lose a lot of blood quickly

Posterior packing, epistaxis catheters, or gel tampon may be used

Observe pt for respiratory distress & for tolerance of packing or tubes

Humidity, oxygen, bed rest and antibiotics may be prescribed

Opioid drugs – may be prescribed for pain
Assess pt receiving opioids at least hourly for gag and cough reflex
Oral care & hydration are important because of mouth breathing
Use pulse ox to monitor for hypoxemia
Tubes or packing usually removed after 1-5 days
After removed, teach pt & family following interventions to use at home for comfort and safety
Petroleum jelly can be applied for lubrication & comfort
Nasal saline sprays & humidification add moisture to prevent rebleeding
Avoid vigorous nose blowing
Use of aspirin or other NSAIDs
Strenuous activities such as lifting for 1 month

Obstructive Sleep Apnea * Breathing disruption during sleep that lasts at least 10 sec and occurs min of 5 times an hour * Most common form occurs as result of upper airway obstruction by soft palate or tongue * Factors that contribute to sleep apnea: * Obesity * Large uvula * Short neck * Smoking * Enlarged tonsils or adenoids * Oropharyngeal edema * Men affected more than women * Risk ↑ w/age

Etiology * During sleep, muscles relax & tongue & neck structures displace * As result upper airway is obstructed even though chest wall movement is unimpaired * Apnea ↑ blood carbon dioxide levels and ↓ pH → stimulates neural centers * Sleeper awakens after 10 sec or longer of apnea & corrects obstruction → resp resumes * After pt goes back to sleep, cycle begins again, sometimes as often as every 5 min * Prevents deep sleep needed for best rest * May have excessive daytime sleepiness, inability to concentrate, & irritability

Assessment * Pt often unaware, should be suspected w/ excessive daytime sleepiness, “wakes up tired” * Snores heavily * Inability to concentrate, & irritability * Polysomnography – during sleep study * Observed while wearing EEG, ECG, pulse ox, EMG * Determines depth of sleep, type, resp effort, O2 sat, muscle movement
Interventions
* Cx in sleeping position, weight loss to correct mild sleep apnea * Position-fixing devices prevent subluxation of tongue & neck may be effective * Positive pressure ventilation to hold open airways. Nasal mask allows mechanical delivery of BiPAP or CPAP * As pt begins to exhale, machine delivers lowe end expiratory pressure * Two pressures hold open airways * Proper fit is key to successful treatment * Modafinil (Attenace, Provigil) is helpful in pt w/narcolepsy (uncontrolled daytime sleep) from sleep apnea by promoting daytime wakefulness. Does NOT treat cause
Surgical – removal of adenoids, uvula, or remodeling entire posterior oropharynx (uvulopalatopharyngoplasty)
Head and Neck Cancer * Curable when tx early * Untreated fatal w/in 2 yrs of dx * 80% - squamous cell carcinomas of mucosa, slow growing – often appear as deep ulcerations * Begins when mucosa is chronically irritated & cx into tougher mucosa (squamous metaplasia) * Lesions may then take form of white, patchy lesions (leukoplakia) or red, velvety patches (erythroplasia) * Growth & metastasis - 1st occur in nearby structures, lymph nodes, muscle & bone * Systemic spread through blood & lymphatic systems to distant sites might occur – usually lungs or liver

Etiology * Actual cause unknown * Most important risk factors tobacco and alcohol use, esp in combination * Voice abuse * Chronic laryngitis * Exposure to industrial chemicals * Hardwood dust * Poor oral hygiene * Long-term or severe GERD * Men more than women 3:1 * Older than 60yrs

Assessment
Hx
* May have difficulty speaking because of hoarseness, shortness of breath, tumor bulk and pain * Tobacco & alcohol use * Hx of laryngitis or pharyngitis * Oral sores * Lumps in the neck * Calculate packs-years * Alcohol intake (how many, how long) * Exposure to environmental or occupational pollutants * Assess problems r/t to risk factors * Nutrition → alcohol intake & impaired liver function * Dietary habits, weight loss * Chronic lung disease → impact pt breathing pattern

Manifestations/Warning Signs * Painless hoarseness may occur because of tumor size & inability for vocal cords to come together for normal speech (phonation) * Lesions of vocal cords are earliest form * Pain * Lump in mouth, throat, or neck * Difficulty swallowing * Color cx in the mouth or tongue to red, white, gray, dk brown, or black * Oral lesion or sore that does not heal in 2 wks * Persistent or unexplained oral bleeding * Numbness of mouth, lips, face * Change in fit of dentures * Burning sensation when drinking citrus juices or hot liquids * Persistent, unilateral ear pain * Hoarseness or change in voice quality * Persistent or recurrent sore throat * Shortness of breath * Anorexia & weight loss
Labs
* CBC * Bleeding times * Urinalysis * Blood chemistries * Chronic alcohol may have low protein & albumin levels – poor nutrition * Renal & liver function tests, to rule out spread & to evaluate pt ability to metabolize meds & chemo

Imaging * X-Rays of skull * Sinuses * Neck * Chest, useful in dx cancer spread, other tumor & extent of tumor invasion * CT of head and neck, w/or w/out contrast, helps evaluate exact location * MRI – can differentiate normal from diseased tissue * Brain, bone, & liver evaluated w/nuclear imaging * Direct & indirect laryngoscopy * Tumor mapping * Biopsy * Panendoscopy is performed under general, to define extent of tumor * Tumor mapping biopsies – location * Biopsy –confirms dx & determine tumor type, cell features, & location * Tumor staging (TNM)

Nursing Dx * Risk for aspiration r/t edema, anatomic cx, or altered protective reflexes * Anxiety r/t threat of death, cx in role status, or cx in economic status * Disturbed body image r/t tumor & tx modalities * Acute pain or chronic pain r/t tumor invasion of tissues & nerves & surgical intervention * Imbalanced nutrition: less than body req. r/t dysphagia, anxiety, tumor process, surgical resection, or chronic alcohol intake * Impaired verbal communication r/t tumor invasion, hoarseness, pain or surgical resection * Impaired skin integrity r/t altered circulation, nutritional deficit, tumor invasion, radiation, chemical factors (body secretions or substances) or surgical wound * Ineffective coping r/t altered body image, communication method or ineffective social support * Impaired social interaction r/t body image disturbance & lifestyle practices * Deficit knowledge (tx regimen & resources) r/t lack of exposure to or lack or interest in learning

Planning & Implementation * Expected to attain & maintain adequate tissue oxygenation * ABGs w/in normal limits * Rate & depth of respiration w/in normal range * Pulse ox w/in normal range * Absence of cyanosis or pallor

Interventions
Goal is remove or eradicate cancer whole preserving as much normal function as possible

Non-surgical * Monitory respiratory system * Respiratory distress may indicate narrowing of airway r/t tumor growth, edema or both * Position pt for optimal air exchange (fowler’s, semi-fowler’s) * Sitting upright in reclining chair may promote more comfortable breathing

Radiation * Small cancers in specific locations has cure rate of 80% * Larger cancers is lower when radiation is used as only therapy * Standard uses 5000-7500 rad, usually over 6 wks in daily or 2x daily doses * May be used alone or in combo w/surgery * Slows tissue healing might not be performed before surgery

S/e * Hoarseness * Dysphagia * Skin problems * Dry mouth for a few weeks * Hoarseness may become worse, voice w/improves w/in 4-6 wks after completion of therapy * Use voice rest & alternate means of communication * May have sore throat * Difficulty swallowing during therapy to the neck * Gargling w/saline or sucking ice may ↓ discomfort * Mouthwashes & throat sprays contain local anesthetic (lidocaine or diphenhydramine) * Analgesics may be rx * Skin at site of irradiation becomes red & tender & may peel during therapy * Avoid exposing area to sun, heat, cold & abrasive tx such as shaving * Wear soft cotton * Wash w/gentle soap such as Dove * Lotions or powders rx by radiation oncologist should be used until healed * Salivary glands are in path of irradiation, pt has dry mouth (xerostomia) * S/e is long-term and may be permanent * Dental caries, ↑ risk for dental caries, ↑ risk for oral inf., halitosis (bad breath), taste cx * No cure, interventions can help * Heavy fluid intake particularly water, humidification * Artificial saliva (salivart) Chemo * TMN determines type of surgery needed for specific head & neck cancer * Very, small, early-stage tumors may be removed by laser therapy or photodynamic therapy * Reconstruction is also determined by tumor and amount of tissue to be resected & reconstructed. * Include laryngectomy (total & partial), tracheostomy, Oropharyngeal cancer resections * Laryngectomy cancer include cord stripping, removal and total laryngectomy * If in lymph nodes in neck or if tumor has ↑ rate of nodal spread, the surgeon performs a nodal dissection along with removal of primary tumor * Pathologist evaluates resected lymph nodes for tumor invasion
Pre-op
* Explain about self-care of airway * Alternate methods of communication * Suctioning, pain control methods * The critical care environment * Nutrition support * Feeding tubes * Goals for discharge * Learn new methods of speech – help prepare for this before surgery
Operative
* Hemilaryngectomy – vertical or horizontal * Supraglottic laryngectomy are types of partial voice conservation laryngectomies * To protect airway, trach is needed, usually temp * Neck dissection include removal of lymph notes, sternocleidomastoid muscle, jugular vein, 11th cranial nerve, & surrounding tissue * Because of 11th cranial nerve (spinal cord) is cut, shoulder drop will be present after

Post op * Often lasts 8hrs or longer * ICU post op * Monitor airway patency, v/s, hemodynamic status, & comfort level * Monitor for hemorrhage & other complications * V/s hourly for first 24 hr, then q2hrs until stable * Generally out of bed by 2nd day * Complications include airway obstruction, hemorrhage, wound breakdown & tumor recurrence * First priorities after surgery are airway maintenance and ventilation * Other priorities: wound * Flap * Reconstructive tissue care * Pain management * Nutrition * Psychological adjustment * Speech & language therapy
Airway maintenance & ventilation * May need vent immediate post-op because of long term smoking hx, chronic lung disease & long duration of anesthesia * Most pt wean easily because thoracic & abdominal cavities are not entered * Secretions may remain blood-tinged for 1-2 days * Total laryngectomy pt need laryngectomy tube & appliance to prevent scar tissue shrinkage of skin-tracheal border * Laryngectomy tube similar shorter and wider w/longer lumen. Care similar except pt can cx tube daily or as needed * Coughing, deep breathing & saline instillation usually effective in clearing secretions * Oral secretions - suctioned by alert pt using yankauer or tonsillar suction or soft red latex catheter * Teach to suction away from side of surgery * Inspect stoma w/flashlight * Inspect stoma w/flashlight * Clean suture line w/half strength hydrogen peroxide to prevent secretions from forming crusts & obstruction airway * Perform care 1-2 hrs during 1st few days post-op * Mucosa of stoma & trachea should be bright & shiny & w/out crusts

Wound, flap & reconstructive tissue care * Tissue “flaps” may be used to close wound & improve appearance * Commonly used flaps are myocutaneous flaps, island flaps, rotation flaps, trapezius flaps, split-thickness skin grafts (STSGs), free flaps w/microvascular anastomosis * Flaps are skin, subcutaneous tissue, and sometimes muscle, taken from other areas of body * 1st 24 hours are critical, evaluate all grafts, and flaps hourly for 72 hours * Monitor capillary refill, color, drainage, Dopler activity of major vessel * Report cx immediately to surgeon * Position pt so side of head & neck w/flaps is not dependent

Hemorrhage * Uncommon w/laryngectomy * Surgical drain in neck to collect blood & drainage for 72hrs post op * Drain also helps maintain position of reconstructed skin flaps * Sudden stoppage of drainage may indicate clot obstructing drain * Monitor drainage, & record amount and character * Ck patency & functioning of drainage system * Report malfunction, cx in flap appearance to surgeon
Wound Breakdown * Common complication caused by poor nutrition, long smoking hx, alcohol use, wound contam & prev. radiation therapy * Manage breakdown w/packing & local care as rx to keep wound clean & to stimulate growth of healthy granulation tissue * Wounds may be extensive & carotid artery may be exposed * Split thickness skin grafts often placed over carotid for protect in event of wound dehiscence * If granulation is slow and carotid is at risk another surgical flap may be made to cover carotid and close the wound * When carotid ruptures, large amounts of bright red blood spurt quickly * Possible for carotid to have a small leak, w/continuous oozing of bright red blood * Usually leak leads to complete rupture in short time * Call rapid response team and do not touch area because additional pressure could cause immediate rupture * If ruptures because of drying or infection, immediately place constant pressure over site & secure airway * Maintain direct manual constant pressure on carotid, and immediately transport pt to OR * Do NOT leave pt * High risk of stoke & death

Pain management * Caused by surgical cutting or manipulation of tissue & nerve compression * Morphine IV by a PCA 1-2 days * As pt progresses liquid opioid analgesics can be given via feeding tube * Oral only started after pt can tolerate oral intake * Adjunct to pain regimen may be NSAIDs or Amitrptyline (Elavil) or other tricyclic antidepressants

Nutrition * NG, gastrostomy or J-tube is placed during surgery * Initially pt receives IV fluids or parenteral nutrition until GI tract has recovered from anesthesia * Common goal is to provide 35-40 kcal/kg of body weight * Replacement of protein & water loss is calculated carefully * NG tube (most common) remains in place 7-10 days * Before removing assess pt ability to swallow if nutrition given by mouth * Aspiration cannot occur after total laryngectomy because airway and esophagus have been totally separated
Speech & language therapy * Speech therapy at first consists of writing, using picture board, using computer

* Pt then uses an artificial larynx, and Ideally eventually learns esophageal speech

* Have a laryngectomee (person who has had laryngectomy) from local self-help organizations is also beneficial

* Esophageal speech – sound can be produced by “burping” air swallowed or injected into esophageal pharynx & shaping words in mouth

* Monotone, cannot be raised or lowered, no pitch * Electrolarynges – may be used by pt who cannot attain esophageal speech. Most are battery powered devices places against side of neck or cheek

* Air inside mouth & throat is vibrated, and pt moves lips and tongue as normal * Tracheoesophageal fistulas (TEF) may be used if esophageal speech is ineffective & pt meets strict criteria

* Surgical connection is created between trachea & esophagus using special catheter. After fistula heals, silicone prosthesis is inserted in place of catheter

* Pt covers stoma & opening of prosthesis w/finger or opens & closes w/special valve to divert air from lungs, through trachea, into esophagus and out of lungs.

* Lip and tongue movement not the prosthesis itself, produces speech

Tracheotomy - Prevention of aspiration during swallowing * Avoid having meals when fatigued * Provide smaller more frequent meals * Provide adequate time; do not “hurry” pt * Provide close supervision if pt self feeding * Avoid water & other “thin” liquids * Thicken liquids * Avoid foods that generate thin liquids during chewing process (fruits) * Position pt in most upright position possible * When possible, completely (or partially) deflate tube cuff during meals * Suction after initial cuff deflation to clear airway & allow max comfort during meal * Feed each bite or encourage pt to take each bite slowly * Encourage pt to “dry swallow” after each bite to clear residue from throat * Avoid consecutive swallows by cup or straw * Provide controlled small volumes of liquids, using spoon * Encourage pt to “tuck” his or her chin down & move forhead forward while swallowing * Allow pt to indicate when he or she is ready for next bite * If pt coughs, stop feeding until pt indicates airway has been cleared * Continuously monitor tolerance to oral food intake by assessing resp rate, ease, pulse ox & HR

When NG is in place help prevent aspiration w/use of routine reflux precautions * Elevate head of bed * Strictly adhering to tube feeding regimens * No bolus feedings at night * Check residual feeding before each feeding (or every 4-6hrs for continuous) * Evaluate pt tolerance of tube feeding * If residual volume is high (above 100 mL for bolus or 2hrs worth of continuous) withhold feeding and notify physician

Supraglottic method of swallowing * Place yourself in upright, preferable out of bed position * Clear your throat * Take deep breath * Place ½ to 1 tsp of food in your mouth * Hold your breath, and clear throat * Swallow twice * Release your breath, clear your throat * Swallow twice again * Breath normal again
This method exaggerates normal protect mech of cessation of resp during swallow. Double swallow attempts to clear food that may be pooling in pharynx, vallecula, & piriform sinuses. Method is used only after dynamic radiographic swallow study has demonstrated it is appropriate & safe for pt.

