Nursing Care of Clients with Respiratory Disorders PDF

Nursing Care of Clients with Respiratory Disorders Joey D. Tandingan, RN Review of Anatomy and Physiology Review of Anatomy and Physiology Review of Anatomy and Physiology  A. Respiratory Diagnostic Procedures Overview Respiratory diagnostic procedures are used...

Nursing Care of Clients with Respiratory Disorders Joey D. Tandingan, RN Review of Anatomy and Physiology Review of Anatomy and Physiology Review of Anatomy and Physiology  A. Respiratory Diagnostic Procedures Overview Respiratory diagnostic procedures are used to evaluate a client’s respiratory status by checking indicators such as the oxygenation of the blood, lung functioning, and the integrity of the airway. Respiratory diagnostic procedures that nurses should be knowledgeable about include the following: Pulmonary function tests (PFTs) ABGs Bronchoscopy Thoracentesis Pulmonary Function Test (PFT) Pulmonary function tests determine lung function and breathing difficulties. PFTs measure lung volumes and capacities, diffusion capacity, gas exchange, flow rates, airway resistance along with distribution of ventilation. Helpful in identifying clients for lung disease. Commonly performed for clients who have dyspnea. Can be performed before surgical procedures to identify clients with respiratory risks. If client is smoker, instruct client not to smoke 6 to 8 hr prior to testing. If a client uses inhalers, withhold 4 to 6 hr prior to testing. (This may vary according to facility policy.) Pulmonary Function Test (PFT) Indications Patients presenting with dyspnea Evaluating disease severity and monitoring response to treatment Determine fitness for surgery Thoracis surgery/lung resection Pulmonary Function Test (PFT) Available Measures Spirometry Airflow (how much air, how fast) (Static) Lung Volumes Volume (how much air) Diffusing Capacity Gas exchange (how effective) Other Testing Airway responsiveness Respiratory muscle strength testing Compliance of the lungs Pulmonary Function Test (PFT) Patterns of Disease with PFT Obstructive Asthma COPD Bronchiolitis/Bronchiectasis Restrictive Interstitial lung disease Neuromuscular weakness Pleural disease Chest wall deformities Obesity Mixed Both obstructive and restrictive Arterial Blood Gas (ABG) An ABG sample reports the status of oxygenation and acid-base balance of the blood. An ABG measures the following: pH – the amount of free hydrogen ions in the arterial blood (H+). PaO2 – the partial pressure of oxygen. PaCO2 – the partial pressure of carbon dioxide. HCO3 – the concentration of bicarbonate in arterial blood. SaO2 – percentage of oxygen bound to Hgb as compared with the total amount that can be possibly carried. ABGs can be obtained by an arterial puncture or through an arterial line. Arterial Blood Gas (ABG) Indications Potential Diagnoses Blood pH levels may be affected by any number of disease processes (respiratory, renal, malnutrition, electrolyte imbalance, endocrine, or neurologic). These assessments are helpful in monitoring the effectiveness of various treatments (such as acidosis interventions), in guiding oxygen therapy, and in evaluating client responses to weaning from mechanical ventilation. Arterial Blood Gas (ABG) Nursing Care Pre-procedure Perform an Allen’s test prior to arterial puncture to verify patent radial and ulnar circulation. The nurse should compress the ulnar and radial arteries simultaneously while instructing the client to form a fist. Then, have the client relax his hand while releasing pressure on the radial artery. His hand should turn pink quickly, indicating patency of the radial artery. Repeat this process for the ulnar artery. Arterial Blood Gas (ABG) Nursing Care Post-procedure Immediately after an arterial puncture, hold direct pressure over the site for at least 5 min. Pressure must be maintained for at least 20 min if the client is receiving anticoagulant therapy. Ensure that bleeding has stopped prior to removing direct pressure. Monitor the ABG sampling site for bleeding, loss of pulse, swelling, and changes in temperature and color. Document all interventions and client response. Report results to the provider as soon as they are available. Administer oxygen as prescribed. Change ventilator settings as ordered or notify a respiratory therapist. Note: Arterial puncture is frequently done by a respiratory therapist in hospital settings. Arterial Blood Gas (ABG) Complications Hematoma, arterial occlusion A hematoma occurs when blood accumulates under the skin at the IV site. Nursing Actions Observe the client for changes in temperature, swelling, color, loss of pulse, or pain. Notify the provider immediately if symptoms persist. Apply pressure to the hematoma site. Arterial Blood Gas (ABG) Complications Air embolism Air enters the arterial system during catheter insertion. Nursing Actions Place the client on his left side in the Trendelenburg position. Monitor the client for a sudden onset of shortness of breath, decrease in SaO2 levels, chest pain, anxiety, and air hunger. Notify the provider immediately if symptoms occur, administer oxygen therapy, and obtain ABGs. Continue to assess the client’s respiratory status for any deterioration.  