Exam 1 ~ Respiratory and Post-Op PDF

Exam 1 ~ Respiratory and Post-Op 1.​ Respiratory Assessment/Management: Nursing assessment of patient’s oxygenation status, signs and symptoms of poor oxygenation, nursing interventions to promote oxygenation, including positioning to maximize airway/breathing 2.​ Diagnostic Tests: Bronchosc...

Exam 1 ~ Respiratory and Post-Op 1.​ Respiratory Assessment/Management: Nursing assessment of patient’s oxygenation status, signs and symptoms of poor oxygenation, nursing interventions to promote oxygenation, including positioning to maximize airway/breathing 2.​ Diagnostic Tests: Bronchoscopy (purpose, pre and post procedure nursing care, priority assessment of procedure and outcomes) 3.​ Lung Cancer: S&S; collaborative and nursing care; treatment options; staging; screening Describe various lung surgeries, nursing care pre and post op, assessment findings and concerns, patient education, priority nursing diagnoses, interventions, monitoring outcomes. Therapeutic communication with a cancer patient. Patient teaching regarding lifestyle modification. Post-surgical pulmonary interventions/patient education (TC&DB, use of IS, splinting of incision, HOB elevation, ambulation etc. how will you explain, and encourage your patient to implement these interventions?) 4.​ TB: S&S, latent vs. active disease, diagnosis, collaborative and nursing care (check your book for management in an acute care setting), medications (adherence to regimen), when is it not communicable any longer? What is a PPD and what does a positive indicate? Other diagnostic tests and indications. Patient education. Priority nursing diagnoses, outcomes and interventions? Personal Protective Equipment (PPE), special isolation procedures and patient/family education to prevent transmission. 5.​ Pneumo/Hemothorax/Tension Pneumothorax/flail chest: S&S, collaborative and nursing care. Differentiate between the different types of lung problems and how to manage. Why and how is tension pneumothorax different? How is the collaborative care different with tension pneumothorax? How do you manage a patient with a sucking chest wound? Risk factors with a flail chest, s/sx paradoxical chest movement, patient management. Nursing role in chest tube placement. Post-surgical management of a patient with a chest tube drainage system. Respiratory Assessment/Management Nursing Assessment of Oxygenation -​ Ask health hx - COPD, asthma, lung cancer, recent respiratory illness -​ RR, oxygen saturation -​ Inspect breathing ~ use of accessory muscles, pursed lip breathing, quality of breathing -​ Auscultate lung sounds ~ abnormal (crackles, wheezing, rale, stridor), presence of breath sounds (muffled or clear, muffled = liquid) -​ Feel ~ presence of fluid →crepitus, air in pleural space → hyperresonance Numbers SaO2 (%) >90% (in CO) >95% (elsewhere) PaCO2 35-45 mmHg PaO2 (#) 80-100 mmHg HGB 12-15.5 HCT 37-45% (3x HGB) WBC 4.5-11 Diagnostic Tools Chest X-ray Look for fluid and air in the lungs or in surrounding cavity CT Changes to lung structure and lung cancer Culture Detect foreign objects Supplemental O2 -​ Nasal Cannula: 1-6 L/min -​ Simple Mask: 6-12 L/min -​ Less than 6L → pt will retain CO2 → just don’t -​ Non-Rebreather: 10-15 L/min -​ Short-term only Medications -​ Can be given via inhalers or nebulizers -​ Nebulizers will humidify the air and medication → easier to take -​ To reduce viscosity of secretions… -​ Guaifenesin → will cause coughing of secretions → get rid of bacteria -​ To reduce inflammation -​ Prednisone -​ Prednisolone -​ Rescue inhalers that cause bronchodilation… -​ Albuterol → also prevents bronchospasms -​ Ipratropium -​ Maintenance inhalers… -​ Advair