Home management * Extensive preparation is needed after laryngectomy for cancer * Convalescent period is long, airway management is complicated * General cleanliness of home is assessed * For pt w/severe resp problems, home changes to allow for one-floor living may be needed * Increased humidity is needed * Be sure to stress meticulous cleaning of humidifiers is needed to prevent spread mold or other sources of infection

* Home care nurse to assess pt & home for problems in self-care, complications, adjustment, & adherence to medical regimen

* Avoid swimming, use care when showering or shaving * Lean slightly forward & cover stoma when coughing or sneezing * Wear stoma guard or loose clothing to cover stoma * Clean stoma w/mild soap and water. Lubricate stoma w/non-oil-based ointment as needed * Increase humidity by using saline in stoma as instructed, a bedside humidifier, pans of water and houseplants

* Obtain & wear a MedicAlert bracelet & ER card for life threatening situations

* Stop smoking

Non-infectious Lower Respiratory Problems (ch 32)
Chronic Obstructive Pulmonary Disease (COPD)
Most patients w/emphysema have chronic bronchitis at the same time, but each condition has its own pathophysiologic process

Emphysema * Two major cx occur w/pulmonary emphysema; loss of lung elasticity and hyperinflation of lung * Result in dyspnea and need for ↑ resp rate * ↑ amount of air becomes trapped in lungs * Causes of air trapping are loss of elastic recoil in the alveolar walls, overstretching & enlargement of alveoli into air-filled spaces called bullae, and collapse of small airways (bronchioles) * These cx greatly ↑ work of breathing * Hyperinflated lung flattens the diaphragm weakening the effect of the muscle (barrel chest) * Pt with emphysema needs to use additional (accessory muscles) in neck, chest wall and abdomen to inhale & exhale * ↑ effort ↑ need for oxygen, making pt work harder & have “air Hunger” sensation * Often inhalation starts before exhalation is completed, resulting in uncoordinated pattern of breathing * Gas exchange is affected by ↑ work of breathing & loss of alveolar tissue * Some alveoli enlarge, the curves of alveolar walls decrease & less surface area is available for gas exchange * Often pt adjusts by ↑ resp rate, so ABGs may not show gas problems til advanced disease * CO2 is produced faster than it can be eliminated → CO2 retention & chronic resp acidosis * Pt w/late stage emphysema also has low arterial oxygen (PaO2) level, because it is difficult for oxygen to move from diseased lung into bloodstream * ↑ CO2 ↓ O2 * Classified as panlobular, centrilobular or paraseptal depending on pattern of destruction & dilation of gas exchange until

Chronic Bronchitis * Inflammation of bronchi & bronchioles caused by chronic exposure to irritants esp. tobacco smoke * Irritant triggers inflammation, with vasodilation, congestion, mucosal edema, & bronchospasm * Unlike emphysema, bronchitis affects only the airway – no alveoli * Chronic inflammation causes ↑ in number & size of mucous glands → produce large amounts of thick mucus * Bronchial walls thicken (often 2x normal) and impair airflow * Thickening along w/excessive mucus blocks some of smaller airways & narrow large ones * Small airway are affected before large airways become involved * Hinders airflow and gas exchange because of mucous plugs and infection narrowing airway * PaO2 ↓ (hypoxemia) and arterial blood carbon PaCO2 ↑ (resp acidosis)

Etiology & Genetic Risk * Cigarette smoking is MOST IMPORTANT risk factor * Harmful effects of tobacco result in part because inhaled smoke triggers release of excessive amounts of proteases from lungs in the cells * These enzymes break down elastin, major component of alveoli * By impairing action of cilia, smoking also inhibits cilia from clearing bronchi of mucus, cellular debris & fluid * Passive (2ndhand smoke) contributes * Alpha1-antitrypsin def – less common but import risk factor * Special enzyme AAT is made by liver and normally pres in lungs

* One purpose of AAT is to regulate proteases that are present to break down inhaled pollutants and organisms

* Air pollution – small role Complications Hypoxemia & acidosis occur because pt w/COPD is less able to exchange gases, O2↓ and CO2↑ Respiratory infection * Risk ↑ because of ↑ mucus & poor oxygenation * Organisms most often causing bacterial inf. Streptococcus pnumoniae, Haemphilus influenza, & Moraxella catarrhalis Cardiac failure * Cor pulmonale (right sided hear failure cause by pulmonary disease) occurs w/bronchitis or emphysema * Air trapping, airway collapse, and stiff alveolar walls ↑ lung tissue pressure, making blood flow through lung vessels more difficult * ↑ pressure makes workload heavy on right side of the heart, which pumps blood to the lungs * As disease progresses, amount of O2 in blood ↓, causing major vessels to constrict * To pump blood through these narrowed vessels, tight side of the heart must generate ↑ pressures * In response to heavy workload, right chambers enlarge and thicken, causing right sided heart failure w/back up of blood into general venous system

Key features of Cor Pulmonale * Hypoxia & hypoxemia * ↑ dyspnea * Fatigue * Enlarged & tender liver * Warm, cyanotic hands & feet, w/bounding pulses * Cyanotic lips * Distended neck veins * Right ventricular enlargement (hypertrophy) * Visible pulsations below the sternum * GI disturbances; nausea or anorexia * Dependent edema * Metabolic & respiratory acidosis * Pulmonary hypertension Cardiac dysrhythmias Result from hypoxemia (↓ O2 to heart), Cardiac disease, drug effects or acidosis Assessment * Seen more in older men * Describe breathing problems * Assess whether pt has difficulty breathing while talking? * Can he speak in complete sentences, or is it necessary to take breath between every word or 2? * What activities trigger * Presence, duration, or worsening of wheezing, cough & shortness of breath * Cough pattern * Is cough productive? Sputum color * Many pt sleep in semi-sitting position because breathlessness worse when lying down (orthopnea) * Daily activities, difficulty w/sleeping, bathing, dressing, or sexual activity * Weigh pt, comparing * Unplanned weight loss occurs w/increase in COPD severity * ↑ Metabolic needs as result of ↑ work breathing * Dyspnea & mucus production often result in poor food intake & inadequate nutrition General Appearance * Observe his weight in proportion to height, posture, mobility, muscle mass, & overall hygiene * Pt w/increasingly severe COPD is thin, w/loss of muscle mass in extremities, although neck muscle may be enlarged

* Tends to be slow moving, slightly stooped * Sits w/forward bending posture, sometimes with arms held forward (tripod) * When dyspnea severe, activity intolerance may be so great bathing & general grooming are neglected Respiratory Cx * As a result of obstruction, cx in chest size, & fatigue * Pt w/respiratory muscle fatigue breathes w/rapid shallow, respirations * May have paradoxical respirations * Use accessory muscle in neck or abdomen * RR could be as high as 40-50 breaths/min * Respiratory movement is jerky & appears uncoordinated * Ck pt chest for abnormal retractions & for symmetric chest expansion * Pt w/emphysema has limited diaphragmative movement (excursion) because diaphragm is flattened & below its usual resting state * Chest vibration (fremitus) often ↓ & chest sounds hyperresonant on percussion due to trapped air * Auscultate chest to asses depth of inspiration & abnormal breath sounds * Wheezes and other abnormal sounds occur w/emphysema & chronic bronchitis * Often on inspiration & expiration, crackles usually not present * Silent chest may indicate obstruction or pneumothorax * Assess degree of dyspnea using assessment tool * Examine pt for presence of “barrel chest” * Ratio between anteroposterior diameter of chest & its lateral diameter is 2:2 rather than 1:2 * Chronic bronchitis pt often has cyanotic/blue tinged, dusty appear & has excess sputum prod * Assess for clubbing of fingers

Cardiac Cx * Occur as result of anatomic cx * Asses HR & rhythm * Check for swelling of feet and ankles (dependent edema) * Examine nail beds & oral mucus membranes * Pt w/later stage emphysema may have pallor or frank cyanosis
Laboratory assessment * ABGs – obtain baseline * As COPD worsens amount of O2↓ CO2 ↑ * Chronic resp. acidosis results (↑arterial CO2- PACO2) metabolic alkalosis (↑ bicarb) occurs as compensation by kidney retention of bicarb * Cx on ABGs seen as ↑ HCO3 * H&H to determine polycythemia (compensatory ↑ in RBC in chronically hypoxic pt)

Imaging assessment * Chest x-rays rule out other chest diseases * W/advanced emphysema, shoe hyperinflation & flattening of diaphragm

Other diagnostic assessments * Pulmonary function tests (PFT) airflow rates & lung volume measurements help distinguish airway disease (obstructive) from interstitial lung disease (restrictive)

* Determine lung volumes, flow volume curves & diffusion capacity * Each test performed before & after pt inhales bronchodilator * Lung volumes measured for COPD are vital capacity (VC), residual volume (RV) & total ling capacity TLC)

* RV most profoundly affected, although all volumes & capacities change to some degree * RV ↑ reflects trapped, stale air remaining in the lungs * Flow volume curves measure pt ability to move air into and out of lungs * Rate of airflow out of lungs during rapid, forecul, & complete exhalation from TLC to RV * Diffusion tests measure how well a test gas (CO2) diffuses across alveolar-capillary membrane & combines w/hemoglobin of RBC

* In emphysema, alveolar wall destruction causes large ↓ in surface area for diffusion of gas into the blood → to ↓ diffusion capacity

* In bronchitis, even though lung volumes are ↑ diffusion capacity usually normal * Pt w/COPD has ↓ oxygen saturation often much lower than 90%
Nursing Dx * Impaired gas exchange r/t alveolar capillary membrane cx, reduced airway size, ventilatory muscle fatigue, & excessive mucus production * Ineffective breathing pattern r/t airway obstruction, diaphragm flattening, fatigue, & ↓energy * Ineffective airway clearance r/t excessive secretions, fatigue, ↓ energy & ineffective cough * Imbalanced nutrition: less than body requirements r/t dyspnea, excessive secretions, anorexia, & fatigue * Anxiety r/t dyspnea, cx in health status, & situational crisis * Activity intolerance r/t fatigue, dyspnea, & imbalance between O2 supply & demand * Fatigue r/t cx in metabolic energy or hypoxemia * Deficient knowledge (disease process, rx treatments, activity limits) r/t unfamiliarity w/information resources * Sexual dysfunction r/t extreme fatigue * Impaired spontaneous ventilation r/t ventilatory muscle fatigue * Sleep deprivation r/t dyspnea or an unfamiliar environment (hospital) * Disturbed thought process r/t hypoxemia or sleep deprivation * Ineffective coping r/t high degree of threat, inadequate level of perception of control, cx in lifestyle, situational crisis, or knowledge deficit * Potential for pneumonia or other respiratory infections * Potential for Respiratory failure * Potential for right sided heart failure

Planning and implementation
Impaired gas exchange
Outcomes:
* Maintenance of Spo2 of at least 88% * Absence of cyanosis * Maintenance of cognitive orientation * Interventions *
Airway maintenance is most intervention to improve gas exchange – Keep pt head, neck, & chest in alignment. Assist him to liquefy secretions & clear airway of secretions

Monitoring for changes in resp status is key to providing prompt interventions to ↓ complications. * Assess every 2 hours, provide prescribed O2, assess pt response to tx, prevent complications * If pt condition continues to worsen despite tx, more aggressive therapy needed * Intubation may be necessary

Cough enhancement can improve gas exchange by helping ↑ airflow in larger airways
Promotion of deep inhalation by pt w/subsequent generation of high intrathoracic pressures & compression of underlying lung parenchyma for forceful expulsion of air * Monitor results of PFT, particularly VC, max inspiratory force, forced expiratory air in 1 sec * Assist pt to sitting position w/head slightly flexed, shoulders relaxed, and knees flexed * Encourage to take several deep breaths * Take deep breath, hold for 2 sec, & cough 2 or 3 times in succession * Instruct to inhale deeply several times, exhale slowly, & cough at end of exhalation * Follow coughing w/several maximal inhalation breaths

Oxygen therapy rx for relief of hypoxemia (↓ blood O2 levels) and hypoxia (↓ tissue oxygenation) Administered O2 and monitoring of its effectiveness

* Pt with COPD may need O2 flow of 2-4L/min via nasal cannula or up to 40% venture mask * Pt who is hypoxemic & also has chronic hypercarbia requires ↓ levels of oxygen delivery usually 1-2L/min via nasal cannula * Low arterial oxygen level is pt primary drive for breathing, do not ↑ O2 flow rate in pt w/hypercarbia because this may lower respiratory rate or even make them stop breathing spontaneously * Clear oral, nasal, & trach suctioning, as appropriate * Restrict smoking * Maintain airway patency * Set up O2 equip & admin thru heated, humidified system * Monitor O2 liter flow * Monitor position of O2 deliver device * Periodically ck O2 delivery device to ensure that rx concentration is being delivered * Monitor effectiveness of O2 therapy as appropriate * Assure replacement of O2 mask/cannula whenever device is removed * Monitor pt ability to tolerate removal of O2 while eating * Observe for signs of O2-induced hypoventilation * Monitor for signs of O2 toxicity & absorption atelectasis * Monitor O2 equipment to ensure that it is not interfering w/pt attempts to breathe * Monitor pt anxiety r/t need for O2 therapy * Provide for O2 when pt is transported * Instruct pt & family about use of O2 at home * Arrange for use O2 devices that facilitate mobility & teach pt accordingly
Drug therapy – involves same inhaled & systemic drugs as for asthma * Drugs include beta-adrenergic agents, cholinergic antagonist, methylxanthines, corticosteroids & NSAIDs * Focus on long term control therapy w/longer duration drugs arformoterol (Brovana) & tiotropium (Spiriva) * Pt w/COPD is more likely to be taking systemic agents (in addition to inhaled drugs) * Additional drug class for COPD is mucolytics, which thin secretions, making them easier to expectorate * Mucolytic agents are rx for pt w/thick, tenacious (sticky) mucous secretions * Nebulizer tx w/normal saline or mucolytic agent such as acetylcysteine (Mucosil, Mucomyst) or dornase alfa (Pulmozyme) & normal saline & facilitate expectoration * Guaifensin (Organidin, Naldecon) is system mucolytic taken orally

Pulmonary rehab can be used to improve function & endurance in pt w/COPD * Pt responds to dyspnea of COPD by limiting activity, even basic ADLs. * Over time, muscles of ventilation & other large muscle groups weaken & are less efficient in use of O2 → is increased dyspnea w/lower activity levels * Involves education & exercise training to prevent general & pulmonary muscle deconditioning * Formal programs are usually at least 6 wks long; pt can benefit ongoing exercise * 2 – 3x each week * Walk daily at self paced rate, followed by rest period, & continue walking until 20 min of actual walking * As rest time during rest periods, pt can add 5 more min of walking time

Surgical Management – lung transplant for end pt w/end stage COPD * Lung transplant & lung reduction surgery can improve gas exchange in pt w/COPD

* After successful lung reduction, most pt have at least 75% improvement in FEV1, ↓ TLC & RV, ↑ activity tolerance

* O2 therapy may no longer be needed

Ineffective Breathing Pattern * Pt w/COPD is expected to achieve an effective breathing pattern that ↓ work of breathing * Respiratory rhythm w/in normal limits for pt age * Presence of synchronous thoracoabdominal movement * Use of accessory muscles appropriate to pt activity level * Increased activity tolerance * Before intervention, assess pt to determine breathing pattern, esp rate, rhythm, depth, & use of accessory muscles * Pt w/COPD relies more on accessory muscles than on the diaphragm for breathing * These muscles are less efficient than diaphragm, and work breathing ↑ * Breathing techniques such as diaphragmatic or abdominal & pursed lip breathing

Diaphragmatic breathing * lie on your back w/your knees bent * place your hands or a book on your abdomen to create resistance * Begin breathing from your abdomen while keeping your chest still. You can tell if you are breathing correctly if your hands or the book rises & falls accordingly

