ATI Respiratory Powerpoint

7/28/2019 ATI Respiratory Powerpoint

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Kelsey LeVan


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Respiratory Diagnostic Procedures1. Pulse oximetry (non invasive measurement of the

oxygen saturation of the blood). (Measures arterialoxygen saturation).

2. ABG

3. Bronchoscopy

4. Thoracentesis


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ABG Terms pH- amount of free hydrogen ions in the arterial

blood. (H+)

PaO2- the partial pressure of oxygen PaCO2- the partial pressure of carbon dioxide

HCO3- bicarbonate in arterial blood

SaO2- % of oxygen bound to Hgb as compared to the

total amount that can be possibly carried.


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Normal ABG Values

pH- 7.35-7.45

PaO2- 80-100

PaCO2- 35-45

HCO3- 22-26

SaO2- 95-100%


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RULES FOR AN ABG Perform the ALLENs Test. Compress ulnar and radial

arteries SIMULTANEOUSLY while instructing thepatient to form a fist.

Then have the client relax hand while RELEASINGpressure on the RADIAL ARTERY.

HAND SHOULD TURN PINK QUICKLY

INDICATING PATENCY OF THE RADIAL ARTERY.REPEAT FOR THIS PROCESS FOR THE ULNARARTERY


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Rules for an ABG continued Hold DIRECT PRESSURE over the site for 5 Minutes.

(20 minutes if pt. is on anticoagulants)

Monitor ABG site for bleeding, loss of pulse, swelling,and changes in temp and color

BLOOD CAN ALSO BE DRAWN

FROM AN ARTERIAL LINE


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Bronchoscopy Uses Can visualize abnormalities such as tumors,

inflammation, and strictures

Biopsy of suspicious tissue (lung tissue) (biopsy canhave additional risks for bleeding)

Aspiration of deep sputum


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Bronchoscopy- Pre procedure NPO (usually 8-12 hrs. to reduce aspiration risk)

Ensure that consent form is signed

Remove the clients denturesAdminister medications are prescribed such as

lidocaine


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Laryngospasm Uncontrolled muscle contractions of the laryngeal

cords that impede the clients ability to inhale


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Pneumothorax Collapsed lung

S/S- diminished breath sounds


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Asthma Chronic inflammatory disorder of the airways in

intermittent and reversible airflow obstruction of thebronchioles

The obstruction occurs either by inflammation orairway hyperresponsiveness

Cause is unknown.


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Manifestations of Asthma 1. Mucosal edema

2. Bronchoconstriction

3. Excessive mucous production


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S/s of AsthmaCoughing, wheezing, mucus production, poor oxygensaturation, barrel chest or increased chest diameter


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Asthma based on symptoms and

classified into 4 categories 1. Mild intermittent- symptoms occur less than 2x a

week

2. Mild persistent- symptoms arise more than 2x aweek but not daily

3. Moderate persistent- daily symptoms occur inconjunction with exacerbations 2x a week

4. Severe persistent- symptoms occur continually,along with frequent exacerbations that limit theclients physical activity and quality of life.


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Health Promotion/Disease

prevention


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Triggering Agents of Asthma


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Pulmonary function tests (PFT) are

the most accurate tests for

diagnosing asthma and its severity!


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Laborative Tests for AsthmaABG

- Hypoxemia- PaO2


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Asthma Therapy Exercise (promotes ventilation/perfusion)

Medications


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Medications Bronchodilators (inhalers)

Anti-inflammatory agents- used to decrease airwayinflammation

Combination agents- (bronchodilators and anti-inflammatory)


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Bronchodilators Short acting beta2 agonists such as albuterol (Proventil,

Ventolin)- provide rapid relief of acute symptoms andprevent exercise induced asthma. Watch for tremors and

tachycardia

Anticholinergic meds- ipratropium (Atrovent)- increasesbronchodilation and decreased pulmonary secretions.(sympathetic nervous system) (GIVE PATIENT CANDY

FOR DRY MOUTH!!!))) Methylxanthines- (Theo-Dur)- requires close monitoring

of serum med. Levels due to a narrow therapeutic range.Toxicity =tachycardia, nausea, diarrhea


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Anti-inflammatory Agents Corticosteroids- fluticasone (Flovent), prednisone

(Deltasone)

ENCOURAGE THE PATIENT TO TAKEPREDNISONE WITH FOOD.