diskus -​ Salmeterol and fluticasone -​ Lower and Upper Respiratory Tract Antibiotics -​ Ceftriaxone -​ Azithromycin -​ Pneumonia Antibiotics -​ Levofloxacin -​ Vancomycin -​ Very potent, usually in a PICC or midline central line -​ Flu Antiviral -​ Oseltamivir Tuberculosis -​ Airborne infectious disease that can be pulmonary or extrapulmonary -​ Can affect other surrounding tissues → joints, liver, kidneys -​ Active and latent stages -​ Latent stage is when the immune system has it surrounded in the tubercle -​ It’s not able to grow or metastasize -​ Incidence is often associated with HIV (in US) Signs and Symptoms -​ Will appear 2-3 weeks after contraction of the disease Hallmark Signs Other symptoms -​ FATIGUE -​ Weight loss (anorexia) -​ PERSISTENT COUGH -​ Malaise -​ LOW-GRADE FEVER -​ NIGHT SWEATS Screening and Diagnostics Screening ~ possible exposure to TB -​ Skin test -​ Positive sign: >10mm indentation, erythema -​ Negative sign: little bump at injection site -​ Blood test -​ Quantiferon Gold -​ Gold standard screening -​ Chest x-ray -​ Positive signs: infiltrates and lymph node involvement suggesting TB -​ Negative signs: clear -​ Chest xray will not show latent TB -​ False Positive: due to allergy to injection or TB vaccine Diagnosis ~ TB present in pt -​ Sputum Culture -​ Positive test: acid-fast bacilli present -​ Negative test: no acid-fast bacilli present -​ Three positive tests to be diagnosed -​ Three negative tests to be cleared of TB -​ Tests must be on separate occasions Nursing Diagnosis -​ Risk-prone health behavior -​ Might not take precautions around others -​ Hypoxia -​ Fatigue -​ Nutrition deficiency -​ Activity intolerance Tuberculosis Treatment -​ Active disease → FOUR IV DRUGS USED, aggressive treatment to combat resistant TB, requires hospital stay -​ After IV antibiotics → ORAL ANTIBIOTICS -​ Ethambutol -​ Rifampin → starts with R for red fluid secretions -​ Isoniazid -​ Pyrazinamide -​ Monitor LFTs and avoid ETOH -​ Ocular and hepatic toxicity -​ LFT : liver function tests; aka ALT, AST -​ Educate patient on the importance of taking all the medications Nursing Care -​ ISOLATION! -​ Isolate for 2-3 weeks after started the IV antibiotics before pt is no longer infectious -​ Negative air pressure room and N95 masks -​ EDUCATION -​ Coughing into elbow, wash hand -​ Wearing surgical mask around others when leaving room and if still infectious -​ Take all abx -​ Meet people where they are -​ NUTRITION -​ Anorexia symptoms may cause deficiencies -​ Consult nutritionist to assist in getting all needed nutrient to fight infection -​ COLLABORATION -​ Diagnostics ~ three negative sputum tests to confirm no longer infected -​ Medications Acute Nursing Interventions -​ If suspicious of TB (without positive diagnosis) → ISOLATE IMMEDIATELY AND AIRBORNE PRECAUTIONS -​ Patients wear surgical mask outside of their room -​ Take antibiotic and antiviral medications -​ Obtain sputum cultures every morning for three days, or until 3 positive or negative tests How do we know treatment was effective? -​ Three negative sputum cultures -​ No one else that came in contact with pt is infected -​ Pulmonary function tests ~ IS -​ CXR Airborne Precautions Education -​ Explain to family that airborne infections spread through small droplets -​ Sneezing, coughing, talking and they can shoot far -​ They can also stay in the air longer than droplets -​ PPE includes: gown, N95 mask, gloves, and goggles -​ Negative air pressure rooms keep air in the rooms, so the air doesn’t escape outside → not infecting others Bronchoscopy -​ Allows for visualization of airways through a flexible fiberoptic tube -​ Allows for obtaining biopsy samples for