Unit 10 Nursing Care of the Client: Oxygenation and Perfusion.

transcript

Unit 10

Nursing Care of the Client: Oxygenation and Perfusion

Chapter 35

Respiratory System

Anatomy and Physiology Review

• Primary function:– Delivery of oxygen to and removal of carbon

dioxide from lungs

Anatomy and Physiology Review

Assessment

• Health history

• Inspection

• Palpation and percussion

• Auscultation

Assessment

Diagnostics

• pH 7.35 – 7.45

• PO2 80 – 100 mm Hg

• PCO2 35 – 45 mm Hg

• HCO3 22 – 26 mm Hg

The client has a long history of COPD and is currently experiencing an exacerbation of

COPD. The following lab work is done this morning: CBC, ABG’s and an electrolyte panel consisting of K+, Na+, Cl, CO2, BUN and FBS. Which lab data requires immediate follow up?

A. Increased PaO2

B. Increased RBC’s

C. Increased PaCO2

D. Hgb Within Normal Limits

A is the answer

Hypoxemia provides the stimulus for the respiratory drive in clients with COPD. Increased oxygen levels may depress the respiratory drive.

Option B and C are expected findings

Option D does not require immediate follow- up.

Nursing Interventions

General Respiratory Medications

• Anti-tussive– Narcotic– Non-narcotic

• Expectorant– What is the best one?

• Mucolytic

• Antihistamine

• Decongestant

Infectious/Inflammatory Disorders: Upper Respiratory

• Common

• Self-limiting

• Caused by viruses, bacteria, and allergic reactions

(continued)

Infectious/Inflammatory Disorders: Upper Respiratory

• Symptoms:– Malaise, fever, edema of affected tissues,

nasal or sinus congestion, headache, sore throat, and cough

• Treatment– Symptomatic

Pneumonia

• Inflammation of bronchioles and alveoli accompanied by consolidation in lungs

• Can result from bacteria, viruses, mycoplasms, fungi, chemicals, or parasite invasions

(continued)

Pneumonia

• Symptoms:– Sudden or high fever, productive cough with

thick sputum, dyspnea, coarse crackles, diminished breath sounds, and pleuritic chest pain

(continued)

Pneumonia

• Treat to clear airways and maintain adequate oxygenation (postural drainage and percussion)

• Treatment:– Respiratory therapy, hydration medications,

and turn, cough, deep breathe (TCDB)

Pneumonia

• Antibiotics:– Penicillins– Tetracyclines– Aminoglycosides– Cephalosporins– “Other”

• Side Effects:– Allergy/

Hypersensitivity– Anaphylaxis– Indirect toxicity– Direct toxicity

Nursing Responsibilities?

Tuberculosis

• Caused by inhalation of Mycobacterium tuberculosis

• Symptoms:– Low-grade fever, persistent cough,

hemoptysis, hoarseness, dyspnea, night sweats, fatigue, and weight loss

(continued)

Tuberculosis

• Treatment:– Airborne precautions and long-term multi-drug

regimen

Tuberculosis

• Medications

• Nursing Responsibilities

Pleurisy/Pleural Effusion

• Pleurisy– Painful condition from inflammation of pleura– Symptoms:

• Pain on inspiration

(continued)

• Pleural effusion– Pleural fluid accumulation within pleural

space– Symptoms depend on amount of lung

tissue compressed and source of effusion

(continued)

• Treat to eliminate underlying cause, maintain adequate oxygenation to tissues, and prevent complications

• Treatment:– Oxygen, respiratory therapy, incentive

spirometry, thoracentesis, thoracotomy and chest tube drainage, and medications

The nurse is preparing to assist with the insertion of a chest tube that will be attached to a closed-chest drainage system without suction.

In monitoring the closed-chest drainage system, the nurse would expect to initially

assess for:A. Fluctuation of water in the water-seal

chamber during respirations.B. Constant fluid fluctuations in the drainage-

collection chamber.C. Continuous bubbling in the suction-control

chamber.D. Occasional bubbling in the suction-control

chamber.

A is the answer

Fluctuations of water during inspiration and expiration in the water-seal chamber indicates normal functioning.

Option B should not be seen in the collection chamber.

Options C and D should not be seen because suction has not been applied to the suction-control chamber.

