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Major Topics
• Anatomy
http://www.argosymedical.com/Respiratory/samples/animations/Respirati
on/index.html
http://www.argosymedical.com/Respiratory/samples/animations/Sherwoo
d%20Respiration/index.html
• Assessment
• Labs
• Diagnostics
• Meds
• Common Diagnoses
Activity
• Each team will be assigned one of the following topics to research and
present to the entire group:– Assessment
• Normal assessment – what makes up a complete respiratory assessment?
• Abnormal findings & significance
– Labs• What labs are relative to respioratory status?
• Normals
• Abnormals & significance
– Diagnostics• What diagnostic tests are relative to pulmonary status?
• Normals
• Abnormals & significance
• Any significant patient care measure before, during, or after tests
– Meds• Major categories / actions of Respiratory meds
• Significant side-effects
• Nursing measures specific to meds
Assessment
• Screening Exam Techniques
http://depts.washington.edu/physdx/pulmonary/tech.html
http://depts.washington.edu/physdx/pulmonary/demo.html
Resp Assessment
• Breathing Pattern– I:E ratio– Kussmaul – Rate
• Dyspnea– Orthopnea– PND – Paroxysmal nocturnal dyspnea
• Cough and Sputum– Frequency– Dry / moist– Amount– Color– Thickness– Odor– Hemoptysis
Assessment (Cont.)
• Inspection– Symmetry– Skin color – lip color / finger clubbing– WOB – accessory muscles
• Auscultation– Adventitious sounds
• Chest pain
• History– Diagnoses– Smoking
• Quick, Focused Assessment
Breath Sounds Link
• Normal and Adventitious breath sounds
http://faculty.etsu.edu/arnall/www/public_html/heartlung/breathsounds/contents.html
Labs
• H/H
• Sputum Analysis– C&S
– Gram Stain
– Acid-Fast smear (AFB)
– Cytology
• ABG’s
• WBC
• O2 Sats
Diagnostic Tests
• CXR
• CT Chest
• MRI
• V/Q Scan
• Bronchoscopyhttp://www.nlm.nih.gov/medlineplus/tutorials/bronchoscopy/htm/_no_50_no_0.htm
• Thoracentesis
• PFTs – Pulmonary Function Tests–Spirometry
Diagnostics
• PFR– http://www.argosymedical.com/Respiratory/samples/
animations/Peak%20Flow%20Meter/index.html
Diagnostic Tests
• Endoscopic Exams
– Bronchoscopy: direct inspection of airways
• Only __________ ___________ of airways
– Purposes:• diagnose diseases• find obstructions• obtain tissue samples• remove mucous plugs,
foreign bodies• find bleeding sources
Pulmonary Meds
• Oxygen (later)
• Corticosteroidshttp://www.argosymedical.com/Respiratory/samples/animations/Inhaled%20Corticosteroids/index.html
• Antibiotics
• Beta-Agonists
Respiratory Med Delivery
Metered Dose InhalersMetered Dose Inhalers
– deliver constant dose of drug directly to airways
– requires hand-lung coordination
– propellant based
– compact & portable
– relatively inexpensive
– wait 1 minute between puffs
Methods of Delivery
Dry Powder InhalersDry Powder Inhalers
– no propellants used
– breath activated easier to use
– delivers more drug to airways than MDIs
http://www.mayoclinic.com/health/asthma/MM00405
Methods of Delivery
NebulizersNebulizers
– used at home or hospital
– continuous aerosol spray with external energy source (O2)
– takes longer to deliver drug
– choice if patient unable to use MDIs
Respiratory Treatments
• Coughing and Deep Breathing (later)
• Incentive Spirometry (later)
• Oropharngeal Suctioning
• Inhaled Medication
• Oxygen Therapy (Supplementation)
Coughing & Deep Breathing
• Position for maximal lung expansion
• Splint with hand(s) or pillow
• Slow inspiration via nose, hold 3-5 seconds, exhale via mouth. Cough after 2-3 breaths.