diagnosis, as well as removing mucus plugs and foreign objects -​ PRE-OP -​ Explain procedure -​ NPO -​ Getting the correct equipment -​ Sedatives and analgesic -​ DURING -​ Confirm proper tube placement -​ Make sure there’s adequate ventilation/oxygenation during procedure -​ POST-OP -​ Monitor respiratory system ~ gag reflex, airway -​ Vitals -​ Complications -​ Bleeding, infection, airway obstruction COVID-19 Novel Disease -​ SARS-COV2 → new pathogen responsible for covid-19 -​ There was no individual or community immunity to this disease -​ Treatment, transmission, other issues needed to be dealt with in real time -​ Is one of the many coronaviruses, but only one that the population has no immunity to Patho -​ Transmission not entirely clear -​ Leaning more towards droplet/airborne (supplemental O2 → airborne? idk) -​ Considered a upper respiratory infection with symptoms ranging from mild to catastrophic -​ Affects GI, nervous, and other systems -​ HYPERCOAGULABILITY AND HYPER-INFLAMMATORY Symptoms -​ URI is common -​ Cough, congestion, shortness of breath -​ Diarrhea, vomiting, GI upset -​ Fever + malaise -​ Early variants → loss of cough and smell -​ Later variants → sore throats Long COVID? -​ Poorly understood, but up to 20% experience long COVID -​ Fatigue and brain fog -​ Loosely linked to severity of virus (longer, more severe) Screening -​ Based on symptoms -​ Talk about treating this more like a cold -​ BUT it depends on people individually and their own health, as well as who they’re at risk of exposing  Diagnosis -​ PCR -​ Test taken to diagnosis COVID-19 -​ Antigen testing -​ COVID is late to test positive -​ Wait ~ 5 days after symptoms/exposure started to test for COVID Mild to Moderate Disease Severe Disease Nursing Problems -​ Psychosocial effects of isolation -​ Psychosocial effects of isolation -​ Risk of disease progressing -​ Inadequate oxygenation -​ Risks from antiviral therapies -​ Hopelessness -​ Anxiety -​ Inadequate knowledge about -​ Fatigue medication therapy -​ Noncompliance (find better word) -​ Noncompliance Medical Management -​ Antiviral -​ Antiviral -​ PO paxlovid -​ IV remdesivir -​ For those at risk for severe -​ Risk for progressing disease -​ Anticoagulants -​ Similar to tamiflu → only -​ Heparin effective within 5 days of virus -​ Enoxaparin exposure -​ Anti Inflammatories -​ Helps with symptoms -​ Dexamethasone -​ Other symptoms -​ If taking O2 -​ Treat with appropriate drugs ~ analgesics, antipyretics, antitussives Nursing Plan -​ Proning!!! -​ Great for getting patients sats up -​ Calls with family, coloring, puzzles, rest -​ Help to combat isolation and loneliness -​ Medication therapy -​ To help defeat virus and to manage symptoms -​ High flow oxygen !!! INTUBATION LAST RESORT  Non-Invasive Ventilation High Flow Oxygen CPAP BiPAP -​ Warms oxygen at high -​ Used for OSA -​ Pressure both ways → flow rates -​ Creates pressure → exhalation and -​ Creates positive hold airway open inhalation pressure -​ Great for COPD Hydroxychloroquine? Ivermectin? -​ Drugs that cak down the immune system -​ Were small studies showing their benefit against COVID-19 -​ Risks > reward -​ Could prolong QT and is fatal in overdoses -​ This is why it’s important to explore MULTIPLE, MANY treatment modalities -​ Don’t settle! Find what works and is more helpful than harmful Vaccine! -​ Yes there is one! -​ The COVID vaccine is SAFER than the medications being used to treat COVID-19 -​ COVID-19 Vaccine Info -​ mRNA vaccine → synthetic mRNA that tells your body to create proteins (identical to COVID), your body won’t like these proteins, they’ll make antibodies against them, fight! -​ Cannot get COVID from these vaccines and won’t