Bronchoscopy Bronchoscopy permits visualization of the larynx, trachea, and bronchi through either a flexible fiberoptic bronchoscope or a rigid bronchoscope. Bronchoscopy can be performed as an outpatient procedure, in a surgical suite under general anesthesia, or at the bedside under local anesthesia and moderate (conscious) sedation. Bronchoscopy also can be performed on clients who are receiving mechanical ventilation by inserting the scope through the client’s endotracheal tube. Bronchoscopy Indications Potential Diagnoses Visualization of abnormalities such as tumors, inflammation, and strictures Biopsy of suspicious tissue (lung cancer) Clients undergoing a bronchoscopy with biopsy have additional risks for bleeding and/or perforation. Aspiration of deep sputum or lung abscesses for culture and sensitivity and/or cytology (pneumonia) Note: Bronchoscopy is also performed for therapeutic reasons, such as removal of foreign bodies and secretions from the tracheobronchial tree, treating postoperative atelectasis, and to destroy and excise lesions. Bronchoscopy Pre-procedure Assess the client for allergies to anesthetic agents or routine use of anticoagulants. Ensure that a consent form is signed by the client prior to the procedure. Remove the client’s dentures, if applicable, prior to the procedure. Maintain the client on NPO status prior to the procedure as ordered, usually 8 to 12 hr, to reduce the risk of aspiration when the cough reflex is blocked by anesthesia. Administer preprocedural medications as prescribed, such as viscous lidocaine or local anesthetic throat sprays. Bronchoscopy Intraprocedure Position the client in a sitting position. Administer medications as prescribed, such as sedatives, antianxiety agents, and/or atropine to reduce oral secretions. Assist in collecting and labeling specimens. Ensure prompt delivery to the laboratory. Monitor the client’s vital signs, respiratory pattern, and oxygenation status throughout the procedure. Sedation given to older adult clients who have respiratory insufficiency may precipitate respiratory arrest. Bronchoscopy Postprocedure Continuously monitor the client’s respirations, blood pressure, pulse oximetry, heart rate, and level of consciousness during the recovery period. Assess the client’s level of consciousness while recognizing that older adult clients may develop confusion or lethargy due to the effects of medications given during the bronchoscopy. Bronchoscopy Postprocedure Assess the client’s level of consciousness, presence of gag reflex, and ability to swallow prior to resuming oral intake (usually takes about 2 hr). Allow adequate time for the cough and gag reflex to return prior to resuming oral intake. The cough reflex may be slower to return in older adult clients receiving local anesthesia due to impaired laryngeal reflex. Once the cough reflex returns, the nurse may offer ice chips to the client and eventually fluids. Bronchoscopy Postprocedure Monitor the client for development of significant fever (mild fever for less than 24 hr is not uncommon), productive cough, significant hemoptysis indicative of hemorrhage (a small amount of blood-tinged sputum is expected), hypoxemia. Be prepared to intervene for unexpected responses and/or aspiration, laryngospasm. Provide oral hygiene to the client. Evaluate and document the client’s response to the procedure (stable vital signs, return of gag reflex). Bronchoscopy Complications Laryngospasm Laryngospasm is uncontrolled muscle contractions of the laryngeal cords (vocal cords) that impede the client’s ability to inhale. Nursing Actions Continuously monitor the client for signs of respiratory distress. Maintain a patent airway by repositioning the client or inserting an oral or nasopharyngeal airway as appropriate. Administer oxygen therapy to the client as prescribed. Humidification can decrease the likelihood of laryngeal edema. Bronchoscopy Complications Pneumothorax Pneumothorax can occur following a rigid bronchoscopy. Assess client’s breath sounds and oxygen saturation, and obtain a follow-up chest x-ray. Aspiration Aspiration can occur if the client chokes on oral or gastric secretions. Nursing Actions Prevent aspiration in the client by withholding oral fluids or food until the gag reflex returns (usually 2 hr). Perform suctioning as needed.  Thoracentesis Thoracentesis is the surgical perforation of the chest wall and pleural space with a large-bore needle. Thoracentesis is performed under local anesthesia by a provider at the client’s bedside, in a procedure room, or in a provider’s office. Use of an ultrasound for guidance decreases the risk of complications.  Thoracentesis Indications Potential Diagnoses Transudates (heart failure, cirrhosis, nephritic syndrome) Exudates (inflammatory, infectious, neoplastic conditions) Empyema Pneumonia Blunt, crushing, or penetrating chest injuries/trauma, or invasive thoracic procedures, such as lung and/or cardiac surgery  Thoracentesis Nursing Responsibility Pre-procedure Ensure that the client has signed the informed consent form. Gather all needed supplies. Obtain preprocedure x-ray as prescribed to locate pleural effusion and to determine needle insertion site. Position the client sitting upright with his arms and shoulders raised and supported on pillows and/or on an overbed table and with his feet and legs well- supported.  