Pursed-Lip Breathing * Close your mouth, and breathe in through your nose * Purse your lips as you would to whistle. Breathe out slowly through your mouth, without puffing your cheeks. Spend at least twice the amount of time it took you to breathe in * Use your abdominal muscles to squeeze out every bit of air you can. * Remember to use pursed-lip breathing during any physical activity. Always inhale before beginning the activity and exhale while performing the activity. Never hold breath

Positioning in upright position w/head of bed elevated can help alleviate dyspnea by↑ chest expansion, relaxing chest muscles & placing diaphragm in proper position to contract * Also conserves energy by supporting arms & upper body

Energy conservation is planning and pacing activities for max tolerance & min discomfort * Rest periods are paced between activities * Avoid working w/arms raised. Decrease exercise tolerance because accessory muscle of ventilation are then used to stabilize arms and shoulders * Do these activities sitting at a table leaning on elbows * Teach pt to adjust work heights to reduce back strain & fatigue
Ineffective airway clearance * Expected to maintain patent airway * Coughs effectively * No occurrence of aspiration * Maintenance of Spo2 of at least 88%

Coughing- at specific times of the day is helpful because pt has excessive mucus * Teach to cough on arising in am and eliminate mucus that collected during night * Cough to clear mucus before mealtimes may facilitate more pleasant meal * Before bedtime may ensure clear lungs

Chest physiotherapy (PT) with postural drainage helps some pt more secretions into central airways, re-expand lung tissue, and have more efficient use of ventilatory muscles * Combines chest percussion w/vibration to loosen secretions * Uses specific positions & gravity to help remove secretions

Suctioning – only when abnormal breath sounds are present – not on routine schedule * For pt w/weak cough, weak pulmonary muscles, & inability to expectorate effectively * Assess pt for dyspnea, tachycardia, & dysrhythmias durance procedure * Assess for improved breath sounds after
Positioning
* May improve airway clearance * Assist pt who can tolerate sitting in chair out of bed for 1 hr periods 2-3x a day * Helps move secretions & keep diaphragm in better position for ventilation

Hydration * helps airway clearance by thinning secretions, making them easier to remove by coughing * Unless contraindicated, 2-3L/day fluid * Humidifiers may be useful

Flutter valve mucus clearance devices – helpful to assist pt to remove airway secretions * Small, handheld plastic pipe w/short fat stem & a perforated lid over the bowl * Inside bowl is free moving steel ball * Pt inhales deeply & exhales forcefully through device causing ball to move & set up vibrations that are transmitted to pt chest and airways * Vibrations loosens secretions & allow them to be coughed out more easily

Imbalance nutrition: Less than body requirements * Maintains appropriate weight/height ratio * Maintains serum albumin or pre-albumin w/in normal the normal range * Pt often has food intolerance, nausea, early satiety, loss of appetite, and meal-related dyspnea * ↑ work of breathing raises calorie & protein needs * Conditions lead to protein-calorie malnutrition for may pt * Malnourished pt lose total body mass, ventilatory muscle mass & strength, lung elasticity & alveolar capillary surface are * All problems reduce effectively * Monitor weight & other indicators of nutrition such as skin cond & serum pre-albumin levels * Dyspnea management is needed because shortness of breath most common problem r/t nutrition * Plan biggest meal of day for the time when most hungry & well rested * 4-6 small meals a day may be preferred to 3 large ones * Use pursed-lip & abdominal breathing to alleviate dyspnea * Use bronchodilator 30 min before meal may help to reduce dyspnea due to bronchospasm * Food selection can help prevent weight loss & improve appetite * Abdominal bloating & feeling of fullness often prevent pt from eating complete meal * Foods that are easy to chew & not gas forming * Dry foods stimulate coughing & foods such as milk and chocolate may ↑ thickness of saliva & secretions… avoid these foods when symptomatic * Caffeinated beverages should be avoided ↑ UOP & may lead to dehydration * Urge pt to eat ↑ calorie, ↑ protein foods * Dietary supplements, such as Pulmocare, proved nutrition w/↓ CO2 production * If early satiety is a problem, advise to avoid drinking fluids before & during meal

Anxiety * Id factors that contribute to anxiety * Id activities to decrease anxiety * Verbalizing anxiety is reduced or absent * Pt often have ↑ anxiety during acute dyspneic epis, esp if they feel they are choking on secretions * Anxiety causes dyspnea

Potential for Pneumonia or other respiratory infections * Pneumonia is one of most common complications of COPD * Pt who have excessive secretions or who have artificial airways are at ↑ risk fir resp tract infect * Greatly ↑ in older adults * Avoid large crowds, & stress importance of receiving pneumonia vaccine & yearly flu shot
Home care/health teaching
Pt need to know as much about disease as possible so they can better manage it & themselves
Home care visits may be warranted, particularly if using home O2 therapy 1st time
Meals on wheels
Better Breather clubs sponsored by American lung Association

Home care Assessment
Assess respiratory status & adequacy of ventilation * Measure rate, depth, & rhythm of respirations * Examine mucous membranes & nail beds for evidence of hypoxia * Determine use of accessory muscles * Examine chest & abdomen for paradoxical breathing * Count # of words pt can speak between breaths * Determine need & use of supplemental O2 (liters per min) * Determine LOC & presence/absence of confusion * Auscultate lungs for abnormal breath sounds * Measure O2 sat by pulse oximetry * Determine sputum production, color, amount * Ask about activity level * Observe general hygiene * Measure body temp
Assess cardiac status * Measure rate, quality, & rhythm of pulse * Check dependent areas for edema * Check neck veins for distention w/pt in a sitting position * Measure capillary refill
Assess Nutritional Status * Weight maintenance, loss or gain * Food & fluid intake * Use of nutritional supplements * General condition of skin * Assess pt & caregivers adherence & understanding of illness & tx, including; * Correct use of supplemental O2 * Correct use of inhalers * Drug schedule & side effects * Manifestations to report to HCP indicating need for acute care * Increasing severity of resting dyspnea * Increasing severity of usual symptoms * Development of new symptoms associated w/poor O2 * Respiratory infection * Failure to obtain usual degree of relief w/rx therapies * Unusual cx in condition * Use of pursed-lip & diaphragmatic breathing techniques * Scheduling of rest periods & priority activities * Participation in rehab activities
Occupational Pulmonary Disease
Exposure to occupational or environmental fumes, dust, vapors, gases, bacterial or fungal antigens, & allergens can result in variety of resp. disorders
Teach importance of using special resp & ensuring adequate ventilation when working in potentially harmful environments

Occupational Asthmas * Latency (allergic) asthma * Irritant-induced asthma
Pneumoconiosis
* Silicosis * Coal Miner’s disease (black lung)
Diffuse interstitial Fibrosis * Asbestosis * Talcosis * Berylliosis
Extrinsic Allergic Alveolitis * Farmers lung * Bird Fancier’s lung * Machine operator’s lung

Lung Cancer * Leading cause of cancer-related deaths world wide * Overall 5 yr survival for all pt w/lung cancer is only 14% * Poor-long term survival is due to fact that most lung cancers are dx at late stage when metastasis is present * Only 15% of pt have small tumors and localized disease at time of dx * Over all prognosis for lung cancer remains poor unless tumor can be removed completely by surgery * Tx of lung cancer often aimed toward palliation rather than cure * Most arise from bronchial epithelium (bronchogenic carcinomas) * Classified according to histologic cell type as small cell lung cancer (SCLC), epidermoid (squamous cell) cancer, adenocarcinoma & large cell cancer * Last 3 types are referred as non-small cell lung cancer (NSCLS) because of their similar responses to tx * Metastasis (spread) of lung cancer occurs by direct extension, thru blood, & by invading lymph glands & glands * Tumors in bronchial tubes can grow & obstruct bronchus partially or completely * Tumors in other areas of lung tissue can grow so large that they can obstruct airway by compressing it * Tumors in edges of lungs spread & can compress alveoli, nerves, blood vessels, & lymph vessels * All these problems interfere w/oxygenation & tissue perfusion * Patterns of metastasis depend on type of tumor cell & location of tumor, Lung lymph nodes, as well as distant lymph nodes, can be invaded * Hematogenous (blood borne) metastasis of lung cancer is due to invasion of blood vessels in lungs * Emboli (tumor pieces) spread to distant body areas, sites include bone, liver, brain, adrenal glands * Staging is based on TNM system

Incidence/prevalence * Result of repeated exposure to inhaled substances that cause chronic tissue irritation or inflammation * Cigarette smoking is major risk factor & is responsible for 85% of all cancer deaths * Directly r/t to total exposure to cigarette smoke as determined by number of years smoking & number of packs of cigarettes smoked per day (pack-years) * Pipe & cigar smoking also increase risk
Etiology and genetic risks * Nonsmoker exposed to “passive” or “secondhand” smoke also have a greater risk for lung cancer than do nonsmokers who are minimally exposed to cigarette smoke * Passive smoke has many of carcinogens found inhaled, or “mainstream” tobacco smoke * Risk factors for lung cancer include chronic exposure to asbestos, beryllium, chromium, coal distillates, radiation, tar nickel, & uranium * Air pollution that benzopyrenes and hydrocarbons also ↑ risk for lung promotion

Health promotion & maintenance * Primary prevention for lung cancer is directed at reducing tobacco smoking * Teach workers in industrial settings about safety precautions, such as wearing specialized masks & protective clothing, to reduce occupational hazards * Encourage people who are at ↑ risk for lung cancer development to seek frequent health exams * Secondary prevention by early detection has not been considered feasible in past w/earlier detection not making a difference in long term rates

HX * Risk factors; including smoking, hazards in workplace & warning signals * Pack-year smoking hx * Presence of lung cancer manifestations, such as hoarseness, cough, sputum production, hemoptysis, shortness of breath, cx in endurance * Describe any recent cx in symptoms or of position affects symptoms * Warning Signs – Lung Cancer * Hoarseness * Cx in respiratory pattern * Persistent cough or cx in sputum * Rust-colored or purulent sputum * Frank hemoptysis * Chest pain or chest tightness * Shoulder, arm, or chest wall pain * Recurring episodes of pleural effusion, pneumonia or bronchitis * Dyspnea * Fever associated w/1 or 2 other signs * Wheezing * Weight loss * Clubbing of fingers
Warning Signs – Lung Cancer * Hoarseness * Cx in respiratory pattern * Persistent cough or cx in sputum * Rust-colored or purulent sputum * Frank hemoptysis * Chest pain or chest tightness * Shoulder, arm, or chest wall pain * Recurring episodes of pleural effusion, pneumonia or bronchitis * Dyspnea * Fever associated w/1 or 2 other signs * Wheezing * Weight loss * Clubbing of fingers
Assess for chest pain or discomfort, which can occur at any stage of tumor development * Chest pain may be localized or on just one side; can range from mild – severe * Sensation of fullness, tightness, pressure in the chest - may suggest obstruction * Piercing pain or pleuritic pain may occur on inspiration * Pain radiating to arm results from tumor invasion of nerve plexus in advanced disease

Physical Assessment – Pulmonary * Nonspecific & appear late in disease process

* Specific manifestations depend on type & location of tumor * Chills, fever, and cough may be r/t pneumonitis or bronchitis that occur w/obstruction * Assess sputum quantity and quality * Blood-tinged sputum may occur w/bleeding from tumor * Hemoptysis is a later finding in course of disease * Infection or necrosis is present; sputum may be purulent & copious * Breathing patterns may be labored or painful * Obstruct breath pattern may occur as prolonged exhalation altern w/periods of shallow breath

* Rapid, shallow breathing occurs w/pleuritic chest pain & ↑ diaphragm * Inspiratory efforts are ↓ in advanced disease * Abnormal retraction * Use of access muscles, flared nares, stridor, asymmetric diaphragmatic movement on inspiration

* Dyspnea & wheezing; w/airway obstruction * Areas of tenderness or masses may be felt when palpating chest wall * ↑ vibrations felt on chest wall (fremitus) indicates areas of lung where air spaces are replaced w/tumor or fluid

* Fremitus is ↓ or absent when bronchus is obstructed * Trachea may be displaced from midline if mass is present in area * Lung areas w/masses sound dull or flat rather than hollow or resonant on chest percussion * Breath sounds may cx w/presence of tumor * Wheezes indicate partial obstruction of airflow is passages narrow by tumors * ↓ or absent breath sounds indicate complete obstruction of airway by tumor or fluid * ↑ loudness or sound intensity of voice while listen to breath sounds indicates ↑ density of lung tissue from tumor compression

* Pleural friction rub is heard when inflammation also present
Physical Assessment – Non-Pulmonary * Heart sounds may be muffles by tumor or fluid around the heart (cadiac tamponade) * Dysrhythmias may occur as result of hypoxemia or direct pressure of tumor on the heart * Cyanosis of lips & fingertips or clubbing of fingers may be present * Bones become thin w/tumor invasion & break easily * Pt may have bone pain or pathologic fractures * Heavy coughing can break a rib * Late manifestations of lung cancer usually include fatigue, weight loss, anorexia, dysphagia, & nausea/vomiting * Superior vena cava syndrome may result from tumor pressure in or around vena cava. This syndrome is an emergency! Requires immediate medical attention * Lethargy & somnolence may develop, pt may have confusion or personality cx; as result of brain metastasis * Bowel & bladder tone or function may be affected by tumor spread to spine & spinal cord

Dx Assessment * Direct exam of cancer cells * Cytology of early morning sputum specimens may ID tumor cells; or may not be present * When pleural effusion present, fluid can be obtained by Thoracentesis for cytology * Most commonly, lung lesions are first ID’d on chest X-Rays * CT exams are then used to ID lesions more clearly * Fiberoptic bronchoscopy provides direct visibility of tracheobronchial tree; Specimens & bronchial brushing can be obtains * Thorascopy, allows direct visualization of lung tissue * Mediastinoscopy may be performed through small chest incision * Biopsy of lymph nodes – spread of cancer; direct surgical biopsy * MRI * Radionuclide scans of liver, spleen, brain & bone help determine location of metastatic tumors * Pulmonary Function test; ABG’s help determine overall resp status * Positron Emission tomography (PET), most thorough way to locate metastases

Nonsurgical Management

Chemotherapy * Often tx of choice; esp. small cell lung cancer (SCLC) * Used alone or as adjuvant therapy in combo w/surgery for non-small cell lung cancer (NSCLC)
Side Effects * Chemo-induced N/V (CIN) * Alopecia (hair loss) * Open sores on mucous membranes (mucositis) * Immunosuppression * Anemia * Thrombocytopenia (↓ platelets) * Peripheral neuropathy (PN) * Chemo agents use for tx are emetogenic (including N/V) * Use antiemetic meds * Frequent mouth assessment & oral hygiene are key * Stress importance of good, frequent oral hygiene, incl. tooth cleaning & mouth rinsing * Use soft-bristled toothbrush or disposable mouth sponges * Avoid dental floss & water pressure gum cleaners * Immunosuppression, greatly ↑ risk for infection * Can be managed by using biological response modifiers

Targeted therapy * Becoming more common in late stage lung cancer * Agents take advantage of one or more differences in cell growth or metabolism that is either not present or only slightly present in normal cells * Agents used as targeted therapies often are antibodies that work to disrupt cancer cell division in one of several ways * Some “target” & clock growth factor receptors, esp. in epithelial growth factors (EGFR) or vascular endothelial growth factor receptors (VEGFR) * When lung cancer cell’s growth depends on having growth factors bind to their specific receptors, blocking receptors at least slows cancer cell’s growth * 2 agent most often used for targeted therapy of certain types of non-small cell are erlotinib (Tarceva) oral drug, bevacizumab (Avastin) given IV * Neither is used alone as therapy
Radiation Therapy * Usually radiation therapy for lung cancer is performed daily for 5-6 wk period * Only areas thought to have cancer are positioned in radiation path * Best results seen when used in addition to surgery or chemo * May be performed before surgery to shrink tumor & make resection easier * Immediate s/e skin irritation & peeling * Fatigue, nausea, taste cx * Some pt have esophagitis, making nutrition difficult * Eat foods that are soft, bland, ↑ in calories * Drink liquid nutrition supplements, Ensure or Boost between meals to maintain weight & energy levels * Avoid direct skin exposure to sun during tx & for at least 1yr after radiation complete