The client has a chest tube connected to a closed-chest drainage system attached to

suction and is being prepared to transfer to another room on a stretcher. To safely

transport the client, it is most important for the nurse to:

A. Clamp the chest tube during the transport.

B. Get a portable suction before transferring the client.

C. Keep the closed-chest drainage system below the level of the chest.

D. Place the closed-chest drainage system next to the client on the stretcher.

C is the answer

Keeping the closed-chest drainage system below the level of the chest allows for continuous drainage and prevents any back flow pressure.

Options A and D should not be done because they will increase pressure in the pleural space.

Option B is not the most important.

The physician is preparing to remove the client’s chest tube. Just before removing the

chest tube, the physician tells the client to take a deep breath and hold it. This intervention is

done primarily to:

A. Distract the client during the chest tube removal.

B. Minimize the negative pressure within the pleural space.

C. Decrease the degree of discomfort to the client.

D. Increase the intrathoracic pressure temporarily during removal.

D is the answer

This is done to decrease the risk of atmospheric air entering the pleural space during removal.

Options A and C are not the primary reasons for this intervention.

Option B is not correct since negative pressure is desired within the lung.

Severe Acute Respiratory Syndrome (SARS)

• Viral illness with flu-like symptoms

• Spread by close personal contact or contact with infectious material

• Treatment:– Supportive care

Acute Respiratory Tract Disorders: Atelectasis

• Collapse of lung or portion of lung

• Signs of respiratory distress proportional to amount of lung tissue involved

• Treatment:– Respiratory therapy, postural drainage and

percussion, suctioning, oxygen, bronchoscopy, thoracentesis, thoracotomy and chest tube drainage, and medications

Atelectasis

Pulmonary Embolism

• Develops when substance (emboli, fat, or amniotic fluid) lodges in branch of pulmonary artery and obstructs flow

• Symptoms:– Abrupt anxiety, restlessness, inspiratory chest

pain, dyspnea, cough, and hemoptysis

(continued)

Pulmonary Embolism

• Treatment:– Medications and embolectomy

Pulmonary Edema

• Life-threatening condition– Rapid shift of fluid from plasma into alveoli

• Symptoms:– Hemoptysis, dyspnea, orthopnea, cyanosis,

anxiety, significant airway obstruction, and increased HR and respiratory rate (RR)

(continued)

Pulmonary Edema

• Treatment:– Oxygen, medications, and ventilation

MAD DOG

Acute Respiratory Distress Syndrome (ARDS)

• Life-threatening condition– Dyspnea, hypoxemia, and diffuse

pulmonary edema

• Symptoms:– Severe dyspnea, tachypnea, cyanosis,

crackles, wheezes, and hemoptysis

• Treatment is intensive, supportive, and includes many body systems

Acute Respiratory Distress Syndrome (ARDS)

Acute Respiratory Failure

• Occurs as result of client literally becoming too tired to continue “work” of breathing

• Mechanical ventilatory support required during acute phase

Chronic Respiratory Tract Disorders: Asthma

• Intermittent airway obstruction in response to variety of stimuli

• Symptoms:– Sudden inspiratory and expiratory wheezing,

increasing dyspnea, and chest tightness

• Treatment:– Taking medications and avoiding known

allergens

Asthma

Chronic Bronchitis

• Inflammation of bronchial tree with hypersecretion of mucus

• Symptoms:– History of recurrent respiratory infections,

dyspnea, cyanosis, productive cough, and adventitious breath sounds

(continued)

Chronic Bronchitis

• Treatment:– Respiratory therapy, medications, and

immunizations

Emphysema

• Complex and destructive lung disease

• Airflow impeded as it leaves lungs– Results in alveoli distention

• First symptom:– Morning cough

(continued)

Emphysema

• Later symptoms:– Dyspnea upon exertion or at rest

• Treatment:– Smoking cessation, low levels of oxygen, and

medications

Bronchiectasis

• Chronic dilation of bronchi

• Symptoms:– Chronic productive cough, dyspnea, weight

loss, fatigue, thick sputum, crackles, and use of accessory muscles

• Treatment:– Percussion and postural drainage,

respiratory therapy, suctioning, bronchoscopy, and medications

Bronchiectasis

Medications

• Bronchodilators:– Adrenergic– Xanthine– Anticholinergic

• Corticosteroids

The nurse is caring for a client who was admitted with an exacerbation of COPD. The client’s respirations are 28 with dyspnea on

exertion. The client is receiving 2L of oxygen per nasal cannula. The morning pulse oximetry

is 92%. Which nursing intervention is of priority?

A. Monitor the client.

B. Notify the physician.

C. Get an order to increase the oxygen.

D. Place in semi-Fowler’s position.

A is the answer

The client is manifesting signs and symptoms consistent with COPD. Clients with COPD experience some degree of hypoxia.