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CombinationAgents Ipratropium and albuterol (Combivent)

Fluticasone and salmetrol (Advair)

IF PRESCRIBED SEPERATELY FOR INHALATION ATTHE SAME TIME, ADMINISTER THEBRONCHODILATOR 1stin order to increase the

absorption of the anti-inflammatory agent.


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Complications of Asthma Respiratory failure

- persistent hypoxemia related to asthma can lead torespiratory failure

-if in respiratory failure, monitor oxygen levels and acid-base balance

Status asthmaticus

-LIFE THREATENING! Episode of airway obstruction thatis often unresponsive to common treatment. Extreme

wheezing, labored breathing, distended neck veins, use ofaccessory muscles


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COPD


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COPD Encompasses 2 diseases- EMPHYSEMA and

CHRONIC BRONCHITIS

Irreversible


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Emphysema Loss of lung elasticity and hyperinflation of lung

tissue

Causes destruction of alveoli leading to a decreasedsurface area for gas exchange, carbon dioxideretention, and resp. acidosis


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Chronic Bronchitis Inflammation of the bronchi and bronchioles due to

chronic exposure to irritants


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Risk Factors
http://www.google.com/url?sa=i&rct=j&q=smoking&source=images&cd=&cad=rja&docid=H1OrHukTTvUSqM&tbnid=zsiCovMoHNOikM:&ved=0CAUQjRw&url=http://www.sabotagetimes.com/life/10-ways-to-carry-on-smoking/&ei=-wQ4UZnfCPGn0AHbxIG4CA&bvm=bv.43287494,d.dmQ&psig=AFQjCNF9ZOYUjqwNeWFeuEh1S5IOEupYEA&ust=1362712173747742


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Signs and Symptoms of COPD Chronic dyspnea, productive cough that is most severe

in the morning, resp. acidosis, and comp. metabolicalkalosis, crackles, wheezes, rapid and shallow resps,

use of accessory muscles, barrel chest or increasedchest diameter, clubbing, decreased o2 levels,


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Laboratory Tests Increased hematocrit is due to low oxygenation levels

Sputum cultures and WBC counts to diagnose acuterespiratory infections


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Diagnostic Procedures Pulmonary function tests

- comparisons of forced expiratory volume (FEV) toforced vital capacity (FVC) are used to classify COPDas mild to very severe

As COPD advances, the FEV to FVC ratio decreases.The expected reference range is 100%. For mild COPD,

the FEV/FVC ratio is decreased to


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Chest x-ray Reveals hyperinflation of alveoli and flattened

diaphragm in the late stages of emphysema


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ABG results.Will show..

Hypoxemia decreased PaO2- 45 Resp. acidosis, metabolic alkalosis compensation


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AAT (alpha1 antitrypsin) levelsA deficiency in a special enzyme produced by the liver

that helps regulate other enzymes (that helpbreakdown pollutants) from attacking lung tissue.


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Nursing Care Fowlers

Cough and deep breathe

Incentive spirometer Suction secretions

Breathing treatments

Adequate nutrition (soft, high calorie foods) (fluids)


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For a patient with diaphragmatic

breathing
http://www.google.com/url?sa=i&rct=j&q=diaphragm+breathing+exercise&source=images&cd=&cad=rja&docid=zTmgrg0AgHLh5M&tbnid=rgkJfRK0sxAH0M:&ved=0CAUQjRw&url=http://www.webmd.com/balance/stress-management/breathing-with-your-diaphragm&ei=aws4UZOFNPCJ0QG2x4HACQ&psig=AFQjCNHuc-xVVbRhokke8rvunILg8et5ZQ&ust=1362713826952641


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Incentive Spirometry

Instruct client tokeep a tight seal

aroundmouthpiece andto inhale andhold breath for

3-5 sec.


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COPD OXYGEN? Give pt. 2-4 L/min NC or up to 40% via VENTURI
http://www.google.com/url?sa=i&rct=j&q=2+L+nasal+cannula&source=images&cd=&cad=rja&docid=g8T4K21BW09M4M&tbnid=4Dm66CdlXfkhTM:&ved=0CAUQjRw&url=http://quizlet.com/12569150/print/&ei=ww84UYuuH42s0AGs4IGgDA&psig=AFQjCNGq2CiJdLYHgEZmnwyCOgA29NOClQ&ust=1362714927436740


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IMPORTANT!!! IT IS IMPORTANT TO RECOGNIZE THAT LOW

ARTERIAL LEVELS OF OXYGEN SERVE AS THEPRIMARY DRIVE FOR BREATHING..