affect your DNA Future of COVID -​ Almost all people have been exposed and have some sort of immunity -​ We’ll probably be recommended to get COVID boosters yearly (like flu vaccines) -​ Healthcare providers could’ve done better about educating the population about COVID and vaccines -​ Lots to learn from this → hopefully better response to any future pandemics Lung Cancer Risk Factors -​ CIGARETTE SMOKING ~ 80-90% of lung cancer cases from smoking -​ Second-hand and third-hand smoking -​ Any kind of smoking ~ pipe, cigar, marijuana -​ Gene mutations, hereditary -​ Other inhaled carcinogens ~ asbestos, radon, air pollution Pathophysiology -​ Different types of lung cancer -​ Non-small cell lung cancer (most common), small cell lung cancer -​ Lung cancer at risk for metastasis -​ Can metastasize VIA lymph system, circulation, direct extension -​ Frequently to liver, brain, bones, scalene lymph nodes, adrenal glands -​ If it’s close to the lungs, it could spread there -​ After 5 years, increased mortality rate Signs and Symptoms Early Late -​ In some cases ~ silent and -​ FATIGUE ~ due to poor gas asymptomatic exchange -​ Persistent cough ~ hemoptysis -​ Anorexia, N/V -​ Dyspnea -​ Dysphagia -​ Chest pain -​ Palpable nodes -​ Wheezing -​ Pleural or pericardial fluid -​ Pneumonitis-obstructed bronchi -​ Can lead to cardiac tamponade -​ Fever, chills -​ Dysrhythmias What to Ask -​ Symptoms ~ OPQRSTU -​ Changes to appetite -​ Exposure to smoke -​ Contact with chemicals, fumes, dust -​ Personal and family hx of respiratory problems -​ Other medical conditions Imaging -​ Masses can only be seen if they’re bigger than 1 centimeter -​ CXR -​ CT -​ MRI -​ PET Confirming Diagnosis of Cancer -​ BIOPSY IS GOLDEN STANDARD FOR CANCER DIAGNOSES -​ Sample can be obtained by… -​ Sputum cytology -​ Direct needle biopsy -​ Bronchoscopy -​ VATS ~ video-assisted thoracoscopic surgery Stages of Lung Cancer -​ Stage 0 -​ Abnormal cells that can become cancer, not considered cancer at this point -​ Stage I -​ Cancer is small and contained -​ Stage II -​ Cancer has not spread, but is larger than at stage 1 -​ Stage III -​ Cancer is large and has spread to surrounding lymph nodes and tissues -​ Stage IV -​ Cancer has spread through blood or lymph system to a distant site Nursing Problems -​ Hopelessness -​ Impaired gas exchanges -​ Risk for activity intolerance -​ Impaired coping -​ Fatigue -​ Aspiration risk -​ Pain Medical Interventions -​ Surgery -​ Segmentectomy, lobectomy, pneumonectomy -​ Removing affected parts of the lung -​ Radiation -​ Radiation that alters the DNA of cancer cells → effectively killing them -​ Chemotherapy -​ Taking drugs that will kill cancer cells Nursing Plan -​ Health promotion -​ Avoid smoking, smoking cessation programs -​ Proper PPE to wear in area where there’s possible exposure -​ Way to clean areas that ash may linger -​ Acute interventions -​ Offer support during diagnostic evaluation -​ Monitor side effects -​ Pain reduction methods -​ Diagnosis and treatment -​ Medications ~ what they are, side effects -​ Therapeutic communication -​ Sympathy ~ pity and sorrow for someone else -​ Empathy ~ understanding and sharing the feelings of another -​ Discuss concerns with patient Evaluation -​ Resolution? Is this realistic? -​ Metastasis makes it harder to resolve, treatment efficacy, size of mass -​ Pulmonary function -​ What is our new normal? How do we deal with this -​ Absence of complications -​ Complications from chemo, radiation, stress, anxiety -​ Fatigue, N/V, anorexia, feelings of hopelessness -​ Realistic expectations -​ Patient education!!! Make sure they understand their diagnosis and prognosis Thoracic Trauma Includes… -​ Rib