Photodynamic Therapy (PDT) * May be used to remove small bronchial tumors when accessible by bronchoscopy * Used also for cure of select lung cancers * Pt 1st injected w/agent that sensitizes cells to light * Drug enters cancer cells * Usually w/in 24hrs, most of drug has collected in ↑ concentrations in cancer cells * At this time, pt goes to operating room where, under anesthesia & intubation, laser light is focused on tumor * Light activates chemical reaction w.in those calls retaining sensitizing drug that induces irreversible cell damage * Some cells die & slough immediately; others continue to slough for several days * Photosensitizing drug has many effects that require special pt teach & care before & after laser tx * When PDT is used in airways, pt usually requires stay in ICU for airway management * Sloughing tissue can block airway as can edema from inflammatory response of tissues * Pt at risk for bronchial hemorrhage, fistula formation, & hemoptysis * Complicating factor in caring for pt now supersensitive to light and will remain 30-90 days * Special precautions are needed along w/enviro manipulation to keep pt safe during hospital stay & next 3mo

Operative procedures * Main tx for stage I & stage II NSCLC * Total removal of non-small cell primary lung cancer is undertaken in hope of achieving cure * If complete resection not possible, surgeon removes bulk of tumor * Specific surgery depends on stage of cancer & pt overall health & functional status * May involve removal of tumor only * Removal of lung segment * Removal of lobe (lobectomy) * Removal of entire lung (pneumonectomy)

Post-operative procedures * Care for pt who have undergone thoracotomy (except pneumonectomy) requires closed-chest drainage to drain air & blood that accumulate in pleural space * Chest tube; drain place in pleural space to restore intrapleural press, allows for re-expansion of lung * Prevents air & fluid from returning to chest * Drainage system consists of 1 or more chest tubes or drains, collection container placed below chest level, and water seal to keep air from entering chest * May be stationary disposable, self-contained system * Basic principles of gravity & pressure are same w/both systems * Nursing priorities for pt w/chest tube are to ensure integrity of system, promote comfort, ensure tube patency, & prevent complications

Chest tube placement & Care * Tip of tube is used to drain air is placed near front lung apex * Tube that drains liquid is placed on side near base of lung * Post lung surgery, 2 tubes, anterior & posterior are used; puncture wounds are covered w/airtight dressings * Tube is connected to about 6ft of tubing that leads to collection device placed several feet ↓ chest * Keeping collection device ↓ chest allows gravity to drain pleural space * When 2 chest tubes are inserted, they are joined by Y-connector near pt body; 6ft of tubing is attached to Y-connector Stationary chest tube systems * Usually use a water seal mechanism that acts as 1 way valve to prevent air or liquid from moving back into chest cavity * Pluer-Evac system is common device using 1-pc disposable place unit w/3 chambers * Tubes from pt are connected to 1st chamber is series of 3 * This chamber is drainage collection container * 2nd chamber in series is water seal to prevent air from backing up tubing system in chest * 3rd chamber, when suction applied, is suction regulator * In setting up system, chamber 1 (nearest to pt) does not at 1st have fluid in it * Tubing from pt penetrates shallowly into this chamber, as does tube connecting chamber 1 w/ chamber 2 * Chamber 1 collects fluid from pt * Fluid is measured hourly during first 24hrs * Fluid in chamber 1 must never fill to point that it comes in direct contact w/either tube draining from pt or tube connecting this chamber to chamber 2. * If tubing from pt enters fluid, drainage stops & can lead to tension pneumothorax

* Chamber 2 is water seal that prevents air from entering pt pleural space * Air from pleural space also enters chamber 1 but moves immed to chamber 2 through connect tube * This tube must always be under water level in chamber 2 to prevent air from returning to pt * Tube acts as 1 way valve, allow air to move into H2O & prevent air in chamber from re-entering tube * Action is similar to blowing air into straw placed in glass of liquid; because air is lighter than liquids, when person sucks on straw, he can pull air back up into straw only after water has 1st been pulled up straw. This as long as tip of tube from 1st chamber is underwater in water seal chamber, air that has escaped pt chest tube cannot re-enter * Bubbling of water in chamber 2 indicates air drainage from pt * Bubbling usually seen when intrathoracic pressure is ↑ than atmospheric pressure; when pt exhales, coughs, sneezes * When air in pleural space has been removed, bubbling stops * Blocked or kinked chest tube can also cause bubbling to stop * Excessive bubbling in water seal chamber 2 may indicate air leak * Rise of 2-4in during inhalation & fall during exhalation – normal Stationary chest tube systems cont. * Absence of fluctuation may mean chest tube is obstructed, expanded lung has blocked eyelets of tube, or no more air is leaking into pleural space * Chamber 3 is suction control of system, has 3 connections; 1 from 2nd chamber; long open tube dipped into water to serve as air vent; short tube connecting to suction unit

* Suction enhances pressure difference between pleural space & drainage system, causing pressure to drop inside system by 15-20cm * Although amount of suction generated by suction unit can be ↑, amount of suction in system is determined not by suction unit but by depth of open tube in water * HCP rx amount of water to be placed & maintained in this chamber * While suction is applied, gentle bubbling is seen in this chamber * Manipulation of chest tube should be kept to min, do not vigorously strip tube; this can create up to 400cm of water neg pressure & damage lung tissue * If manipulation needed, gentle hand over hand “milking”; w/stopping between each hand hold is used to move blood clots and prevent obstruction

* Continuous bubbling indicates air leak that must be ID’s * On physicians rx, gently apply padded clamp briefly on drainage tubing close to occlusive dressing * If bubbling stops, air leak may be at tube insertion site or w/in chest, req. physician intervention * Air bubbling that does not cease when padded clamp is applied indicates air leak is between clamp and drainage system * Release clamp as soon as assessment made

Management of Chest Tube Drainage System Patient * Ensure that dressing on chest around tube is tight & intact. Depending on agency policy & surgeon’s preference, reinforce or cx loose dressings * Assess for breathing difficulty * Assess breathing effectiveness by pulse ox * Listen to breath sounds for each lung * Ck. alignment of trachea * Ck. tube insertion site for condition of skin. Palpate area for puffiness or crackling; indicate subcut emphysema * Observe site for signs of infection or excessive bleeding * Ck. To see if tube “eyelets” are visible * Assess for pain & location, intensity, and admin meds as rx * Assist pt to deep breathe, cough, perform max sustained inhalations, & use spirometry * Reposition pt who reports “burning” pain in chest Drainage System * Do not “strip” chest tube * Keep drainage system lover than level of pt chest * Keep tubes as straight as possible, avoiding kinks & dependent loops * Ensure chest tube is securely taped to connector & that connector is taped to tubing going into collection chamber * Assess bubbling in water seal chamber; gentle bubbling on pt exhalation, forceful cough, position. cx * Assess for “tidaling” * Ck water level in water seal chamber & keep level at recommended by manufacturer * Ck. Water level in suction control chamber and keep at level rx by surgeon * Ck. And doc amount, color, & characteristics of fluid in collection chamber, as often as needed according to pt condition & agency policy * Empty collection chamber or cx system before drainage makes contact w/bottom of tube * When sample of drainage needed for culture or other lab test, obtain it from chest tube; after cleansing chest tube use 20 gauge (or smaller) needle & draw up specimen in syringe

Immediately Notify Physician or Rapid Response Team for: * tracheal deviation * Sudden onset or ↑ intensity of dyspnea * O2 sat <90% * Drainage >70 mL/hr * Visible eyelets on chest tube * Chest tube falls out of pt chest (1st, cover area w/dry sterile gauze) * Chest tube disconnects from drainage system (1st put end of tube in container of sterile water & keep below level of pt chest * Drainage in tube stops (in first 24hr)
Pain Management post-op * Intense pain after open thoracotomy for at least 24hrs * Administer rx drugs for pain, as assess pt responses to them; PCA * Monitor v/s before & after giving opioid analgesics, esp for pt not being mechanically vented * Plan care activities around timing of analgesia to ↓ stimulation of additional pain

Respiratory Management * After pneumonectomy, pleural cavity on affected side is empty space * Surgeon sometimes inserts clamped chest tube for only a day so serous fluid does not accumulate is empty space & create adhesions, which ↓ mediastinal shift toward affected side; closed-chest drainage not usually used

* Complications can include empyema & development of bronchopleural fistula * Positioning of pt after pneumonectomy varies according to surgeon preference & pt comfort * Some – nonoperative side immediately post to reduce stress on bronchial stump incision * Some – operative side to allow fluids to fill in space formerly taken up by lungs

Interventions for palliation * O2 therapy is rx when pt is hypoxemic; even if not severe to relieve dyspnea & anxiety * Humidification is used w/O2 for pt w/lung cancer * Drug therapy w/bronchodilators & corticosteroids is rx for pt w/bronchospasm to ↓ bronchospasm, inflammation & edema * Mucolytics may be of use to ease removal of thick mucus & sputum * Bacterial infections tx w/appropriate antibiotics * Radiation can help relieve hemoptysis, obstruction of bronchi & great veins * Dysphagia from esophageal compression * Pain from bone metastasis * Usually radiation for palliation uses ↑ doses for shorter periods * Thoracentesis & pleurodesis – used when pleural effusion a problem * Excess fluid ↑ dyspnea, discomfort & risk for infections * Goal of tx is to remove pleural fluid & prevent formation * When fluid development is continuous & uncomfortable, continuously draining catheter may be placed into intrapleural space to collect * Insert chest tube to drain fluid & instill sclerosing agent (agent that is irritant & causes inflammation). Aim is to cause pleurodesis (inflammatory response that causes pleura to stick to chest wall) * If pleurodesis occurs, it prevents formation of effusion liquid. Agents are instilled after some of effusion fluid has been removed * Pt asked to assume variety of positions to ensure widest spread of fluid w/in pleural space * Dyspnea management pt tires easily & is often most comfortable resting in Semi-Fowler’s position * Dyspnea is ↓ w/O2 and use of morphine drip & positioning for comfort * Severely dyspneic pt may be most comfortable sitting in lounge chair or reclining chair * Pain management may be needed for chest pain & pain radiating to arm or bone pain * Perform complete pain assessment w/attention to onset, intensity, quality, duration, pt description * Goal is to help pt be as pain-free & comfortable as possible * Opioid drugs as oral, parenteral or transdermal * Positioning, hot or cold compresses * Distractions, guided imagery, may also be helpful * Rx analgesics most effective when given around the clock; additional PRN meds used for breakthrough pain * Hospice care beneficial to pt in terminal phase * Provide support to terminally ill pt & family by meeting physical & psychosocial beeds

Infectious Respiratory Problems (ch 33)
Disorders of the nose and sinuses

Rhinitis * Inflammation of nasal mucosa, most common problem of nose & sinuses * Inflammation can be caused by infection (viral or bacterial) or contact w/allergens * Often allergic rhinitis will make mucous membranes more susceptible to invasion & infection will accompany allergy

* Usually, doesn’t interfere w/person’s ability to meet human need for oxygenation & tissue perfusion * Allergic rhinitis, often called hay fever or allergies is triggered by hypersensitivity reactions to airborne allergens, esp. plant pollens or molds

* Some episodes are seasonal in that they tend to recur at same time each yr and last only a few wks * Chronic rhinitis occurs either intermittently w/no seasonal pattern or continuously whenever person exposed to allergens (dust, animal dander, wool, foods)

* Other causes include “rebound” nasal congestion from overuse of nose drops or sprays (rhinitis medicamentosa) & chronic nasal inhalation of cocaine

* Acute viral rhinitis (coryza, common cold) is caused by any one of at least 200 viruses * Spreads from person to person by droplets from sneezing or coughing * Colds most contagious in 1st 2-3 days after symptoms appear * Colds are self-limiting unless a bacterial infection occurs at same time

* Complications occur most often in immunocompromised or older adults, esp if live or work in crowded conditions or group settings

Patient-Centered collaborative care * Both acute & chronic rhinitis, presence of allergen causes release of natural chemicals, such as histamine from WBC receptor sites, causing local blood vessel dilation & capillary leak, leading to edema & swelling of nasal mucosa * Resulting symptoms – headache, nasal irritation, sneezing, nasal congestion, rhinorrhea (watery drainage from nose), itchy watery eyes * Viral or bacterial invasion of nasal passages cause same local tissue responses as allergic * Often pt also has systemic manifestations, incl. sore, dry throat, low grade fever * Focus on symptom relief & pt education

Drug therapy * Antihistamines & decongestants, rx but must be used w/caution in older adult because of
S/E
* Vertigo, Hypertension * Urinary retention, Insomnia * Antihistamines block chemicals release by WBC from binding to receptor sites on blood vessels & nasal tissues, preventing local edema & itching * Decongestants – constrict blood vessels, thus ↓ edema * Antipyretics – given if fever present * Antibiotics – rx only for bacterial rhinitis * Rhinitis caused by overuse of nose drops or sprays tx by discontinuing offending drug * Steroid nasal sprays may be used to ↓ rebound nasal congestion during 1st wk after discont drug

Complimentary & alternative therapies * Used to ↓ severity of acute viral rhinitis for some early in course of problem * Echinacae * Large doses of Vit C * Zinc preps – COLD-EEZE or Zicam * Not clear how they reduce symptom severity of duration of illness; believed may help ↑ nonspecific immune function
Supportive Therapy * ↑ pt comfort & help spread of infection * Rest – 8-10hrs a day * Fluid intake of at least 2000mL/day * Humidifying air helps relieve congestion * Pt most likely to spread infection during 1st 2-3 days after symptoms begin * ↓ risk of spread by washing hands; esp after nose blowing, sneezing, coughing, rubbing of eyes or touching face * Stay home from work, school, or places where people gather * Cover nose & mouth w/tissue when sneezing or coughing * Disposing properly of used tissues immediately * Avoid close contact w/other people (kissing, hugging, hand shaking)
Sinusitis
* Inflammation of mucous membranes of 1 or more of sinuses * Swelling can obstruct flow of secretions from sinuses, then may become infected * Often follow rhinitis * Other conditions that lead to sinusitis include; deviated septum, nasal polyps, or tumors, inhaled air pollutants, cocaine, facial trauma, nasal intubation or ↓ immune function * In chronic, mucous membrane is permanently thickened from repeated inflammation * Most common organism causing sinus infection streptococcus pneumonia, Haemophilus influenza, Diplocococus, Bacteroides * Most often develops in maxillary & frontal sinuses * Complication – cellulitis, abscess, meningitis * Dx made on basis of pt history and manifestations * Transillumination (reflection of light through tissues) of affected sinuses is ↓ * Non-swollen sinuses reflect light through skin as seen as red glow on cheek between eye & lip * Sinuses that are swollen or filled w/secretions have ↓ or absent glow * Sinus X-Ray, Endoscopic exam, CT * Bacterial sinusitis requiring antibiotic usually indicated by purulent drainage from 1 or both nares & lack of response to decongestant therapy Patient-Centered Collaborative Care * Assess for manifestations * Nasal swelling & congestion, headache, facial pressure, pain (usually worse when head is tilted forward or is in dependent position) * Tenderness to touch over involved area, low-grade fever, cough, purulent or bloody nasal drainage Non-surgical management * Broad spectrum antibiotics (amoxicillin) * Analgesic for pain, fever (acetaminophen) * Decongestants (phenylephrine (Neo-Synephrine)) * Steam humidification * Hot & wet packs over sinus area * Nasal irrigation * ↑ fluid intake to more than 10 glasses or water or juice a day Surgical management Antral irrigation, AKA maxillary antral puncture & lavage – outpatient * Local anesthesia, large gauge needle inserted into maxillary sinus on affected side * Fluid or pus drained from sinus * Sinus then irrigated w/saline solution, antibiotic solution or both