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Medications? Bronchodilators (inhalers)- Albuterol (Proventil,

Ventolin) (provide RAPID relief)

Cholinergic antagonists- ipratropium (Atrovent)

Methylxanthines- Theo-Dur which relax smoothmuscles of the bronchi. Needs close monitoring ofserum levels

Anti-inflammatories- fluticasone (Flovent) andprednisone (Deltasone). Monitor for side effects(immunosuppresion, fluid retention, hyperglycemia,poor wound healing)


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Therapeutic Procedures Chest PT

Raising the foot of the bed slightly higher than thehead can facilitate optimal drainage and removal ofsecretions by gravity.


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Complications of COPD Respiratory infections- results from increased mucus

production and poor oxygenation levels

Right sided heart failure (COR PULMONALE)- airtrapping, airway collapse, and stiff alveoli lead toincreased pulmonary pressures.. Blood f low throughthe lung tissue is difficult= increased workload andenlargment and thickening of the right atrium andventricle.

-s/s= low o2 level, cyanotic lips, enlarged liver,distended neck veins, edema


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Pneumonia!


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Pneumonia Inflammatory process in the lungs that produces

excess fluid. Pneumonia is triggered by infectiousorganisms or by the aspiration of an irritant, such as

fluid or a foreign object The inflammatory process in the lung parenchyma

results in edema and exudate that fills the alveoli

Immunocompromised are more susceptible.Immobility can be a contributing factor


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2 Types of Pneumonia 1. Community Acquired (CAP)- most common type.

Occurs as a complication of influenza

2. Hospital acquired pneumonia (HAP)- has a highermortality rate

**** Older adults are more suspectible to infections

and have DECREASED PULMONARY RESERVES DUETO NORMAL LUNG CHANGES, including decreasedLUNG ELASTICITY and thickening alveoli


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S/SAnxiety, fatigue, weakness, chest discomfort, fever,

chills, diaphoretic, SOB, crackles, wheezes, sputumproduction (YELLOW), coughing, dull chest

percussion over areas of consolidation, decreased O2,pleuritic chest pain

*****CONFUSION!!!!! FROM HYPOXIA IS THE MOSTCOMMON MANIFESTATION OF PNEUMONIA INOLDER PEOPLE!!!!!!!!!


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LAB Results Elevated WBC count

ABG shows hypoxemia (decreased PaO2 < 80)


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Chest X-rayWill show consolidation (solidification, density) of

lung tissue

Important


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Medications Cephalosporins- observe client for frequent stools, take

with food

Penicillin- take with food

Monitor kidney function for people taking thesemedications!

Bronchodilators- given to reduce bronchospasms andreduce irritation. (albuterol)

Cholinergic antagonists (anticholinergic meds)- Atrovent

Methylxanthines- Theo-Dur- requires close monitoring ofserum levels


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Medications continuedAnti-inflammatories- decrease airway inflammation

Glucocorticosteroids- fluticasone (Flovent) andprednisone (Deltasone). Help with inflammation.Monitor for immunosuppression, fluid retention,hyperglycemia, hypokalemia, and poor wound healing.


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Complications of PneumoniaAtelectasis

- airway inflammation and edema lead to alveolarcollapse and increase the risk of hypoxemia

SOB, diminished or absent breath sounds, chest xraywill show an area of density


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Complications of Pneumonia Bacteremia (SEPSIS!!!)

- this can occur if pathogens enter the bloodstreamfrom the infection in the lungs


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TB Infectious disease caused by MYOBACTERIUM

TUBERCULOSIS

AIRBOURNE

Primary affects the LUNGS, but can spread to anyorgan

Risk of transmission decreases after 2-3 weeks of

antibiotics Slow onset


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Mantoux test Intradermal injection of tubercle bacillus Should be read in 48-72 hrs

Will be positive within 2-10 weeks of exposure

An induration (palpable, raised, hardened area) of 10 mmor greater in diameter indicates a + skin test

An induration of 5 mm is considered + forimmunocompromised clients

A + Mantoux test indicates that the client has developed animmune response to TB. It doesnt confirm that activedisease is present. Clients who have been treated for TBmay retain a positive reaction.