• Pulmonary disease: exhale via pursed lips & cough after expiration started
• More frequent coughing if productive
• Coughing contraindicated: post-eye, ear, brain
or neck surgery
Incentive Spirometry
• Prevents atelectasis & PNA
– Position for maximal lung expansion
– Exhale completely
– Close mouth around mouthpiece
– Inhale slow & deep, watching meter for flow rate
– Make inspiration last for 3-5 seconds
– 10 X Q/hr WA
Major Pulmonary Diagnoses
• COPD– http://video.about.com/copd/Emphysema.htm – http://video.about.com/copd/COPD.htm
• Pneumonia
– CAP vs HAP
Major Pulmonary Diagnoses
• Asthma
– http://www.argosymedical.com/Respiratory/samples/animation
s/Asthma%20TLC_AZ/index.html
– http://www.argosymedical.com/Respiratory/samples/animation
s/Asthma/index.html
• Sleep Apnea
– http://www.argosymedical.com/Respiratory/samples/animation
s/CPAP%20Sleep%20Apnea/index.html
Pneumonia Collaborative Care
• Appropriate antibiotic therapy
• Increased fluid-- 3 liters/day
• Good nutrition--1500 cal/day
• analgesics
• Reduced activity and rest
• Antipyretics
• Supplemental oxygen
• Vaccine prophylaxis
• CORE Measure
Assessment Findings
• Fever, restlessness, fatigue, splinting painful chest
• (New) cough with or without sputum
• Shortness of breath, RR & HR
• Pleuritic chest pain
• Infiltrates on CXR
• Crackles or bronchial sounds in the peripheral lung fields
Collaborative Care
• Appropriate antibiotic therapy
• Increased fluid-- 3 liters/day
• Good nutrition--1500 cal/day
• Analgesics
• Oxygen
• Reduced activity and rest
• Antipyretics
• Supplemental oxygen
• Vaccine prophylaxis
• CORE Measure
Oxygen
• Medication– Requires MD order– Side Effects
• Highly combustible gas– Clear– Odorless
• Set-up is part of initial room check
Indications for O2 therapy
• Goal– Prevent or relieve hypoxia
• Keep SaO2 > 90%
– Reduce work of breathing– Room Air / FIO2 = 21%
• Used with hypoxia due to:– Respiratory Disorders– Cardiovascular disorders– Central nervous system disorders
Safety Precautions
• O2 sign posted
• No smoking or flames
• Electrical equipment grounded
• Check tank level before transport
• No oil-based lubricants / lotions
Delivery Devices
• Nasal Cannula• Masks
– Simple face– Partial rebreathing– Non-rebreathing– Venturi (Venti Mask)
• Tracheostomy– Collar
• Ventilator• Flow Meter• Humidification
Nasal Cannula
• Advantages– Safe, simple, tolerated well– Allows eating and drinking– Can humidify
• Disadvantages– Easily dislodged
• Check regularly
– Skin breakdown• Check regularly
• O2 Concentrations– 1L/min = 24%– 2L/min = 28%– 3L/min = 32%
Simple Face Mask
• RA enters via side holes
• Advantages– Humidified
• Disadvantages– Imprecise FIO2– High FIO2 needed to prevent rebreathing CO2
• Concentrations– 5-6L/min = 40%– 6-7L/min = 50%– >7L/min = 60%
Non-rebreather Mask
• Use– Valve prevents air from flowing
back into bag– Last step, usually, before intubation
• Advantages– High O2 concentrations– Accurate
• Disadvantages– Can’t use high humidity– uncomfortable
Venturi Mask
• Venti-mask– High flow– Adjustable
• Advantages– Very precise– Mask of choice for
COPD
• Disadvantages– uncomfortable
O2 and COPD
• Historically…– Never give O2 >2L/min to COPD pts.
• However…
“There has been concern regarding the dangers of administering O2 to COPD pts and reducing their drive to
breath.”
“This has been a pervasive myth but is not a serious threat.”
“In fact, not providing adequate O2 to these patients is much more detrimental.”
Lewis, p. 643 (7th ed.)
Patient Education
• Monitor color of sputum
• Self care: at-home meds & treatments; avoid triggers
• Prevention– Pneumococcal vaccine, flu shot
• Frequent oral hygiene
• Encourage fluids
• Environmental hazards– altitude, smog, allergies, smoke
• Follow up medical care
• American Lung Association– www.lungusa.org