Open Sinus Cavities * If antral irrigation not successful * Caldwell-Luc procedure; Surgeon make incision under lip into maxillary sinus * Infected mucosa then removed * With nasal antral window procedure, surgeon makes opening in front portion of lower nasal bone to improve drainage through nares * Pt may have difficulty eating post op; due to pain & swelling * Ethmoid sinuses – surgeon uses external incision along-side of nose from middle of eyebrow

* Endoscopic sinus surgery – common method of dx & tx sinus disorders * Direct inspection of sinuses through endoscope is complete w/pt under general anesthesia * Take only minutes, nasal mucosa may take from 4-6 wks. to heal * Pt goes home same day and can return to work 4-5 days * Use saline nasal sprays frequently (4-6hrs) to prevent mucosal crusting & promote healing Post-op Care for Sinus Surgery * Semi-Fowler’s to promote drainage & prevent swelling * Perform gentle oral hygiene to promote healing & prevent injury to surgical incision * Use ice compresses as rx for 24 hours * Change “mustache” dressing under nose, PRN, & doc type & amount of drainage * Teach pt & family to cx this dressing * Teach pt to eat soft foods & ↑ fluid intake * Recommend pt sleep in reclining chair or w/pillows to keep head at about 20 degree angle * Recommend use of room humidifier * Stress need to limit Valsalva maneuver (no coughing, blowing nose, or straining at stool) for at least 2 wks. post-op to prevent bleeding & tissue damage * Take temp twice daily during 1st week post-op & report elevation to 100 F or ↑ to surgeon
Post-op Care for Sinus Surgery * Semi-Fowler’s to promote drainage & prevent swelling * Perform gentle oral hygiene to promote healing & prevent injury to surgical incision * Use ice compresses as rx for 24 hours * Change “mustache” dressing under nose, PRN, & doc type & amount of drainage * Teach pt & family to cx this dressing * Teach pt to eat soft foods & ↑ fluid intake * Recommend pt sleep in reclining chair or w/pillows to keep head at about 20 degree angle * Recommend use of room humidifier * Stress need to limit Valsalva maneuver (no coughing, blowing nose, or straining at stool) for at least 2 wks. post-op to prevent bleeding & tissue damage * Take temp twice daily during 1st week post-op & report elevation to 100 F or ↑ to surgeon

Disorders of the Larynx and Lungs
Laryngitis – Pharyngitis * “Sore” throat – common inflammation of mucous membranes of pharynx * Accounts for more than 15 million visits yearly in US * Often occurs w/acute rhinitis & sinusitis * Can be caused by bacteria, viruses, other organisms, trauma, dehydration, irritants, tobacco use, alcohol consumption * Most common bacteria – A beta-hemolytic Strep, but most adult cases are caused by virus

Assessment * Throat soreness & dryness throat pain, pain on swallowing (odynophagia), difficulty swallowing (dysphagia) & fever * Viral & bacterial are often difficult to distinguish on physical assessment * Mild to severe hyperemia (redness) may be seen w/or w/out exudate * Ask about nasal discharge; can vary from thin & watery to thick & purulent * Lymph node enlargement in neck occurs w/both viral & bacterial pharyngitis * When tonsillar abscess w/pharyngitis, pt may have “hot potato” voice- thick voice of poor quality * Bacterial infections are more often associated w/enlarged red tonsils, exudate, purulent nasal dx, & local lymph node enlargement * Viral is contagious for 2-3 days * Symptoms usually subside w/in 3-10 days after onset, & disease is usually self-limiting * Group A strep infections can lead to serious complications; including acute glomerulonephritis & rheumatic fever carditis * Acute glomerulonephritis may occur 7-10 days after acute infection * Rheumatic fever may develop 3-5 weeks after acute infection * Throat cultures important in distinguishing viral from group A strep * CBC performed when pt condition is severe or does not improve; high fevers, lethargy, manifestations of complications * Ask whether ill w/symptoms of cold or upper resp infection recently * Previous hx of strep infections, rheumatic fever, valvular heart disease, or PCN allergy

Complications of Strep * Rheumatic fever * Acute glomerulonephritis * Peritonsillar abscess * Otitis media * Sinusitis * Mastoiditis * Bronchitis * Pneumonia * Scarlet Fever
Complications of Strep * Rheumatic fever * Acute glomerulonephritis * Peritonsillar abscess * Otitis media * Sinusitis * Mastoiditis * Bronchitis * Pneumonia * Scarlet Fever

Key features Acute & Bacterial Pharyngitis

Temp viral – low grade/ no fever Bacterial - ↑ temp (>101 F & usually 102-104 F)

Ear viral – retracted or dull tympanic membrane Bacterial - retracted or dull tympanic membrane

Throat viral – scant or no tonsillar exudate Slight erythema of pharynx & tonsils Bacterial – severe hyperemia of pharyngeal mucosa, tonsils, & uvula Erythema of tonsils w/yellow exudate

Neck viral – Possible lymphadenopathy Bacterial – anterior cervical lymphadenopathy & tenderness

Skin viral – no rash Bacterial – possible scarlantiniform rash Possible petechiae on chest/abdomen or both

Dysphagia, odynophagia viral – present Bacterial – present

Other viral – no cough Rhinitis Mild hoarseness Headache Bacterial – no cough Voice characterized by pain on voicing/slurred speech Headache Arthralgia Myalgia
Labs viral – CBC – usually normal WBC usually ≤10,000 Neg throat cultures Bacterial - CBC –abnormal WBC usually >12,000 Throat cultures pos for beta-hemolytic strep

Onset Viral – gradual Bacterial - abrupt
Interventions
* Most sore throats in adults do not require antibiotics * Rest * Increase fluid intake * Humidify air * Use analgesics for pain * Gargle several times each day w/warm saline * Use throat lozenges containing mild anesthetics * Bacterial – involves use of antibiotics * Strep – oral PCN or cephalosporin; macrolide class (azithromycin/erythromycin) recommended if allergic to PCN

* Stress importance of completing entire rx! * If adherence concern or cannot swallow pills, long acting PCN can be given IM in single dose * Re-evaluate in 3 days if no improvement * Rare complication is infection of epiglottis & supraglottic structures * Can swell & cause obstructed airway, EMERGENCY

Influenza * Highly contagious acute viral resp infection that can occur in adults of any age * 5-20% of US population develop each year * More than 36,000 deaths * Hospitalization may be required * Severe headache * Muscle aches * Fevers * Chills * Fatigue * Weakness * Anorexia * Adults contagious from 24hrs before symptoms begin & up to 5 days after begin * Pt who are immunocompromised may remain contagious for several weeks * Sore throat, cough, rhinorrhea generally follow initial symptoms for a week or longer * Most continue to feel fatigued for 1-2 wks after
Promotion & maintenance * Vaccine cx each year on basis of which specific viral strains are most likely to pose problem * Usually contains 3 antigens for 3 expected viral strains * IM (dead) or live attenuated intranasal spray * Attenuated virus – live virus that has been scientifically altered to ↓ ability to cause infection; can cause symptoms; recommended ↓ 50 yrs * People recommended to be vaccinated; ↑ 50yrs, chronic illness, immune compromise, living in institutions, people living or caring for adults w/health problems that put them at risk for severe complications, health care professionals providing direct care to py
Patient teaching * Pt who is sick ↓ risk of spread by washing hands esp after nose blowing, sneeze, cough, rubbing eyes or touching face * Stay home from work, school, places where people gather * Cover mouth & nose when sneezing or coughing * Avoid close contact w/people

Collaborative Care * Antiviral agents may be effective for prevention & tx of some types * Amantadine (symmetrel) & rimantadine (flumadine) – influenza type A * Ribavirin (virazole) severe influenza B * Xanamivir (Relenza) oral, oseltamivir (Tamiflu) , oral – prevent spread in resp tract by inhibiting viral enzyme that allows virus to penetrate resp cells * May shorten duration of influenza A & B if take w/in 24-48 hrs after onset of manigestation, may be used for prevention * Stay in bed for several days & drink large amounts of fluid * Saline gargles may ease sore throat * Antihistamine may reduce rhinorrhea
Pneumonia
* Excess of fluid in lungs resulting from inflammatory process * Inflammation triggered by may infectious organisms & by inhalation of irritating agents * Inflammation occurs in interstitial spaces, alveoli, & often bronchioles * Process begins when organisms penetrate airway mucosa & multiply in alveolar spaces

* WBC migrated to area of infection, causing local capillary leak, edema & exudate

* These fluids collect in & around alveoli, & alveolar walls thicken * Seriously ↓ gas exchange & lead to hypoxemia, interfering w/oxygenation & tissue perforation; can lead to death

* RBC & fibrin also move into alveoli * Capillary leak spreads infection to other areas of lung * If organisms move into bloodstream, sepsis results; if infection extends into pleural cavity, empyema results

* Fibrin & edema of inflammation stiffen the lung, ↓ compliance & ↓ vital capacity * Alveolar collapse (atelectasis) further ↓ ability of lungs to oxygenate blood * As result, arterial oxygen tension falls, causing hypoxemia, ↓ oxygenation & tissue perfusion * May occur as lobar pneumonia w/consolidation (solidification, lack of air spaces) in segment or entire lobe of lung

* Bronchopneumonia w/diffusely scattered patched around bronchi * Tissue necrosis results when organisms form abscess that perforates bronchial wall * People generally develop when immune systems cannot combat virulence of invading organisms * Bacteria, virus, mycoplasmas, fungi, rickettsiae, protozoa, helminthes (worms)

* Inhalation of toxic gases, chemicals & smoke, aspiration of water, food, fluid, vomit

* 2-5 million cases – 7th leading cause of death * ↑ older adults, nursing home residents, hospitalized pt, mechanically vented

Risk for Pneumonia
CAP
* Older adult * Has never rcvd pneumonia vaccine or rcvd more than 6yrs ago * Did not rcvd flu vaccine year in previous yr * Chronic health problem or other coexisting condition * Recently exposed to resp. viral or flu * Uses tobacco or alcohol

HAP * Older adult * Chronic lung disease * Presence of gram-neg colonization of mouth, throat, stomach * Altered LOC * Recent aspiration event * ET tube, Trach or NG tube * Poor nutritional status * Immunocompromised status * Uses drugs that ↑ gastric pH (histamine H2 blockers, antacids) or alkaline feeding tubes * Currently rcving mechanical vent (VAP)
Risk for Pneumonia
CAP
* Older adult * Has never rcvd pneumonia vaccine or rcvd more than 6yrs ago * Did not rcvd flu vaccine year in previous yr * Chronic health problem or other coexisting condition * Recently exposed to resp. viral or flu * Uses tobacco or alcohol

HAP * Older adult * Chronic lung disease * Presence of gram-neg colonization of mouth, throat, stomach * Altered LOC * Recent aspiration event * ET tube, Trach or NG tube * Poor nutritional status * Immunocompromised status * Uses drugs that ↑ gastric pH (histamine H2 blockers, antacids) or alkaline feeding tubes * Currently rcving mechanical vent (VAP)
Hospital acquired * Nonsomial infection (as result of hospital stay)
Community acquired * More common than hospital acquired * Occurs late fall & winter as complication of flu
Ventilator acquired * Specific type of HAP is ventilator associated pneumonia (VAP) * 20-50% mortality rate; ↑ incidence infected w/pseudomonas aeruginos, acinetobacter * Mortality rate also ↑ in pt who have sever hypoxemia (arterial O2 <80_ * Those who develop widespread atelectasis, pleural effusion or vent failure

Prevention * Pt education is most important part of prevention * Strict handwashing * Avoid large gatherings of people during cold, flu & holiday season * See HCP if fever lasts more than 24hrs, If problem lasts longer than 1wk, Symptoms worsen * Avoid indoor pollutants; dust, secondhand smoke, aerosols * Rest & sleep on daily basis * Eat healthy, balance diet * Drink at least 3L of nonalcoholic fluids daily

VAP prevention * Equipment should be well maintained & decontaminated or cx as recommended * Use sterile water rather than tap water in GI tubes & institute aspiration precaustion * Perform oral care w/disinfecting oral right before intubation * Wash hands before & after contact w/pt * Provide complete oral care at least q12hrs * Remove subglottic secretions frequently (q2hrs) or continuously * Keep head of bed elevated at least 30 degrees * Verify initial X-Ray placement of NG tube before instilling drugs, fluids or feedings * Avoid turning or placing on supine position w/in hour after bolus tube feeding * Work w/pt & health care team to assist in weaning process as soon as possible
Manifestations
General appearance * Flushed cheeks, bright eyes, anxious expression * Chest or pleuritic pain * Discomfort * Myalgia * Headache * Chills * Fever * Cough * Tachycardia * Dyspnea * Tachypnea * Sputum production * Severe chest muscle weakness – from coughing
Observe
* Breathing pattern * Position * Use of accessory muscles * Hypoxic pt may be uncomfortable in lying position; sit upright, balancing w/hands
Assess
* Cough * Amount, color, consistency, odor of sputum * Crackles heard w/auscultation when fluid is interstitial & alveolar areas * Wheezing may be heard as result of inflammation & exudate in airways * Bronchial breath sounds heard over areas of density or consolidation * Tactile fremitus is ↑ over areas of pneumonia * Percussion dulled in these areas * Chest expansion may be diminished or unequal on inspiration
Psychosocial
* Pain * Fatigue * Dyspnea * All promote anxiety * Most common manifestation in older adult is confusion from hypoxia * Assess anxiety by looking at facial expressions, general tenseness of facial & shoulder muscles
Labs
* Sputum obtained & examined by Gram strain, culture & sensitivity * CBC – ID leukocytosis (↑ CBC count); common except in older adults * Blood cultures to determine whether has invaded blood * Urine examined for blood, pus, or protein * ABGs – determine baselines, ID need for supplemental O2 * Serum electrolyte, BUN & creatnine - ↑ BUN as result of dehydration, hypernatremia (↑ sodium) w/dehydration & fever
Imaging/DX
* Chest x-ray - most common dx test - but may not show changes until 2 or more days after manifestations * Usually appears as area of ↑ density * May involve lung segment, lobe, one ling or both lungs * Pulse ox to assess for hypoxemia

Nursing Dx * Impaired gas exchange r/t effects of alveolar capillary membrane cx * Ineffective airway clearance r/t effects of infection, excessive tracheobronchial secretions, fatigue, & decreased energy, chest discomfort, muscle weakness * Potential for sepsis * Acute pain r/t effect s of inflammation of parietal pleura, coughing * Deficient fluid volume r/t ↑ respiratory rate, fever, infection, ↑ metabolic rate * Sleep deprivation r/t pain, dyspnea, unfamiliar environment (hospital) * Potential for Pleural effusion

Interventions * Incentive spirometry, used to improve inspiratory muscle performance & to prevent or reverse atelectasis * Perform 5-10 breaths every hour while awake * Oxygen therapy * Clear oral, nasal & tracheal secretions as appropriate * Restrict smoking * Maintain patent airway * Monitor position of O2 delivery device * Monitor effectiveness of O2 therapy (pulse ox, ABGs) * Assure replacement of O2 mask/cannula whenever removed * Monitor pt ability to tolerate removal of O2 while eating * Cx O2 from mask to cannula during meals, as tolerated * Monitor for signs of O2 toxicity & absorption atelectasis * Monitor for skin breakdown from friction of O2 device * CO2 retention not common * Help cough * Avoid dehydration – 3L of fluid daily, may help thin secretions * Broncodilators, esp beta 2 agonists, when bronchospasms present * Aerosol nebulizer then by metered dosed inhaler * Inhaled steroids w/bronchial asthma or airway swelling
Pulmonary Tuberculosis * Pulmonary TB is a highly communicable disease transmitted via aerosolization (airborne) * Caused by Mycobacterium tuberculosis * Initial infection seen more often in middle or lower lubes of lung * Asymptomatic period usually follows initial infection and can last for years or decades * Not infectious to others until manifestations occur * Secondary TB is reactivation of disease in previously infected person * Upper lobes most common site of reactivations

Risk Factors * Constant, frequent contact w/untreated person * Immune dysfunction or HIV * Living in crowded areas such as long-term facilities, prisons, mental health facilities * Older & homeless people * Abusers of IV drugs or alcohol * Lower socioeconomic groups * Foreign immigrants (esp Mexico, Philippines, Vietnam)