Thoracentesis Nursing Responsibility Intraprocedure Assist the provider with the procedure (strict surgical aseptic technique). Prepare the client for a feeling of pressure with needle insertion and fluid removal. Monitor the client’s vital signs, skin color, and oxygen saturation throughout the procedure. Measure and record the amount of fluid removed from the client’s chest. Label specimens at the bedside, and promptly send them to the laboratory. Thoracentesis Nursing Responsibility Postprocedure Apply a dressing over the puncture site, and assess dressing for bleeding or drainage. Monitor the client’s vital signs and respiratory status (respiratory rate and rhythm, breath sounds, oxygenation status) hourly for the first several hours after the thoracentesis. Auscultate lungs for reduced breath sounds on side of thoracentesis. Encourage the client to deep breathe to assist with lung expansion. Obtain a postprocedure chest x-ray (check resolution of effusions, rule out pneumothorax). Thoracentesis Complications Mediastinal shift Shift of thoracic structures to one side of the body. Monitor client’s vital signs. Auscultate client’s lungs for a decrease in or absence of breath sounds. Thoracentesis Complications Pneumothorax is a collapsed lung. It can occur due to injury to the lung during the procedure. Nursing Actions Monitor the client for signs and symptoms of pneumothorax, such as diminished breath sounds. Monitor postprocedure chest x-ray results.  Chest Tube Insertion and Monitoring Overview Chest tubes are inserted into the pleural space to drain fluid, blood, or air; reestablish a negative pressure; facilitate lung expansion; and restore normal intrapleural pressure. Chest tubes can be inserted in the emergency department, at the client’s bedside, or in the operating room through a thoracotomy incision. Chest tubes are removed when the lungs have re- expanded and/or there is no more fluid drainage. Chest Tube Systems A disposable three-chamber drainage system is most often used. First chamber: drainage collection Second chamber: water seal Third chamber: suction control Chest Tube Insertion Indications Diagnoses Pneumothorax (collapsed lung) Hemothorax (blood in lung) Postoperative chest drainage (thoracotomy or open-heart surgery) Pleural effusion (fluid in lung) Lung abscess (necrotic lung tissue) Chest Tube Insertion Nursing Responsibility Preprocedure Verify that the consent form is signed. Reinforce client teaching. Breathing will improve when the chest tube is in place. Assess for allergies to local anesthetics. Assist the client into the desired position (supine or semi-Fowler’s). Prepare the chest drainage system prior to the chest tube insertion per the facility’s protocol (fill the water seal chamber). Administer pain and sedation medications as prescribed. Prep the insertion site with povidone-iodine. Chest Tube Insertion Nursing Responsibility Intraprocedure Assist the provider with insertion of the chest tube, application of a dressing to the insertion site, and set-up of the drainage system. The chest tube tip is positioned up toward the shoulder (pneumothorax) or down toward the posterior (hemothorax or pleural effusion). The chest tube is then sutured to the chest wall, and an airtight dressing is placed over the puncture wound. Chest Tube Insertion Nursing Responsibility Intraprocedure The chest tube is then attached to drainage tubing that leads to a drainage system. Place the chest tube drainage system below the client’s chest level with the tubing coiled on the bed. Ensure that the tubing from the bed to the drainage system is straight to promote drainage via gravity. The nurse should continually monitor the client’s vital signs and response to the procedure. Chest Tube Insertion Nursing Responsibility Postprocedure Assess the client’s vital signs, breath sounds, SaO2, color, and respiratory effort as indicated by the status of the client and at least every 4 hr. Encourage coughing and deep breathing every 2 hr. Keep the drainage system below the client’s chest level, including during ambulation. Monitor the chest tube’s placement and function. Chest Tube Insertion Nursing Responsibility Monitoring Chest Tube Placement and Function Check seal level 2hr; check oscillation. Monitor for kinks, occlusions or loose connections Monitor insertion site for redness, pain, infection and crepitus Semi-Fowler’s or high Fowler’s position Must at bedside: Two padded hemostats Sterile water Occlusive dressing Thoracentesis Thoracentesis is the surgical perforation of the chest wall and pleural space with a large-bore needle. It is performed to obtain specimens for diagnostic evaluation, instill medication into the pleural space, and remove fluid (effusion) or air from the pleural space for therapeutic relief of pleural pressure. Aspiration of pleural fluid Thoracentesis Interpretation of Findings Aspirated fluid is analyzed for general appearance, cell counts, protein and glucose content, the presence of enzymes such as lactate dehydrogenase (LDH) and amylase, abnormal cells, and culture. Thoracentesis Complication Mediastinal Shift Monitor client’s vital signs Auscultate lungs for a decrease or absence of breath sounds Thoracentesis Complication Pneumothorax Monitors signs – diminished lung sounds, shortness of breath Monitor post-procedure CXR results Monitor for signs of tension pneumothorax Tracheal deviation Pain on the affected side that worsens upon exhalation Affected side does not move in and out upon inhalation and exhalation Increased heart rate Rapid, shallow breathing Nagging cough Feeling of air hunger Thoracentesis Complications Bleeding can occur if the client is moved during the procedure or is at an increased risk for bleeding. Nursing Actions Monitor the client for coughing and/or hemoptysis. Monitor the client’s vital signs and laboratory results for evidence of bleeding (hypotension, reduced Hgb level). Assess thoracentesis site for bleeding. Thoracentesis Complications Infection Infection can occur due to the introduction of bacteria with the needle puncture. Nursing Actions Ensure that sterile technique is maintained. Monitor the client’s temperature following the procedure.