Respirations and Heart Failure

Respirations

• Bradypnea is an abnormally slow breathing rate of less than 12 breaths per minute in adults
  • Causes include drug overdose (opioids), brain injury, and metabolic disorders
• Tachypnea is rapid breathing, more than 20 breaths per minute in adults
  • Causes include fever, anxiety, sepsis, pneumonia, and pain
• Kussmaul respirations are a deep, labored, often fast breathing pattern
  • Can be seen in metabolic acidosis, like diabetic ketoacidosis
• Apnea is the cessation of breathing for 10 or more seconds
  • Causes include sleep apnea, brain injury, and cardiac arrest
• Cheyne-Stokes respirations are cycles of increasing and decreasing rate and depth of breathing, followed by periods of apnea
  • Can be seen at the end-of-life, and with heart failure, stroke, or brain injury
• Dyspnea is the subjective feeling of difficulty breathing
• Assessment of breathing includes the use of accessory muscles, nasal flaring, and tripod position

Heart Failure

• Right-Sided Heart Failure is caused by left-sided heart failure and pulmonary disease
  • Signs and symptoms include peripheral edema, JVD, ascites, and hepatomegaly
• Left-Sided Heart Failure is caused by CAD, MI, and hypertension
  • Signs and symptoms include pulmonary edema, crackles, dyspnea, orthopnea, and fatigue

Cardiac Afterload

• Defined as the pressure the heart must overcome to eject blood
• If increased, the heart works harder, potentially worsening heart failure
• Signs and symptoms of increased cardiac afterload include hypertension, fatigue, and decreased cardiac output
• Measured via blood pressure and echocardiogram (for ventricular resistance)

Oxygen Delivery Devices and Airways

• Bag Valve Mask (BVM) is used for emergency resuscitation in unconscious patients without a patent airway
• High Flow Nasal Cannula (HFNC) is used for moderate to severe respiratory distress, hypoxia, and COPD
• CPAP is used for obstructive sleep apnea, CHF, and COPD with hypercapnia
• Oral Airways are used in unconscious patients to prevent tongue obstruction
• Intubation is used for severe respiratory failure and airway protection in unconscious patients
• Tracheostomy (Trach) is a long-term airway management solution, bypassing upper airway obstructions

Respiratory Conditions

• COPD is a chronic, progressive lung disease including emphysema and chronic bronchitis
  • Signs and symptoms include barrel chest, chronic cough, sputum production, wheezing, and dyspnea
• Atelectasis is the collapse of alveoli
  • Signs and symptoms include diminished breath sounds, hypoxia, and tachypnea
• Hypoxia is low oxygen in tissues
  • Signs and symptoms include restlessness, confusion, cyanosis, and tachycardia
• Hospital-Acquired Pneumonia is a lung infection acquired 48 hours or more after admission
  • Signs and symptoms include fever, productive cough, purulent sputum, crackles, and dyspnea

Lung Sounds & Patient Presentation

• Crackles indicate fluid in the alveoli from heart failure or pneumonia
• Wheezing indicates narrowed airways from asthma or COPD
• Rhonchi indicate mucus in large airways from bronchitis
• Stridor indicates upper airway obstruction and is an emergency

Pain Classification

• Acute pain is short-term with sudden onset, such as after surgery
• Chronic pain is ongoing for more than 3 months, such as with arthritis
• Neuropathic pain is from nerve damage, such as with diabetic neuropathy
• Cancer pain is related to tumor growth or treatment

Pain Assessment & Reassessment

• Use PQRST, Numeric Rating Scale, or FLACC for non-verbal patients
• Reassessment should occur after interventions such as medications or repositioning
• Previous experiences affect current perception of pain, highlighting the importance of psychological and emotional context

PCA Pump (Patient-Controlled Analgesia)

• Used for post-operative or chronic pain by allowing patient-controlled dosing
• Nursing role includes monitoring for sedation and respiratory depression and educating the patient not to allow others to press the button

Wound Care

• Hydrocolloid dressings are for moist, partial-thickness wounds
• Foam dressings are absorptive for moderate to heavy drainage
• Alginate dressings are for heavy exudate and infected wounds
• Transparent film dressings are for superficial wounds and stage 1 ulcers
• Gauze provides basic protection or packing
• Stage 1 pressure ulcers show non-blanchable redness
• Stage 2 pressure ulcers involve partial-thickness skin loss (blister or shallow crater)
• Stage 3 pressure ulcers involve full-thickness loss with visible fat
• Stage 4 pressure ulcers involve full-thickness loss with exposed bone/tendon
• Unstageable pressure ulcers have eschar or slough covering the depth
• DTI (Deep Tissue Injury) presents as a purple or maroon localized area
• High-risk factors for pressure injuries include immobility, poor nutrition, incontinence, and sensory deficits
• Protein, Vitamin C, zinc, and hydration are essential for healing in the context of pressure injuries
• Serous drainage is clear
• Sanguineous drainage is red/bloody
• Serosanguineous drainage is pink/light red
• Purulent drainage is yellow/green and indicates infection
• Wound drainage monitoring includes using wound vacs, assessing dressing weight, marking drainage on the dressing, and measuring output
• Diabetic wounds have a high risk of infection and delayed healing, requiring monitored blood glucose and daily foot care
• Antibiotics should be taken for the full course, even if symptoms improve, and patients should watch for signs of allergic reactions or superinfections
• Dehiscence is wound separation, which should be covered with sterile moist gauze, and the provider should be notified
• Evisceration is when organs protrude, requiring an emergency response of covering with sterile saline-soaked gauze, and calling for help

Skin Layers

• Epidermis is the outermost layer
• Dermis contains capillaries and nerves
• Subcutaneous tissue is fat and connective tissue
• RNs are responsible for assessment, debridement, and dressing changes for complex wounds
• LPNs/UAPs can reinforce dressings and document observations
• Mechanical debridement involves wet-to-dry dressings and irrigation
• Autolytic debridement utilizes the body's own enzymes and occlusive dressings
• Surgical debridement is done by a provider
• Enzymatic debridement utilizes topical enzymes
• Goals for pressure injuries include preventing progression, reducing pain, promoting healing, and educating the patient/caregiver

Ethical & Legal Principles

• Autonomy means respecting patient choices
• Beneficence means doing good
• Nonmaleficence means doing no harm
• Justice means fair treatment
• Fidelity means keeping promises
• Nurses are mandated reporters, requiring them to report suspected abuse to appropriate authorities
• Medication errors should be reported immediately, the patient should be assessed, the provider should be notified, and event should be documented factually
• Fall prevention includes hourly rounding, call lights, and bed alarms
• Restraints are a last resort, where the least restrictive option should be used first, requiring an order and ongoing monitoring
• Nursing students are held to professional standards and should always perform within their scope, notifying their instructor if unsure or unsafe