Assessment * TB has a slow onset, and many patients are not aware of symptoms until the disease is advanced. * DX of TB should be considered for any patient with; * Persistent cough or other symptoms * Weight loss * Anorexia, nausea * Night sweats * Hemoptysis * Shortness of breath * Fever, Chills * Progressive fatigue, lethargy * Cough, chest tightness & dull aching chest pain occur w/cough * Dullness w/percussion may be heard over involved lung fields * Brochial breath sounds, crackles * Increased transmission of spoken or whispered sounds * Partial obstruction of bronchus from endobronchial disease or compression by lymph nodes - wheezing
Labs
* Tuberculin Mantoux test result is the most commonly used reliable test of TB infection * Small amount of purified protein derivative (PPD) given intradermally in forearm * Area of induration (not just redness) measuring 10 mm or greater 48-72 hours after * Indicates exposure and infection w.TC * Positive reaction does not mean active disease is present, but indicates exposure to TB or inactive disease * Reaction of 5mm or greater considered pos for HIV or immunocompromised * Failure to have skin response because of ↓ immune function when infection present called anergy * Performed yearly for any ↑ risk * Once skin test pos for TB, chest x-ray is needed to detect active or old, healed lesions * Ask pt from other countries whether or not they have had BCG as a vaccine against TB * Pt who have had BCG usually have a large, positive reaction to a PPD skin test, making test less reliable as an indicator of active TB disease * Positive smear for acid fast bacillus * Blood analysis by enzyme linked immunosorbent assay using QuantiFERON-TB Gold most sensitive, rapid * Sputum culture confirms dx * Enhances TB cultures and automated mycobacterial cultures – 1 to 4 wks

Nursing Dx * Impaired gas exchange r/t disease progression * Deficient knowledge (infection control, therapeutic regimen, nutrition) r/t lack of exposure or information misinterpretation * Fatigue r/t poor tissue oxygenation & ↑ metabolism * Imbalanced nutrition: ↓ than body requirements r/t increased metabolism, poor appetite, drug regimen, or fatigue * Social isolation r/t altered state of wellness or changed appearance

Interventions * Combination drug therapy is the most effective method of treating active TB and preventing transmission * Active TB is tx w/combination of drugs to which organism is sensitive * Therapy continues until disease is under control * Use of multiple drug regimens destroys organism as quickly as possible & ↓ emergence of drug-resistant organisms * Current first-line therapy uses isoniazid (INH) and rifampin throughout therapy * Pyrazinamide is added in 1st 2 months * Protocol shortens therapy from 6-12 mo to 6 mo * Ethambutol is recommended for 4th drug in 1st line therapy * Nursing interventions focus on pt teaching for drug therapy adherence & infection control * Strict adherence to rx drug regimen is crucial for suppressing disease * Determine if pt understands how to take drugs, ask pt to describe tx regimen, major s/e, & when to call HCP * May cause pt to have nausea; prevent by taking at bedtime; antimetics * Well balanced diet to promote healing; ↑ intake in iron rich, protein & vit C &B * Fatigue will diminish as tx progresses * Multi drug resistant TB (MDR TB) * Resists INH & rifampin * Pt is not resistant to drug – organism is * Infection prevention & what to expect regarding disease status monitoring & participating in activities * Cover nose & mouth w/tissue when coughing or sneezing, place used tissues in plastic bags * Wear mask when in contact with crowds * Sputum specimens are needed every 2-4 wks * When results of 3 sputum cultures are negative, pt no longer contagious * Can return to former employment * Avoid exposure to any inhalation irritants – can cause further lung damage * Airborne precautions in hospital * When hand & clothing contamination risk, standard precautions

Teaching * Follow drug regimen exactly as rx always have supply on hand * Teach side effects * Remind that disease is usually no longer contagious after drugs have been taken for 2-3 consecutive wks & clinical improve seen * Continue w/rx for 6-12 months * Pt who has had weight loss & severe lethargy should gradually resum usual activities * Follow up care for at least yr during active tx * Assess the patient receiving first-line drug therapy for TB for any manifestation of liver * impairment, such as dark urine, clay-colored stools, anorexia, jaundiced sclera or hard palate * Id pt who may require a directly observed therapy program in which they must be directly observed by a HCP while swallowing the drug. * Teach women taking rifampin or rifapentine as drug therapy for TB that these drugs reduce the effectiveness of oral contraceptives & that another form of birth control should be used

Acute Respiratory Distress Syndrome (SARS)
Severe acute respiratory syndrome or SARS * New virus from a family of virus types known as coronaviruses * This family of viruses causes many forms of the common cold * SARS is a mutated form of coronavirus & is more virulent than most members of this virus family * Infects cells of resp tract, triggering inflammatory response * Stays in resp passages rather that spreading into blood, grows best at temps slightly lower than normal core body temp * Virus is easily spread by airborne droplets from infected individuals * People at greatest risk for SARS are those in direct contact w/infected person * Portals of entry for infection are mucous membranes; eyes, nose, mouth

Assessment
Ask any pt w/resp infection if from a foreign country or has recently visited a foreign country * Fever >100.4 * Headache * General body aches * Mild cold symptoms of runny nose, sore throat, watery eyes * Within 2-7 days pt develops fry cough & his difficulty breathing * Hypoxia, w/cyanosis * Low O2 * Feeling of breathlessness, indicates more severe illness * Chest X-rays show pattern similar to pneumonia * Dx made by manifestations & use of rapid SARS test, RT-PCR

Interventions * Isolation/strict transmission precautions * Prevented pandemic in 2004 * Prevention infection spread * Airborne and contact precautions * Gowns, eye protection * If pt out of environment must ear mask * Wear respirator N-95 * Keep door closed * Avoid touching your face w/contaminated gloves * Wash hands after removing gown * Wear clean gloves to disinfect equipment
Care of the Adult With Respiratory Problems (ch34)
Pulmonary Embolism (PE) * Collection of particulate matter, usually blood clots, that enters venous circulation & lodges in pulmonary vessels * Large emboli obstruct pulmonary blood flow, leading to ↓ oxygenation of the whole body, pulmonary tissue hypoxia, & potential death * Any substance can cause embolism, blood clot most common * Many patients die within 1 hour of onset or before the diagnosis is suspected * Most common acute pulmonary disease among hospitalized pt * Blood clot from DVT breaks loose from one of veins in legs or in pelvis * Clots breaks off, travels through vena cava into right side of heart, then lodges in pulmonary artery or one or more of its branches * Platelets collect on embolus, triggering release of substances that cause blood vessel constriction & blood vessel constriction * Widespread pulmonary vessel constriction & pulmonary hypertension impair gas exchange * Deoxygenated blood is moved into arterial circulation; causing hypoxemia; some pt with PE do NOT have hypoxemia * Major risk factors for DVT which may lead to embolism include; * Prolonged immobility * Central venous catheters * Surgery, obesity * Advancing age * Increased blood clotting * History of thromboembolism * Smoking * Pregnancy * Estrogen therapy * Heart failure * Stroke * Cancer (particularly lung or prostate) * Trousseau’s syndrome * Trauma * Fat, oil, air, tumor cells, amniotic fluid, foreign objects (broken IV catheters), injected particles & infected clots or pus can enter vein and cause PE * Fat emboli from fracture of long bone & oil emboli from dx do not impede blood flow in lungs * Instead they cause blood vessel and acute respiratory distress (ARDS) * Amniotic fluid embolus has ↑ mortality rate; & occurs as rare complication of childbirth, abortion, or amniocentesis * Septic clots often arise from pelvic abscess, infected IV catheter, nonsterile injections of illegal drugs

Health promotion & Maintenance * Lifestyle cx; stop smoking, esp. women who take oral contraceptives * Reduce weight * Become more physically active * If traveling for long periods, drink plenty of water, cx positions often, avoid crossing legs, get up from sitting positions at least 5 min out of every hour

Manifestations
Respiratory Manifestations * Difficulty breathing * Rapid heart rate * Pleuritic chest pain such as sharp, stabbing-type pain on inspiration * Breath sounds may be normal but crackles usually occur * Often dry cough present * Apprehension, restlessness * Prevention of PE * Start passive & active ROM for extremities of immobilized & post-op pt * Early ambulation * Antiembolism & pneumatic compression stockings * Avoid use of tight garters, girdles, & constrictive clothing * Prevent pressure under popliteal space * Perform comprehensive assessment of peripheral circulation * Elevate affected limb 20 degrees or more, above level of heart to improve venous return * Cx pt position q2hrs or ambulate as tolerated * Refrain from massaging or compressing leg muscles * Instruct pt not to cross legs * Teach to avoid activities that result in Valsalva maneuver * Admin drugs that will prevent episodes of Valsalva maneuver, as appropriate * Teach about precautions * Encourage smoking cessation

Prevention of PE * Start passive & active ROM for extremities of immobilized & post-op pt * Early ambulation * Antiembolism & pneumatic compression stockings * Avoid use of tight garters, girdles, & constrictive clothing * Prevent pressure under popliteal space * Perform comprehensive assessment of peripheral circulation * Elevate affected limb 20 degrees or more, above level of heart to improve venous return * Cx pt position q2hrs or ambulate as tolerated * Refrain from massaging or compressing leg muscles * Instruct pt not to cross legs * Teach to avoid activities that result in Valsalva maneuver * Admin drugs that will prevent episodes of Valsalva maneuver, as appropriate * Teach about precautions * Encourage smoking cessation

Feeling of impending doom * Hemoptysis * Pleural friction rub * ↓ arterial O2 sat (Sao2)

Cardiac manifestations * distended neck veins * Syncope * Cyanosis * Hypotension * Tachypnea * Tachycardia * S3 or S4 heart sound

Misc manifestations * Low-grade fever * Petechia on skin over chest & in axillae * Nausea /vomiting * General malaise
DX
Labs * The hyperventilation triggered by hypoxia and pain first leads to respiratory alkalosis * Indicated by low partial pressure of arterial CO2 (Paco2) * Late, metabolic acidosis, results from build up of lactic acid due to tissue hypoxia * PTT (normal 20-30 sec) therapeutic range for PE (1.5-2.5 times normal, 40-75 sec) * PT (normal 11-12.5 sec) therapeutic range for anticoagulant therapy 1.5-2 times normal value * INR therapeutic range is 2.5-3.0

Imaging * Chest X-ray if large * CT most often used to sx * Transesophageal echocardiograpghy (TEE) * Dopler US * Impedance Plethysomography – detect DVT

Nursing Dx * Decreased cardiac output r/t acute pulmonary hypertension * Anxiety r/t hypoxemia & life threatening illness * Potential for bleeding * Impaired gas exchange r/t disrupted pulmonary perfusion & increased dead space * Fatigue r/t hypoxemia * Impaired oral mucous membrane r/t O2 therapy * Acute confusion r/t hypoxemia * Sleep deprivation r/t ICU environment

Planning & implementation
Hypoxemia
* When pt has sudden onset of dyspnea & chest pain, immediately notify rapid response * Reassure pt, assist to position of comfort w/head of bed elevated * Prepare for O2 therapy & blood gas while monitoring * Assess for other cx * Check O2 sat by pulse ox for pt who has trouble breathing or who develops acute confusion. * Auscultate lung sounds for crackles or other adventitious sounds * Monitor resp patters * Monitor for symptoms of inadequate tissue oxygenation (pallor, cyanosis, sluggish capillary refill)
Interventions
* Goals of management are ↑ gas exchange * Improve lung perfusion * ↓ Risk for further clot formations * Prevent complications * priority nursing interventions; * Implement o2 therapy * Important for pt w/pe * Severly hypoxemic pt may require vent, & close monitoring of abgs * Use pulse ox to monitory o2 sats to determine degree of hypoxemia

* Admin anticoagulation or fibrinolytic therapy * To keep embolis from enlarging * Prevent formation of new clots * Active bleeding, stroke, recent trauma are reasons to avoid this therapy * Heparin usually used unless PE is massive or occurs w/hemodynamic instability * Fibrinolytic drug may then be used * Review pt PTT before therapy started, then q4hrs * Therapeutic PTT values – 1.5- 2.5 times control value * Usually continues for 5-10 days * Most pt are started on oral anticoagulant Warfin (Coumadin) on 3rd day of heparin use * Both heparin & Warfin continues until pt has INR of 2.0-3.0 * Warfin continues 3-6 wks, but some high risk pt take indefinitely * Can lead to excessive bleeding * Critical to keep antidotes to anticoagulant therapy * Antidote for heparin - protamine sulfate * Antidote for Warfin – injectable phytonadione, Vit K * Antidote for fibrinolytic – clotting factors, FFP, aninocaproic acid (Amicar)

* Monitor pt response to interventions * Cx in status * Check v/s * Lung sounds * Cardiac & resp stats every 1-2 hrs * Document ↑ dyspnea, dysrhythmias, distended neck veins, pedal & sacral edema * Assess for crackles & other abnormal lung sounds along w/cyanosis of lips, conjunctiva, oral mucosa & nail beds * Small doses of heparin may be prescribed to prevent excessive clotting in patients after trauma or surgery, or when restricted to bedrest. * Use bleeding precautions for patients on anticoagulants and have antidotes available.

Surgical Interventions
Thrombectomy
* Most common surgical procedure to remove the clot.
Inferior Vena Cava Filter * Vena cava filter may be inserted into the vena cava of pt who cannot take med or if blood thinners are not working. * The filter is a kind of "clot catcher.“

Decreased cardiac output * IV fluid therapy involves giving crystalloid solutions to restore plasma volume & prevent shock * Continuously monitor ECG * Pulmonary artery & central venous/right atrial pressures, because ↑ fluids can worsen pulmonary hypertension & lead to right sided heart failure * Drug therapy w./agents that ↑ myocardia contractility (positive inotropic agents) when IV therapy alone does not improve cardia output milrinone (Primacor) & docutamine (Dobotrex) * Assess cardiac status hourly * Vasodilator such as nitroprusside (Nipride) may be used to ↓ pulmonary artery pressure

Prevention of injury for Pt receiving anticoagulant or Fibrinolytic therapy * Handle pt gently * Avoid IM injections & venipunctures * Apply firm pressure to needle stick site for 10 min or until no longer oozes blood * Apply ice to areas of trauma * Test all urine, vomit, & stool for presence of occult blood * Observe IV sites q4hrs for bleeding * Avoid trauma to rectal tissues * Use electric shaver rather than razor * Use soft bristled toothbrush or toothettes * Do not floss * Make sure dentures fit and do not rub * Do not blow nose forcefully or insert objects into nose * Eat warm, cool, or cold foods to avoid burning mouth * Ck skin & mouth daily for bruises, swelling or areas w/small reddish purple marks that may indicate bleed * Stool softener * No tight clothing or shoes that are tight or rub * Avoid playing musical instruments that raise pressure inside your head * Stop or avoid smoking * Avoid use of oral contraceptives * Avoid contact sports * Provide written and oral signs and symptoms of bleeding. Reinforce the need to report any signs to health care provider immediately * Wear medical alert bracelet that states they are on anticoagulants * Eat well balanced diet with moderate amounts of Vit-K * Obtain a device to measure INR at home * Teach self injection of anticoagulant * Allopurinol, NSAIDs, Acetaminophen, Vit E, Histamine blockers, Cholesterol-reducing drugs, Antibiotics, Antidepressants, Thyroid drugs, Antifungal infections, Corticosteroids, Herbs such as St. Johns wort, garlic, ginseng, Ginkgo biloba
Pneumothorax
* 1st emergency approach to all chest injuries is ABC—airway, breathing, circulation—followed by rapid assess & tx of life-threatening conditions

* Direct force drives the bone ends into the chest, creating risk for deep chest injury, such as pulmonary contusion, pneumothorax or hemothorax