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S/S Persistent cough

Night sweats

Anorexia Fever

Chills

Weight loss


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Latent TB People may have been exposed to TB, but havent

developed the disease. Mycobacterium TB is in thebody, but body was able to fight it. If not treated, it can

lie dormant for several years and then become activeas the individual becomes older orimmunocompromised.

Individuals who have latent TB may have a + mantoux

test and may receive tx to prevent development of anactive form of the disease


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Bacillus Calmette-Guerin (BCG)

vaccine Client who had this vaccine within the past 10 years

may have a false positive mantoux test. These clientswill need a chest xray to evaluate for the presence of

active TB infection.


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Risk Factors Close contact with an untreated person

Low economic status

Homelessness

Age

Substance abuse

Recent travel outside of US

Health care occupation Crowded environments


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Lab Test QuantiFERON-TB gold

- blood test that detects release of interferon-gamma(IFN-g) in fresh heparinized whole blood fromsensitized people

Diagnostic for infection, whether it is active or latent


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Acid-fast bacilli smear and cultureA + acid-fast test suggests an ACTIVE INFECTION

The diagnosis is confirmed by a positive culture formyobacterium tuberculosis

Nursing Actions

1. 3 morning sputum samples are obtained

2. Wear PPE when obtaining specimen 3. Samples should be obtained in a negative airflow

room


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Nursing CareWear an N95 or HEPA respirator

Place the pt. in a negative airflow room

Airborne precautions


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TB medications 4 meds @ a time is recommended

MEDS MUST BE TAKEN FOR 6-12 MONTHS.MEDICATION NONCOMPLIANCE IS A MAJOR

CONTRIBUTING FACTOR IN THE DEVELOPMENTOF RESISTANT STRAINS OF TB


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THE 4 MEDICATIONS 1. ISONIAZID- (INH)

2. RIFAMPIN (RIF)

3. PYRAZINAMIDE (PZA)

4. ETHAMBUTOL (EMB)

5. MAY CONTAIN STREPTOMYCIN SULFATE

(STREPTOMYCIN). DUE TO ITS HIGH LEVEL OFTOXICITY, THIS MED. SHOULD ONLY BE USED INPTS WHO HAVE MULTI DRUG RESISTANCE TB


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ISONIAZID Bactericidal. Inhibits the growth of mycobacteria by

preventing synthesis of mycolic acid in the cell wall

Take on an empty stomach

Monitor for hepatotoxicity and neurotoxicity such astingling of the hands and feet

Vitamin b6 (pyridoxine) is used to prevent

neurotoxicity from isoniazid


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Rifampin Bacteriostatic and bactericidal antibiotic that inhibits

DNA-dependent RNA polymerase activity insusceptible cells

Observe for hepatotoxicity

Urine and other secretions will be orange

Advice client to report yellowing of the skin, pain or

swelling of joints, loss of appetite, or malaiseimmediately.

May interfere with contraceptives


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pyrazinamide Bacteriostatic and bactericidal and its exact

mechanism of action is not known

Observe for hepatotoxicity

Increase fluids

Advise client to report yellowing of skin, pain orswelling of joints, loss of appetite, or malaise

immediately.Avoid alcohol


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Ethambutol Bacteriostatic and works by supressing RNA synthesis,

subsquently inhibiting protein synthesis

Obtain visual acuity tests

Determine color discrimination ability

Not to be given for children under 13

INSTRUCT THE CLIENT TO REPORT CHANGES INVISION IMMEDIATELY


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Streptomycin sulfate

(Streptomycin)Aminoglycoside antibiotic. Potentiates the efficacy of

macrophages during phagocytosis

Highly toxic

Should only be used in clients who have multi-drugresistant TB

Can cause ototoxicity (notify doctor!!!)