Options B and C are not appropriate at this time.

Option D is not the best position for a client with COPD.

The client is admitted with an acute exacerbation of COPD. Which

assessment finding is most indicative of a potential complication?

A. Respirations 32, increasingly anxious and restless.

B. Using accessory muscles during respiration.

C. Pulse oximetry 92%, pursed-lip breathing.

D. Expectorating copious amounts of white phlegm.

A is the answer

Increasing anxiousness and restlessness are signs indicating hypoxemia.

Options B, C and D are expected findings for a client with an exacerbation of COPD.

It’s time for report…

Prioritize the five nursing interventions as you would do them

initially:

A – Auscultate lung sounds.

B – Assess pulse oximeter, O2 and NC.

C – Retake the vital signs.

D – Check theophylline level.

E – Place in high-Fowler’s position.

Pneumothorax/Hemothorax

• Pneumothorax– Air in pleural space

• Hemothorax– Blood in pleural space

• May be traumatic, spontaneous, or tension

• Symptoms determined by severity of injury and amount of lung tissue affected

(continued)

Pneumothorax/Hemothorax

• For affected lung to re-expand, air and/or blood must be removed from pleural space

• Thoracotomy tube inserted to drain fluid and air– Allows lung to re-expand

• Analgesics given for pain

It’s time for report…

Prioritize the five nursing interventions as you would do them

initially:

A – Check the pulse oximetry.

B – Assess for fluctuation in the water-seal chamber and bubbling in the suction-control chamber.

C – Check for the previous shift’s fluid level marking on the tape.

D – Assess chest tube patency and drainage.

E – Ask Mr. G to cough and deep breathe.

Lung Cancer

• May originate in lung or result from metastasis

• Symptoms develop late– May include cough, dyspnea, hemoptysis,

and pain

• Treatment:– Surgery, chemotherapy, and radiation

Lung Cancer

Laryngeal Cancer

• Relatively asymptomatic

• May include hoarseness, difficulty speaking, difficulty swallowing, and laryngeal pain

• Treatment determined by extent of tumor growth:– Surgery, chemotherapy, and radiation

Epistaxis

• Hemorrhage of nares or nostrils

• May stem from dry nasal mucosa, local irritation, trauma, or hypertension

• Treat to maintain airway, stop bleeding, identify cause, and prevent recurrence

• Treatment:– Firm pressure on nares or nasal packing

Chapter 60

Infants with Special Needs:Birth to 12 Months

Laryngotracheobronchitis

• Viral illness causing welling of upper airway

• Symptoms:– Stridor, “barking” cough, and hoarseness

• Treat to maintain patent airway and improve respiratory effort

(continued)

Laryngotracheobronchitis

• Treatment:– Cool mist and medications

• E.g., bronchodilators, corticosteroids

Pneumonia

• Inflammation of bronchioles and alveoli spaces often preceded by upper respiratory infection (URI)

• Symptoms:– Abrupt onset of fever, flaring nostrils,

circumoral cyanosis, chest retractions, cough, and increased pulse and respirations

(continued)

Pneumonia

• Treatment:– Oxygen, cool mist hydration, respiratory

therapy, and medications

Respiratory Distress Syndrome (RDS)

• Most often found in pre-term infants

• Symptoms:– Tachypnea, retractions, grunting, crackles,

pallor, cyanosis, hypothermia, edema, flaccid muscle tone,GI shutdown, jaundice, and acidosis

(continued)

• First 96 hours critical to recovery

• Treatment:– Surfactant and supportive care

Cystic Fibrosis

• Genetic dysfunction of exocrine glands

• Affects lungs, pancreas, liver, and reproductive organs

• Symptoms:– Meconium ileus, intussusception, problems

gaining and maintaining weight, pulmonary problems, and salty taste on skin

(continued)

Cystic Fibrosis

• Treat pulmonary problems and nutrition

Sudden Infant Death Syndrome (SIDS)

• Also known as crib death

• Sudden unexpected death of apparently healthy infant

• No single cause identified

• Provide empathic support to family

• Inform family that autopsy must be done

Chapter 61

Common Problems: 1–18 Years

Respiratory System

• Upper-respiratory infections

• Allergic rhinitis

• Tonsillitis

• Asthma

• Foreign-body aspiration

Tonsillitis

Epiglottitis

Bronchiolitis

Unit 10 Nursing Care of the Client: Oxygenation and Perfusion.

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