* Assess pt w/blunt chest trauma for tracheal position & bilateral breath sounds. * Administer drugs for pain to patients who have rib fractures and encourage deep breaths. * Pneumothorax is often caused by blunt chest trauma, allowing air to enter the pleural space and causing a rise in chest pressure and a reduction in vital capacity * Can be open (pleural cavity is exposed to outside air, through open wound in chest wall) * Reduced breath sounds * Hyperressonance on percussion * Prominence of involved side of chest, moves poorly w/respirations * Deviation of trachea away from (closed) or toward (open) affected side * May have pleuritic pain * Tachypnea * Subcutaneous emphysema (crepitus) * U/S or chest X-ray used for DX * Chest tubes may be needed to allow air to escape & reinflate lung

Spontaneous pneumothorax
Traumatic pneumothorax

Tension pneumothorax * Tension pneumothorax, a rapidly developing and life-threatening complication of blunt chest trauma * results from an air leak in the lung or chest wall. * Air collects under pressure, collapsing affected lung, compressing blood vessels, & limiting venous return leading to ↓ filling of the heart & ↓ cardiac output * Air forced into chest cavity causes complete collapse of affected lung * Air that enters pleural space during inspiration does not exit during expiration * If not promptly detected and tx quickly fatal * Causes blunt chest trauma * Mech ventilation w/PEEP * Closed chest tube * Insertion of central venous catheters * Asymmetry of thorax * Tracheal movement away from midline to unaffected side * Respiratory distress * Absence of breath sounds on one side * Cyanosis * Distended neck veins * Hypertypanic sound on percussion over affected area * X-Ray * ABGs shoe hypoxia, & respiratory alkalosis * Large bore needle inserted into 2nd intercostal space in midclavicular line of affected side as initial tx

* After completed, chest tube placed into 4th intercostal space, other end attached to water seal drainage until lung reinflates

Flail Chest * Flail chest is inward move of thorax during inspiration, with outward move during expiration. * Flail chest often occurs in high-speed vehicular crashes, more common in older pt, has a ↑ mortality rate * Also occur from bilateral seperations of ribs from cartilage connections from each other * Gas exchange is impaired, as is ability to cought & clear secretions * Defensive splinting further reduces pt ability to exert extra effort * Assess for paradoxic chest movement (sucking inward) of loose chest area during inspiration & (puffing out) of same area during expiration

* Often anxious, short of breath * Pain * Dyspnea * Cyanosis * Tachycardia * Hypotension

Hemothorax * Hemothorax may occur after blunt chest trauma or penetrating injuries. * Bleeding is caused by injury to lung tissue, such as lung contusions or lacerations that can occur w/rib and sternal fractures

* Most tears of tracheobronchial tree result from severe blunt trauma or rapid deceleration, often involving mainstem bronchi

* Injuries usually occur at junction & cricoid cartilage * Often caused by striking neck against dashboard or steering wheel * Develop massive air leaks * Cause air to enter mediastinum, leads to extensive subut emphysema * Upper airway obstruction may occur * Causing severe respiratory distress, inspiratory stridor * Large tracheal tears are managed by cricothyroidectomy or trach below level of injury * Can develop tension pneumo once intubated & vented w/PEEP * Assess for hypoxemia w/ABGs * Apply O2 * Assess VS q15min, likely to be hypotensive and in shock * Listen to lungs 1-2 hrs * Decreased breath sounds, wheezing may indicate further obstruction, atelectasis or phneumothorax

Mechanical Ventilation * Supports the pt who has severe problems w/gas exchange, helps support until underlying problem improves or resolves * Usually a Temporary life-support technique * Trach may be recommended if the pt needs an artificial airway for longer than 10 -14 days to ↓ tracheal & vocal cord damage. * Goals of intubation are to maintain a patent airway * Provide a means to remove secretions * Provide ventilation and oxygen * Most often used for pt w/hypoxemia & progressive alveolar hypoventilation w/resp acidosis * Used for pt who need vent support post-op * Expend too much energy w/work of breathing & barely maintain adequate gas exchange

Nursing Dx * Impaired verbal communication r/t physical barrier * Sleep deprivation r/t interruptions for monitoring, noisy environment * Death anxiety t/t loss of independent breathing ability * Impaired oral mucous membrane r/t presence of ET tube * Potential for VAP

May need life time use for * Patients w/ severe restrictive lung disease * Patients w/ Chronic, progressive neuromuscular diseases that reduce effective ventilation.

Main uses are * Pt w/ hypoxemia (due to pulmonary shunting of blood when other methods of O2 do not provide efficient supply.) * Progressive alveolar hypoventilation with respiratory acidosis.

Endotracheal Intubation * most common type of airway for a short-term basis is the endotracheal tube * Artificial airway * Passed through mouth or nose into trachea * ET tube enters and rest 2cm above carina * Oral intubation is the easiest and quickest way of est airway. * Nasal route causes sinusitis and otitis media and is reserved for facial and oral traumas * Cuff at distal end of tube is inflated after placement and can create seal between trachea & cuff * Seal ensures delivery of set tidal volume when vent used

Preparing for Intubation: * Explain procedure to patient * Know proper procedure for summoning intubation personal in facility

Until help arrives: * Begin basic life support measures * Obtain a patent airway * Deliver 100% O2 by manual bag with mask * Have crash cart at bedside w/airway equipment box & suction equipment

During intubation: * Nurse coordinates response & continuously monitors VS * Signs of hypoxia * Hypoxemia * Dysrhythmias * Aspiration * Be sure that each attempt last no longer than 30 secs, preferably less than 15 * After 30 secs, provide O2 by mask & manual resuscitation bag to prevent hypoxia & cardiac arrest * Suction as needed

Verifying placement of the ET * Immediately after insertion-placement should be verified by X-Ray * Assess breath sounds bilaterally * Symmetrical chest movement * Air emerging from ET tube. * *if breath sounds and chest wall movement are absent on the left side, tube may be in right mainstream bronchus. * should be able to reposition tube w/o repeating procedure
Stabilizing tube * Nurse, respiratory therapist, or anesthesia provider stabilized ET at mouth or nose. * Tube marked at level where it touches incisor tooth or naris * Oral airway may be inserted to keep pt from biting oral ET tube.

Nursing care: * Assess tube placement, Minimal cuff leak, Breath sounds * Chest wall movement regularly * Prevent pulling or tugging on tube by pt to prevent dislodgement or “slipping” of tube. * suctioning, coughing, and speaking can cause dislodgement * neck flexion moves tube away from carina, extension moves it closer * Rotation of head causes ET tube to move * Mouth secretions & tongue move can loosen tape & cx tube position * When other measures fail, apply soft wrist restraints, as rx; this is a last resort to prevent accidental extubation

Mechanical Ventilation * Goals are to improve gas exchange & decrease work needed for effective breathing * Used to support pt until lung function adequate or unit acute episode has passed * Does not cure diseased lungs; it provides ventilation until pt can resume process of breathing * Positive pressure vents; During inspiration, pressure generated that pushes air into lungs & expands chest * Pressure cycled venilators push air into lungs until present airway pressure reached * Tidal volumes & inspiratory time vary * Used for short periods, post op, resp therapy; Bi-PAP * Time-cycled vents push air into lungs until preset volume is delivered * Constant tidal volume is delivered regardless of pressure needed to deliver tidal volume * Set pressure limit, prevents excessive pressure from being exerted on lungs * Advantage; constant tidal volume is delivered regardless of cx compliance of lungs & chest wall or airway resistance * Assist controlled (AC) ventilation mode used most often & mainly resting mode * Vent takes over work of breath for pt - TV & vent rate preset * If pt does not trigger spontaneous breaths, minimal vent pattern is established * Disadvantage; if pt spontaneous breathing rate increases - Vent continues to deliver preset TV w/each breath * Hyperventilate, respiratory alkalosis occurs
CPAP
* Applies positive airway pressure throughout entire resp cycle for spontaneously breathing pt * Sedating drugs given cautiously or not at all, so resp effort not suppressed * Keeps alveoli open during inspiration & prevents alveolar collapse during inspiration * Prevents alveolar collapse during expiration * Used to help in weaning process * Normal levels are 5 to 15
Positive end expiratory pressure (PEEP) * Positive pressure exerted during expiratory phase of ventilation * PEEP improves oxygenation by enhancing gas exchange * Preventing atelectasis * Used to treat persistent hypoxemia * Need for PEEP indicates severe gas exchange problems * Lower Fio2 delivered whenever possible, high can damage lungs from toxic effects of O2

Complications of Mechanical Ventilation
Cardiac
* Hypotension caused by positive pressure that ↑ chest pressure & inhibits blood return to heart * Decreased venous return, ↓ cardiac output; Reflected as hypotension * Most often seen in pt who are dehydrated or need high PIP for ventilation * Fluid is retained because ↓ cardiac output * Kidneys receive less blood flow, which then stimulates renin-angiotensin-aldosterone system to retain fluid * Humidified air in vent system contributes to fluid retention * Monitor I & O, weight, dehydration, signs of hypovolemia
Lungs
* Barotrauma – damage to lungs by positive pressure * Volutrauma – damage to lungs by excess volume delivered to one lung over another * Acid base imbalance; Barotrauma includes; pneumothorax, subcut emphysema, pneumonmediastinum
GI & nutritional * Stress of mechanical ventilation; Stress ulcers occur in many pt * Complicate pt nutritional status, because mucosa not intact, ↑ risk for system infection * Antacid, sucralfate and histamine blockers (Zantac) or proton pump inhibitors such as esomeprazole (Nexium) rx * Cx in chest & abdominal cavity pressure can lead to paralytic ileus; Require short term TPN * Malnutrition extreme problem & major reason they cannot be weaned from vent * In malnutrition resp muscles loose mass & strength; diaphragm, major muscle of resp affected early
Ventilator Acquired Pneumonia * Often w/in 48 hrs artificial airway is colonized w/bacteria * Strict adherence to infection control; Oral care q2hrs
Muscle deconditioning * Weakness can occur because of immobility; Gave pt get out of bed, ambulate w/assistance * Perform exercises improves strength and boosts moral * Enhances gas exchange; Promotes O2 delivery to all muscles
Ventilator dependence * Inability to wean * Can by psychological or physiologic * Longer pt uses vent, more difficult

Weaning From Mechanical Ventilation * Extubation is removal of ET tube * Hyperoxygenate pt, thouroughly suction both ET tube and oral cavity * Then rapidly deflate cuff of ET tube and remove at peak inspiration * Immediately instruct to cough * O2 by facemask or nasal cannula * Monitor VS q5min at first * Assess ventilatory pattern for manifestations of resp distress * Common for pt to be hoarse & have sore throat for a few days * Sit in semi-fowlers, take deep breathes every ½ hour * Use incentive spirometer every 2hrs * Limit speaking right after extubation * Stridor is late manifestation of narrowed airway

Priorities in caring for the ventilated patient are: * monitoring * Evaluating patient responses * Managing the ventilator system safely * Preventing complication * Check all ventilator settings against the prescription at least once per shift * Patient first then monitory * Use aseptic technique when caring for a patient requiring pulmonary suctioning * Inspect the mouth and perform oral care every 2 hours * Ensure that alarm systems on mechanical ventilators are always activated and functional * Remember that pt who are receiving mechanical ventilation are being chemically paralyzed usually can hear & can feel pain. * The usual manifestations of ventilatory failure may be less obvious in the older adult * Age-related changes, such as ↑ chest wall stiffness, reduced ventilatory muscle strength, & ↓ lung elasticity, ↓ likelihood of weaning in elderly * Allow pt & family members opportunity to express feelings & concerns about breathing difficulties * or the possibility of intubation & mechanical ventilation * Teach family members ways to communicate w/ventilated patients

REQUIRED READINGS:
Ignatavicius, D. D., Workman, M. L. (2010). Medical Surgical Nursing Patient-Centered Collaboration Care (Ed 6). St. Louis: Saunders Elsevier. Ch 29, 30, 31, 32, 33, 34.

Kee, J. L., Hayes, E.R., & McCuistion, L.E. (2012). Pharmacology: A nursing process approach (Ed 7). St. Louis: Mosby. Ch 29, 30, 31, 32, 33, 40, 41

Wissmann, J. (Ed.). Adult Medical –Surgical Nursing: Content mastery series review module (Ed 7.1). Kansas City, MO: Assessment Technologies Institute, LLC. Ch 3-10; 12-19.

Billings, D. (2010). Lippincott Q & A review for nclex-rn (10th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

CLINICAL SKILLS:
1. Distinguish between normal and abnormal breath sounds.
2. Recognize acute respiratory distress.
3. Monitor an adult client receiving oxygen therapy.
4. Provide teaching/learning of breathing techniques to an adult with COPD.
5. Provide teaching/learning for post-op ventilation exercises.
6. Provide tracheostomy care.
7. Monitor an adult client with a chest tube drainage system.
8. Safely administer medications that affect respiratory function.
9. Perform airway suctioning when needed for secretion removal.

CLINICAL OBJECTIVES:
1. Assess adults for evidence of respiratory infections, respiratory distress or respiratory compromise.
2. Assess adults for risk factors related to respiratory disorders.
3. Monitor lab values pertinent for adults with compromised respiratory function
4. Provide teaching/learning in the area of prevention of respiratory disease.
5. Conduct discharge planning regarding respiratory disease.
6. Utilize the RAM nursing process to provide care for adults with compromised respiratory function.
7. Utilize the RAM nursing process to provide care for adults requiring thoracic surgery.
8. Utilize the RAM nursing process to provide care for adults with a tracheostomy.
9. Utilize the RAM nursing process to provide care for adults with chest tubes/chest trauma.
10. Provide appropriate pre and post procedure nursing care for adults undergoing diagnostic testing for respiratory disorders.

PHARMACOLOGY STUDY GUIDE – ANTIMICROBIALS

Vocabulary Terms:

Superinfection – a secondary infection that occurs when the normal bacterial flora of the body are disturbed by antibiotic therapy. (Occurs most often when a broad-spectrum antibiotic is used and when it is taken for more than a week.)

Opportunistic infection – an infection caused by normally=occurring organism that is only problematic for persons with a weakened immune system.

Narrow spectrum – antibiotics that are specifically effective against one type of organism.

Broad spectrum – antibiotics which are effective against both gram-positive and gram-negative organisms. (Frequently used when organism hasn’t yet been identified)

Extended spectrum – antibiotics which have been developed with special properties to be effective against organisms which have become resistant to other antibiotics of this class only.

Neurotoxicity – caused by a medication which is damaging to the nervous system.

Hepatotoxicity – caused by a medication which is damaging to the liver.

Ototoxicity – caused by a medication which is damaging to the nervous conduction of hearing.

Nephrotoxicity – caused by a medication which is damaging to the kidneys.

Photosensitivity – when eyes and/or skin are more easily affected by light.

Aquired resistance – can occur when infecting organisms are repeatedly exposed to antibiotics allowing mutant strains of the organisms to proliferate because the antibiotic is no longer effective.

Cross-sensitivity – when exposure to a drug may produce an allergic reaction in a person who was previously exposed to a different but chemically-related drug.

Bacteriostatic – decreases or inhibits growth of bacteria.

Bacteriocidal – agent that kills bacteria

Trough – the lowest plasma concentration of a drug which indicates the rate of drug elimination. (generally assessed just prior to delivery of next scheduled IV dose.)

First-line drug – drugs considered to be more effective and less toxic than second-line drugs in treating TB.

Second-line drugs – drugs that may be less effective and possibly more toxic than first-line drugs in treating TB.

Study Questions:

1. When should cultures of infectious areas be obtained in relation to antimicrobial therapy? Why?

2. When a person receives a specific antimicrobial agent (esp. penicillin), what precautions should the nurse take? Why? What problems should you anticipate? How should you be prepared for those problems?

3. Why should you teach a patient to complete the prescribed course of antimicrobial therapy?

#1 –

#2 –

4. Describe a common superinfection that may occur in a patient taking an antibiotic. Why do superinfections occur?

5. What is the purpose of penicillinase-resistant penicillins, like methicillin? Why has methicillin resistance occurred? What precautions should be taken with a patient whose infection is methicillin resistant?