fractures -​ Pleural effusion -​ Hemothorax -​ Pneumothorax -​ Hemo-pneumothorax Rib Fractures Symptoms Expected Outcomes -​ PAIN -​ BREATHING -​ Treat with NSAIDs, opioids -​ Use of incentive spirometer to -​ SHALLOW BREATHING make sure lungs expand -​ Can result in pneumonia, atelectasis -​ Paradoxical chest movement -​ Flail chest -​ Flail segment will be pulled in while the rest of the rib cage expands with decrease in pressure Diagnosis -​ CXR -​ Visualize fractured ribs -​ If multiple ribs are fractured → unstable chest wall -​ Unstable chest wall results in paradoxical chest mvmt that can increase WOB and lead to respiratory distress -​ Monitor for complications -​ Punctured lung, collapsed lung, pneumonia, respiratory failure Pleural Effusion Pathophysiology Signs and Symptoms -​ Abnormal amount of fluid in pleural -​ Grouped into space (norm is 5-15 ml, in effusion -​ Tranudative, exudative (fluid anywhere from 25 ml → 3 L) from infection, inflammation), -​ Due to increase production of fluid or empyema (pus) decreased clearance of fluid -​ Hemothorax, -​ Lymph can’t remove fluid hemo-pneumothorax, -​ Fluid overload pneumothorax -​ Infection -​ White/Yellow group -​ Dyspnea and dim breath sounds -​ Red/Blue group -​ Dyspnea, dim breath sounds, unequal chest expansion -​ SPECIAL → hemothorax -​ Dullness to percussion -​ Decreased HGB/O2 -​ Shock Transudative Pleural Effusion Exudative Pleural Effusion -​ Abnormal collection of serous fluid -​ Abnormal collection of fluid WITH -​ Caused by CHF, PE, ascites, fluid exudate in pleural space overload -​ Caused by cancer, viral infection, PE, PNA Empyema Hemothorax -​ Abnormal collection of pus -​ Abnormal collection of sanguineous -​ Caused by bacterial PNA, fluid in pleural space post-thoracic surgery op -​ Caused by trauma, clotting disorders Hemopneumothorax Pneumothorax -​ Abnormal collection of blood and air -​ Abnormal collection of air in pleural in pleural space space -​ Caused by trauma, clotting disorders -​ Caused by trauma, blebs (collection of air that breaks) Tension Pneumothorax -​ Three different pneumothoraces -​ Open → air in and out of pleural space through wound -​ Closed → air goes into pleural space through the body (lung) -​ Both can result in lung collapse -​ Tension Pneumothorax → air goes into the pleural cavity VIA wound, but cannot come out -​ MEDICAL EMERGENCY -​ Causes tension on heart and vessels -​ S/S -​ Dyspnea, chest pain, tracheal deviation, dim breath sounds, JVD, respiratory distress -​ Can also cause cardiac problem → dysrhythmias, lowered blood pressure -​ Treatment -​ Sterile, non-porous dressing taped on only three sides -​ Breathing in → dressing covers hole, not allowing more air in -​ Breathing out → dressing lifts, allowing air to escape -​ Covering all 4 sides → can create pneumothorax -​ Nursing Problems -​ Impaired gas exchange -​ Impaired physical motility -​ Impaired walking -​ Disturbed sleep pattern -​ Pain -​ Activity intolerance -​ Medical Management -​ Get the stuff out!! -​ Needle decompression -​ Get the air out in pneumothorax -​ Thoracentesis -​ Gets fluid out -​ Pleural effusion -​ Also at risk for creating a pneumothorax -​ Chest tube -​ #1 option -​ Can be used to drain air, fluid, blood from pleural cavity -​ Nursing Management -​ Respiratory support -​ Supplemental oxygen  -​ Managing chest tubes -​ Watch vitals and I/Os -​ Pain Management -​ Lidocaine, oxycodone -​ Follow up for progress -​ Checking chest tube -​ CXR + US → is there still fluid? How much? -​ Should be done -​ At diagnosis, before/during/after procedures, once a day Chest Trauma Implementation -​ Procedure Support -​ Ensure the patient is educated and informed