Report significant changes in urine output and renalfunction studies

Advise pt to drink at least 2-3 L of fluid daily


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Client Education Instruct client to continue with follow up care for 1 full

year

Inform the client that sputum samples are needed

every 2-4 weeks to monitor therapy effectiveness.Clients are no longer considered infectious after 3negative sputum cultures


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Military TB Organism invades the blood stream and can spread to

multiple body organs with complications including:

- headaches, stiff neck, drowsiness

Pericarditis

-dyspnea, swollen neck veins, pleuritic pain,

hypotension due to an accumulation of fluid inpericardial sac that inhibits the hearts ability to pumpeffectively


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Larngeal Cancer More common in men

Greatest risk factors is tobacco and alcohol use


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S/S of Laryngeal Cancer Persistent hoarseness, lump in throat, mouth or neck,dysphagia, persistent or unilateral ear pain, weightloss, foul breath

Hard, immobile lymph nodes in the neck (ifmetastasis has occurred)

Dyspnea (if tumor is an advanced stage)


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Laboratory Tests Tumor mapping may be done by taking multiplebiopsy samples

Mapping verifies where the tumor is located, its

margins, and type

Staging is done using this info


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Diagnostic Procedures X-rays of skull, sinuses, neck and chest CT and MRI scan These help to determine the extent and exact location of the

tumor and level of soft tissue invasion

Indirect and direct laryngoscopy - indirect is done to see if the tumor can be visualized - direct is used to visualize the tumor more closely and to obtain

a biopsy which will determine cell type and staging

Before procedure, pt must be NPO. Post procedure assess for return of GAG reflex Inform clients after topical anesthetic is applied, they may feel

like they cannot swallow.


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Bone Scan and PET scan Determines presence of metastasis


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Interdisciplinary Care If surgical removal of the larynx is done, initiate aspeech therapy consult.

Social work consult for the client if outpatient

radiation or chemotherapy is ordered


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Laryngectomy May be a partial (removal of one or part of 1 larynx) or totallaryngectomy (removal of both larynx)

* if cancer is advanced, all or part of the epiglottis mayneed to be removed

** temp. tracheostomies may be established for clients whorequired only a partial laryngectomy

Permanent tracheal stomas are created for clients who haveundergone total laryngectomies

A laryngectomy tube is inserted into the stomaimmediately after the surgery. This prevents contracturesfrom forming while the stoma is healing.

The 11th cranial nerve may be cut resulting in drop followingsurgery


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Total laryngectomy Pts will lose their natural voice


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Cordectomy/hemilaryngectomy Excision of 1 vocal cord Risk for aspiration (tuck chin under when swallowing)

(arch the tongue in the back of the mouth)


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Client Education Use saline and cotton-tipped swabs to cleanse the stoma Humidifier/ saline atomizer to moisten the environment

and stoma frequently during the day Wear a bib, scarf, bandana, etc to cover stoma Instruct patient to avoid lifting. Client unable to lift

because the client cannot perform the valsalva maneuverwith an open airway

Oxygenate prior to suctioning

Aspiration may lead to the development of pneumonia Those with a total larygenectomy will not be able toaspirate due to the surgical seperation of the trachea fromthe esophagus.


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Lung Cancer One of the leading causes of cancer-related deaths Prognosis is often poor because of late diagnosis

Bronchogenic carcinomas account for 90% of primarylung cancers

Histolic cell type determines lung cancer classification:

Non small cell lung cancer (NSCLC)

- most lung cancers - includes squamous, adeno, and large cell carcinomas


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Small cell lung cancer (SCLC) Fast growingAlmost always associated with a hx of smoking!


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Staging T= tumor N=nodes

M=metastasis


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Chemotherapy Primary choice of treatment Cistplatin (Platinol AQ)


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S/S Persistent cough with or without hemoptysis,hoarseness, dyspnea, unilateral wheezing, chest wallpain, muffled heart sounds, fatigue, weight loss,

clubbing of fingers


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Bronchoscopy Can provide direct visibility of the tumorAllows for specimen and biopsy

NPO before and after scope

Assess for return gag reflex


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Hair loss -Will occur 7-10 days after chemotherapy treatmentbegins


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Opioid agonists Morphine sulfate (MS Contin) Oxycodone (OxyContin)

Fentanyl (Duragesic) (PATCH takes several hrs to take

effect) Short acting pain medication is used for breakthrough pain

All used to treat moderate to severe pain caused by illness.

Act on the mu and kappa receptors that help to alleviatepain

Assess pain q4 hrs


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Surgical Intervention Goal is to remove all tumor cells, including lymphnodes

Often involves removal of a lung, lobe, segment, or

peripheral lung tissue

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