6. In general, what should you know about administration of antibiotics?

Oral administration –

IM injections –

IV infusion–

7. Explain what is meant by cross-sensitivity between cephalosporins and penicillins?

8. What are the most common side effects / adverse reactions to cephalosporins?

9. What are the main drawbacks of vancomycin? What is an important use of vancomycin today?

10. Who should not take tetracyclines and why?

11. Why is it important to draw peak and trough levels on patients taking aminoglycosides? In relation to medication administration times, when should peak and trough levels be obtained? .

12. What are signs of ototoxicity and nephrotoxicity that the nurse should watch for the patient taking aminoglycosides? Ototoxicity –

Nephrotoxicity –

13. What are the side effects/ adverse reactions / nursing implications for Amphotericin B?

Respiratory Medications

Upper Respiratory Infections * Antihistamines * Bendadryl * Chlorpheniramine (Chlor-trimeton) * Loratadine (Alavert, Claritin) * Fexofenadine (allegra) * Cetirizine (Zyrtec) * Oral Decongestants * Cromolyn (nasalcrom) * Intranasal corticosteroids * Ipratropium (Atrovent)

Pharyngitis * Penicillin * Erythromycin * Cephalosporins (clarithromycin) * Macrolides (azithromycin – Zithromax) * Analgesics – Tylenol, codeine * Antitussives * Hydrocodone

Community Acquired Pneumonias * Macrolides * Azithromycin (Zithromax) * Clarithromycin (Biaxin) * Doxycycline (Vibramycin) * Fluroroquinolones * Gatifloxacin (tequin) * Levofloxacin (Levaquin) * Beta-lactam agents * Cefpodoxime (Vantin) * Cefuroxime (Zinacef, Ceftin) * Amoxicillin or amoxicillin/clavulante * Augmentin * Clavulin

Mycoplasma Pneumonia * Doxycycline * Macrolides

Pneumocystis Cariini Pneumonia * Pentamidine (penacarinat, NebuPent) * Trimethoprim-sulfamethoxazole (Bactrim, Septra)
Influenza Type A * Amantadine (Symmetrel) * Rimantadine (Flumadine)

Influenza Type A and B * Zanamivir (Ralenza) * Oseltamivir (Tamiflu)

Hospital Acquired Pneumonia * Second-generation cephalosporins * Cefuroxime (Ceftin, Zinacef) * Cefamandole (Mandol) * Third-generation cephalosporins * Ceftriaxone (Rocephin) * Cefotaxime (Claforan) * Ampicillin-sulbactam (Unasyn) * Flurorquinolones * Ciprofloxacin (Cipro) * Levofloxacin (Levaquin)

MRSA Infections * Vancomycin (Vancocin) * Linezolid (Zyvox)

Tuberculosis * Isoniazid (INH) * Rifampin (Rifadin) * Pyrazinamide * Ethambutol (Myambutol)

Pulmonary Embolus * Anticoagulation therapy * Heparin * Coumadin * Thrombolytic therapy

COPD * Corticosteroids * Bronchodilators * Methyl.xanthines * Aminophylline * Theophylline * Anticholinergic agernts * Beta-Adrenergic Agents * Mucolytic agents * Antitussive agents

DRUG CLASS | ACTIONS | SIDE EFFECTS/TOXIC EFFECTS | NURSING CONSIDERATIONS | BRONCHODILATORSAdrenergic Drugs * Terbutaline (Brethine) * Isotherine (Bronkosol) * Albuterol (Proventil, Ventolin) * Isoproterenol (Isuprel) * Metaproterenol (Metaprel, Alupent) * Levalbuterol (Xopenex) * Epinephrine (short acting) | Relax smooth muscles of trachea and bronchial tree. | Nervousness, tremor, headache, increased pulse, increased blood pressure, palpitations, N/V, abdominal cramps, sweatingSame as above | * Monitor VS, lung sounds and I&O * Can be given orally * Most given by inhalers or nebulizers * Teach correct use of inhalers/nebs * Clean equipment frequently * Use bronchodilators first and then steroids or cromolyn 2nd (if both ordered) * Side effects decrease as tolerance develops * Use cautiously with hyperthyroidism, DM, heart disease * Use correct concentration * Double check dosage with another nurse * Given sub Q for asthma, etc | Methylxanthine drugs * Theophylline (oral) * Aminophylline (IV) | | Irritability, restlessness, insomnia, headache, dizziness, palpitations, tachycardia, hypotension, N/V, anorexia, flushing, diuresisSame as above | * Relaxes smooth muscles; CNS stimulant, acts like caffeine * Give with food to decrease GI effects * Therapeutic range 10 - 20 mcg/ml * Hold med if level >20, call MD * Don’t give with other methylxanthine drugs * Multiple drug interactions, check compatibility * May be used as a respiratory stimulant for infantile apnea | ANTI-INFLAMMATORY AGENTS * Beclomethasone (Vanceril) * Metamethasone * Triamcinolone (Azmacort) * Flusinolide (Aerobid) * Above meds inhaled * Solumedrol (IV) | Decrease inflammation of the airway allowing for better exchange of air during respiration | Euphoria, insomnia, increased blood pressure, CHF, edema, increased appetite, weight gain, GI irritation, peptic ulcer, delayed wound healing, osteoporosis, cataracts, glaucoma, increased glucose, decreased K+, moon face, decreased growth in children, muscle weakness, decreased resistance to infection. | * Minimal side effect with inhaled steroids * Monitor K+ levels * Monitor blood glucose * Use cautiously in patients with active infections * Monitor patients for s/s of infection * Monitor daily weights; report excessive weight gain * Reduce dosage gradually; do not abruptly discontinue (will have rebound effect) * Rinse mouth after use; clean inhaler daily/ assess for oral candidiasis * Not a treatment for acute wheezing or bronchospasm * Use bronchodilators first if both are ordered | MUCOLYTIC AGENTS (inhaled) * Acetylcystiene (Mucomyst) * Domase alfa (Pulmozyme) | Helps to liquefy and thin mucous/secretions. Aids in better removal of secretions. | | * Also used to treat acetaminophen overdose * Primarily used for treatment of cystic fibrosis | EXPECTORANTS * Guiafenesin (Robitussin) * Iodide preparations | Liquefy bronchial secretions and increase amount of excretion in the respiratory tract | . | * Frequently in OTC preparations * Taste bad; take with juice, etc. | ANTI-TUSSIVE AGENTS * Narcotic (may contain codeine) * Non-narcotic – dextromethorphan * Tessalon Perles | Act on cough center in brain to suppress cough reflex. Use with irritating, noncongestive, non-productive cough.Soothe respiratory tract and reduces cough reflex at its source | Sedation, constipation, respiratory suppression. | * Monitor for respiratory depression | ANTIHISTAMINES * Benadryl * Atropine | Block the effects of histamine at peripheral H1 receptor sites and have drying effects and antipruretic (itching) effects. Used for symptomatic relief of allergic rhinitis, conjunctivitis, and urticaria. May also be used as an adjunctive therapy to anaphylactic reactions – relief of lower respiratory conditions Upper Respiratory Infections Handout NOT inclusive, you must read the text
Upper Respiratory Infections Handout NOT inclusive, you must read the text such as bronchoconstriction and bronchospacms | Drowsiness, drying effects of mouth and mucous membranes. CNS depression if used with ETOH or other sedatives. | * Assess allergy symptoms * Monitor BP and pulse * Assess lung sounds * Maintain fluid intake * Safety precautions because it may cause drowsiness * Teach to avoid use of ETOH and other CNS depressants * Frequent oral hygiene or chew sugarless gum to combat dry mouth. * DO NOT give if client has glaucoma |

Disorder | Cause | Patho | Incidence | Manifestations | Management | Complications | URI“Common cold” | VirusSpread by droplets and contact | Virus invades nasal and throat mucosa causing edema and increased mucous production | Most common of infections:Crowding, daycares, low SES, passive smokingAll ages | RhinorrheaSneezingCoughSlight feverSore throatIrritabilityAnorexiaEnlarged lymph nodesMalaise | SymptomaticEncourage fluidsTylenolSaline gargleSaline nose drops/bulb suctionRestDecongestantsPrevent infection spreadAssess for complications | Secondary bacterial infectionsAll lower respiratory tract infectionsSinusitisTonsillitisOtitis media | Sinusitis | Can be viral or bacterial. S. pneumoniae, H influenzae, Moraxella catarrhail. Someimes associated with tooth infections | Nasal congestion, inflammation and edema and increased nasal fluid leads to obstruction of sinus cavities. | Approximately 32 million cases per year in US. Highest rates in Midwest and south. Higher incidence in carpentry, leather work, dye, paint and solvent manufacturing. | Pressure and pain over sinus areas. Purulent nasal secretions. | Treat the infection, decrease nasal mucosa edema and pain relief. Antibiotic of choice is amoxicillin and amoxicillin/clavulanic acid (Augmentin). If allergy to PCN, may give Bactrim DS. 7 – 10 days of ABX. Decongestants. See text. | If left untreated can lead to life-threatening infection such as meningitis, ischemic infarction, and osteomyelitis.Other uncommon complications: orbital cellulitis, subperiosteal abscess, and cavernous sinus thrombosis. | Pharyngitis – a febrile inflammation of the throat. | Usually viral.from Group A streptococcal infection. Usually subside in 3 – 10 days of onset. | | | Fiery-red pharyngeal membrane and tonsils. Exudate on tonsils. Cervical lymphadenopathy. Fever, malaise, sore throat. | Viral – treat symptomsIf bacterial -ABX – PCN is 1st choice for 7 – 10 days. If allergic to PCN, may receive cephalosporins and macrolides Tylenol-fever or pain, Antitussive medications and codeine or hydrocodone if pain severe. | Sinusitis, otitis media, peritonsillar abscess, mastoiditis, rheumatic fever, and nephritis. | InfluenzaBronchitis | Strains A/B/C influenza virus (spread by droplets and contact)Usually viral | Destruction of the lining of resp. tract impairing mucociliary systemCauses nasal congestion and drainageUsually occurs as a secondary infection of a URIInflammation of the trachea and bronchi with increased mucus production | All ages, esp. elderlyUp to 40,000 deaths per year (mostly elderly)Epidemic occur in winterAffects all agesIncreased in winter months | ChillsFeverMalaiseRhinitisMyalgiaCoughSore throatHistory of recent URIGradual onsetCough (may or may not be productive)May have low grade tempMay have cracklesX-ray usually normal | SymptomaticSimilar to URIBedrestAntivirals may be triedAnnual flu shotsManaged at homeSymptomatic careIncrease fluidsRestTylenolAvoid cough suppressants, antihistamines, antibiotics | The main complication of influenza is pneumonia. Assess frequently for change in lung sounds especially new onset of cracklesSecondary bacterial infectionsLower respiratory tract infection |

Ventilator Handout

Positive pressure vents | Vent Settings the Nurse must Monitor | Nursing Considerations for Intubated/Ventilated Patients | Require intubation and/or tracheostomy and inflate the lungs by exerting positive pressure on the airway and force alveolar expansion. Exhalation is passive. Commonly used in hospitals. They deliver a preset volume of air with each inspiration | * VT – Tidal Volume * Rate – number of breaths per minute ventilator is delivering * Patient’s rate – number of breaths per minute patient is taking on their own in addition to delivered rate * FiO2 – Fraction of Inspired Oxygen – percent of oxygen delivered through ventilator * PEEP – Positive end expiratory Pressure * PAP – Positive Airway Pressure * CPAP – Continuous Positive Airway Pressure * Pressure Support. | * Treat the patient, not the ventilator * Assess lung sounds and ABGs frequently * Ambu patient if can’t immediately identify problems with ventilator * ROM, repositioning, DVT prophylaxis, PUD prophylaxis * Collaborate with Respiratory Therapist and MD on patient care * High Pressure Alarm = obstruction. Assess and clear airway. Suction PRN * Low Pressure Alarm = disconnected from patient. Ensure all connections are secure * Infection – airway is kept open artificially, increased risk for infection. Always use gloves when doing patient care. Sterile technique with suctioning. * Impaired communication – patient unable to speak, utilize patience, support and alternate means of communication. |

COMMON DIAGNOSTIC AND LABORATORY TESTS FOR ASSESSMENT OF RESPIRATORY FUNCTIONING Diagnostic Test | Purpose | Normal Values | Important Points | Arterial Blood Gas (ABG) and pH Analysis | Measure pressure of O2 and CO2 in blood and blood pH.To assess the adequacy of the patient’s oxygenation, ventilation, and perfusion. | pH 7.35-7.45PCO2 35- 45 mmHgPO2 80-100 mmHgHCO3 22-26 mEq/L | Explain procedure to patient. (Intra-arterial puncture of either radial, brachial or femoral arteries is performed and collection is obtained, 3-5ml.)Supplemental oxygenation is recorded on lab slip.Specimen is placed on ice and sent to lab immediately.Pressure is applied for 3 to 5 minutes or longer if the patient has an abnormal clotting time or is on anticoagulants (approx. 15 minutes). | Sputum Cytology | Microscopic examination of cells in the sputum. Purpose: To determine malignancy. | Absence of disease. | Best to collect specimen when patient first awakes before eating or drinking.Approximately 1 teaspoon (5 mL) required in a sterile specimen container.Rinse mouth with water to decrease contamination before obtaining. Obtain sputum by having the patient cough after taking several deep breathes.Label, package, and send to lab as soon as possible. | Sputum culture and sensitivity | Microscopic examination of sputum. Purpose: to determine the presence of pathogenic bacteria. | | Specimen to be collected in AM before eating or drinking if possible in a sterile container and before antimicrobial therapy is initiated.Approximately 1 teaspoon (5 mL) required.Rinse mouth before obtaining. Obtain specimen after patient deep breathes and then takes deep cough.Place in appropriate specimen container.Label, package, and send to lab as soon as possible. | Endoscopic studies: pg. 198-201 Mosby diagnostic guide | Direct visualization of a body cavity. | | | Bronchoscopy: examines the larynx, bronchi, and trachea. | To examine lesions, remove foreign objects, drain abscesses or improve drainage, assess trauma, and obtain tissue samples (biopsies). | | Requires informed consent.Patient should be NPO for 4 to 8 hours.Medication may be given prior to procedure for pain or sedation and to decrease secretions.Local anesthetic spray is used to “numb” throat instruct not to swallow spray.Patient must not eat or drink post procedure until gag reflex returns.Post procedure; observe for impaired respiration, laryngospasm, or large amounts of blood in sputum. Vital signs per orders or policy, low grade fever may occur.Assess for respiratory distress.Warm saline gargles and lozenges may be needed for a sore throat. | Skin Tests: Tuberculosis Skin Testing (Box 29-4; pg. 817) | These are intradermal tests done to determine antigen-antibody reactions.Purpose: To determine immune response. | | Check and report hypersensitivity to test antigens prior to performance. Area is to be cleansed with alcohol and allowed to dry prior to testing.Results must be read (timed) at appropriate time.Reaction (amount of erythema or induration) must be documented. Include thename of test, date, time, method, and site administered in the documentation. | Radiography | X-Ray exam of the lungs and thoracic cavity.To diagnose pulmonary diseases, assess the progression of disease and detect fluid/secretions and air in the lungs. | | Prior to X-ray, clothing down to waist is to be removed. Gown should be placed on patient. Remove metal jewelry. | Lung Scan | The recording of the emissions of radioactive waves on a photographic plate. The waves are from a substance which is injected in the patient’s vein and then circulates through the lung. To identify defects in blood perfusion of the lung.Perfusion Scan (Q scan): measures integrity of pulmonary blood vessels and evaluates blood flow problems such as pulmonary emboli.Ventilation scan (V scan) detects ventilation problems such as in emphysema patients.May be used together (VQ scan) for more diagnostic information. | | Obtain informed consent if needed.No fasting needed.Jewelry should be removed from chest area.No special care or radiation precautions needed post procedure. | Pathogen Diagnostic Tests | Sputum Analysis (See above under cytology and sputum culture and sensitivity).Throat Culture (review in Mosby's Diagnostic and Lab Test Reference on pg. 903-904).Complete Blood Count (CBC) and differential (review in Mosby's Diagnostic and Lab Test Reference on pg. 280).Pulmonary function studies (review in Mosby's Diagnostic and Lab Test Reference on pg. 783-788). | | |