on the procedure to be done -​ S/S to be reported immediately -​ Trouble breathing, chest pain, VS changes, LOC -​ Activity -​ Limitations, support, monitoring -​ Splinting -​ No casts (restricts breathing) -​ Instead -​ Hold pillow to fracture to secure bones -​ Done during activity and coughing Evaluation -​ Has pt returned to baseline? -​ No more fluid/air/blood → check with imagine -​ Are they stable? -​ Check vitals, pain, imaging Chest Tube What is it? -​ Tube used post op to expand the lung and remove excess air, fluid, blood -​ REESTABLISHES NEGATIVE PLEURAL PRESSURE -​ You want the pressure in the pleural cavity to be negative (less) than the pressure in the lungs -​ Expiratory positive pressure → chest expansion that pushes fluid out -​ Gravity -​ Suction Chest Tube Systems -​ Water seal -​ Prevents a tension pneumothorax by allowing stuff to drain, but not allowing air to go back in -​ Dry suction -​ Suction is adjustable on the device -​ Requires wall suction -​ Wet suction -​ Suction is based on the amount of water -​ Must watch level because the water will evaporate -​ Requires wall suction Chest Tube Assessment -​ Inspect the dressing and collection devices -​ Look at water seal and at water level in wet suction -​ Gentle bubbling in wet suction, vigorous bubbling → air leak -​ Palpate -​ Check for subcutaneous emphysema → aka crepitus -​ Auscultate -​ Around the insertion sire with BELL -​ Crackles will indicate fluid Chest Tube Disconnected from COLLECTION DEVICE -​ *Put the end of the chest tube into sterile water to seal it* -​ Assess the patient and notify the provider -​ Notify of occurrence and if there’s any changes to their assessment -​ Get a new chest tube to restore it Chest Tube is DISLODGED FROM PATIENT -​ *Apply nonporous dressing tapes on only 3 sides* -​ Assess the patient and notify provider -​ Provider will determine if a replacement is needed Discontinuing a Chest Tube -​ Before Removing -​ VITALS! ~ respiratory!!! -​ Work of breathing, lung sounds, pain/distress -​ No pain or respiratory distress -​ Draining -​ How much is drained -​ Is there a leak -​ Discharge? -​ Patient should stay in hospital for 24 hours after chest tube removal -​ Removal with petroleum dressing, can be completely taped -​ Physician or surgeon will remove -​ Valsalva removal and take out -​ After Removing -​ Respiratory assessment -​ For fluid reaccumulation -​ CXR -​ Assess for fluid in pleural space, repeated at regular intervals Documentation ~ done multiple times per shift -​ Site and dressing -​ Drainage TACCO -​ Amount of suction -​ Presence/absence of tidal changes and/or air leaks -​ Up with inspiratory and down back with expiratory -​ Respiratory status and tolerating -​ Patient education Blood Transfusions What is it? -​ Transfer of blood or blood products from one person to another -​ HIGH RISK OF COMPLICATIONS -​ CANNOT BE COMPLACENT WITH THE PROCESS -​ Homologous -​ Donor to patient -​ Autologous -​ Self to self Blood Products -​ Whole blood → includes cells and plasma -​ Packed RBCs → from whole blood separated by sedimentation and centrifugation -​ Platelets → from whole blood within 4 hours of collection -​ Fresh frozen plasma → liquid portions separated from cells and frozen -​ Has clotting factors → no platelets -​ Albumin -​ Synthetic, to increase osmotic pressure Rate -​ FIRST 15 MINUTES -​ 2ml/min ~ 120ml/hr -​ AFTER -​ Can increase so that the blood is transfused under 4 hours -​ Usually start at 75ml/hr and increase slowly -​ Up to 100-125ml/hr Who Can Donate? -​ 17yrs -​ >110lbs -​ Good health ~ screening for some medical conditions -​ >56 days since last donation -​ Vitals -​ BP: 90-180/50-100 -​ P: 50-100 -​ T: