Gas Exchange: Concept of Gas Exchange: Exemplars PDF

RFHS / College of Nursing Concept of Gas Exchange: Exemplars By Linda Townsend RN, MN© With some contributions from Lisa Banman umanitoba.ca/nursing RFHS / College of Nursing Exemplars: Laryngeal Ca (p 581 Lewis) Lung Ca (p 603 Lewis) umanitoba.ca/nursing RFHS / College of Nursing Recognize/...

RFHS / College of Nursing Concept of Gas Exchange: Exemplars By Linda Townsend RN, MN© With some contributions from Lisa Banman umanitoba.ca/nursing RFHS / College of Nursing Exemplars: Laryngeal Ca (p 581 Lewis) Lung Ca (p 603 Lewis) umanitoba.ca/nursing RFHS / College of Nursing Recognize/ Analyze Cues: Laryngeal Ca Tumour that grows in larynx. Good prognosis if diagnosed in early stages Risk factors smoking and alcohol (main) Voice abuse, exposure to chemicals, Gerd, Cues Early stages Lump in neck, sore throat, hoarseness Late stages Pain, dysphagia, airway obstruction, SOB, Weight loss, unilateral ear pain, numbness umanitoba.ca/nursing  RFHS / College of Nursing Recognize/ Analyze Cues: Labs & Diagnostics Diagnostic tests Laryngoscope to visualize and take bx of tumor to determine ca cell type and stage. X-rays, CT scan, MRI (to determine metastatic sites) Lab assessments Electrolytes , HCT, BUN, HCT may be affected if nutritional and hydration status is poor. umanitoba.ca/nursing  RFHS / College of Nursing Take Action: Laryngeal Ca Treatment Treatment Depends on: Tumor type, size and location Patient & surgeon preference Radiation, Chemo, Biotherapy, Laser Surgery, Surgery or any combination of these. Extensive traditional surgery often required Partial Laryngectomy When only one vocal cord or no vocal cords are removed Can speak, can breathe normally Total Laryngectomy with Radical Neck Dissection Entire larynx/ vocal cords removed Permanent Stoma created in neck Require alternate method to talk umanitoba.ca/nursing  RFHS / College of Nursing Take Action: Laryngectomy Post -op care MAINTAIN PATENT AIRWAY! Suction/ keep stoma clear Post-op VS Position Midline/ HOB elevated Suture lines/ stoma care Flap checks (if present) Nutrition is important Prevent Aspiration NPO for 24-48 hrs then Tube feed Must Re- learn how to swallow Physio (Prevent frozen shoulder) Emotional Support umanitoba.ca/nursing  RFHS / College of Nursing Take Action: Voice Restoration (total laryngectomy) Vocal cords gone Communicate using pen/paper or communication board immediately post op Possible Options for Voice Restoration Electrolarynx (fig A) Esophageal speech (fig B) Transesophageal puncture and prosthetic voice device Puncture created between trachea and esophagus When patient speaks air is rerouted through prosthesis to esophagus and vibration creates sound umanitoba.ca/nursing https://jigsaw.elsevier.com/books/9781771720489/epub/OPS/images/chp00029_f029-011a- 9781771720489.jpg RFHS / College of Nursing Take Action: Discharge Teaching Laryngectomy Stoma –Airway Safety Cover for protection (not sterile) Clean/suction/humidification Bathing/showering/swimming Nutrition Difficulty with eating/ chewing Can’t smell Environmental hazards/ Safety https://mainmed.com.au/products/blom-singer-stomasoft-laryngectomy-tube Smoke detectors, medic alert bracelet, Capability of family/patient to handle emergency, when to seek help Psychological Support. Altered body image Different sounding speech Mucous from stoma embarrassing https://www.brucemedical.com/fasstomscar.html Cannot laugh or cry umanitoba.ca/nursing  RFHS / College of Nursing Recognize/ Analyze Cues: Lung Ca Risk Factors Cigarette smoking is #1 cause 2nd hand smoke exposure Exposure to environmental carcinogens, asbestos, air pollution Cues Symptoms are usually nonspecific and appear late in disease Most common symptoms are persistent cough (may be productive of blood-tinged sputum), wheezing, chest pain, hoarseness weight loss, dyspnea Diagnostics Ct Scan (most effective noninvasive method) Sputum for cytological studies Bx of cancer cells or plural fluid is definitive umanitoba.ca/nursing  RFHS / College of Nursing Take Action: Lung Ca Surgery Tx of choice in stg 1 or 2 Wedge Resection (remove tumor plus margin around) Segmental Resection (a larger segment of lung is removed) Pneumonectomy (entire lung removed) Lobectomy (lobe of lung removed) Radiation High-energy rays or particles targeted to kill cancer cells. Chemotherapy Drugs that work systemically to kill Ca cells Targeted therapy Drugs work to disrupt cancer cell division Immunotherapy Drugs prompt own immune system to better recognize and attack Ca cells. umanitoba.ca/nursing RFHS / College of Nursing Thoracotomy Open Thoracotomy Video Assisted Thoracotomy (VATS) http://www.perfecthealthinfo.com/thoracotomy-incision/a-muscle-saving-posterolateral-thoracotomy-incision-discussion.html umanitoba.ca/nursing  RFHS / College of Nursing Take Action: Lung Ca Post- Op Care for Thoracotomy (See NCP 30-2 UMLearn) Monitor respiratory status– treat hypoxia with O2 as needed. Monitor chest tube and collection device (placed in pleural space) Position changes (semi fowlers or up in chair as soon as possible) Assist with DB & C / incentive spirometry, encourage early mobility Optimal pain management (PCA) Monitor for s/s infection at surgical site or of pleural fluid (empyema) https://newportcts.com/after-lung-cancer-surgery/ umanitoba.ca/nursing RFHS / College of Nursing Chest Tubes Post-op thoracotomy chest tubes- you will learn in skills https://jigsaw.elsevier.com/books/9780323654050/epub/OEBPS/IMAGES/B9780323612425000270/main.assets/f27-10-9780323612425.jpg umanitoba.ca/nursing RFHS / College of Nursing Take Action: Discharge Planning Discharge Teaching Signs and symptoms of progression, recurrent disease, when to seek medical care Home oxygen – safe use Encourage smoking cessation (patient and family) Palliation (to relieve symptoms S0B) Radiation Thoracentesis Pain management https://salem.massgeneralbrigham.org/patients_and_visitors/transition_to_home umanitoba.ca/nursing RFHS / College of Nursing Exemplar: Thoracic Trauma (p610 Lewis) umanitoba.ca/nursing  RFHS / College of Nursing Flail Chest What is it? Results from multiple rib fractures, causing instability of the chest wall Cues: Paradoxical chest movement During inspiration, the affected portion is sucked in, and during expiration, it bulges out Prevents adequate ventilation of the lung in the injured area Can severely compromise gas exchange that rapidly leads to hypoxemia Take Action: What is the Treatment? Oxygen, pain control, DB&C , ribs will heal on own in time If severe may require ICU and intubation (mechanical ventilation) Monitor ABG levels, vital signs, and signs of poor gas exchange umanitoba.ca/nursing  RFHS / College of Nursing Pneumothorax What is it? Presence of air in the pleural space Causes loss of negative pressure in the lung and lung collapses Open pneumothorax (pleural cavity exposed to outside air such as a penetrating wound (knife stab) Closed pneumothorax (happened inside such as injury to lungs from broken ribs or mechanical ventilation or other medical procedures) Cues: Small: mild tachycardia and dyspnea Large: respiratory distress, including shallow, rapid respirations; dyspnea; air hunger; decreased oxygen saturation. No breath sounds on auscultation. umanitoba.ca/nursing RFHS / College of Nursing Hemothorax What is it? Accumulation of blood in the pleural space that can occur from trauma or medical procedures. Can happen along with pneumothorax (called hemopneumothorax) Cues Same as for pneumothorax but if large amount blood loss could go into hypovolemic shock umanitoba.ca/nursing RFHS / College of Nursing Tension Pneumothorax What is it? Medical Emergency Rapid Accumulation of Air in Pleural Space (air enters during inspiration and does not exit), causing mediastinal shift leading to pressure on vena cava/ aorta Cues: Respiratory distress, shallow, rapid respirations, dyspnea; air hunger decreased oxygen saturation. hypoxemia No breath sounds on auscultation. Inadequate Cardiac Output Death umanitoba.ca/nursing  RFHS / College of Nursing Hemothorax/Pneumothorax Tension Pneumthorax Take Action: What is the Treatment? Treatment depends on severity and cause If small hemothorax and hemodynamically stable then supportive nursing care only. Will resolve spontaneously. A chest tube drain placed in the pleural For large pneumothorax, hemothorax or space allows lung tension pneumothorax chest tube re-expansion and insertion with needle aspiration first prevents air and (tension pneumo) if needed. fluid from returning to the chest. Care for chest tubes will be learned in skills and not tested in this course. umanitoba.ca/nursing RFHS / College of Nursing Exemplar: Pulmonary Embolus (PE) (p 622 Lewis) umanitoba.ca/nursing RFHS / College of Nursing Recognize Cues: PE What is it? Blockage of Pulmonary vessels by thrombus (dead space) Can be solid, fatty deposit, air Commonly caused by DVT that breaks off and travels to lungs. https://thoracickey.com/pulmonary-embolism-4/ Risk Factors Prolonged immobility, Surgery, Pregnancy, Obesity, Advancing age, Genetic conditions, Hx of thromboembolism, Smoking, Estrogen therapy, Heart failure, Fractures (fat embolism), Foreign objects (broken IV catheters), umanitoba.ca/nursing  RFHS / College of Nursing Recognize/ Analyze Cues: PE Determine urgency- if symptoms severe may require mechanical ventilation/ ICU Cues Sudden onset of dyspnea, sharp, stabbing chest pain, apprehension, restlessness, cough, hemoptysis, crackles, abnormal lung sounds, diaphoresis, ↑RR, ↑HR, ↑Temp, ↓O2 sats, petechiae over chest (if fat embolism is the cause). **Many patients do not present with classic symptoms so PE is often overlooked** Lab assessments and diagnostics ABGs General metabolic panel (for underlying conditions that may affect clotting) D dimer (increases with fibrinolysis associated with PE) Troponin and Brain natriuretic peptide (BNP) (prognostic markers of R ventricular dysfunction associated with PE) CT scan umanitoba.ca/nursing  RFHS / College of Nursing Take Action: PE- Drug Therapy https://www.activase.com/ais/dosing-and-administration/dosing.html Drug Therapy Begins immediately with anticoagulants to prevent embolus enlargement Type of Anticoag depends on severity of symptoms and size of embolus. Massive PE (mortality >65%) Fibrinolytic tx (tPA to dissolve clot) monitored in ICU while on this. Major risk of hemorrhaging. Low risk PE (mortality 1-3%) Heparin, low molecular weight heparin initiated and on this for 5-10 days. Warfarin initiated on day 1-2 of heparin tx. Treatment with both Heparin and Warfarin continues until INR reaches therapeutic level 2-3. Direct Thrombin inhibitors (riveroxiban apixaban) are becoming more common to use instead of Coumadin Usually on oral anticoags (Warfarin or Direct Thrombin Inhibitors for 3-6 mths. Submassive PE Must weigh benefits of thrombolytic tx to risk of bleeding. Treatment controversial. umanitoba.ca/nursing  RFHS / College of Nursing Take Action: PE General Nursing Care Position to optimize ventilation (high fowlers) O2 therapy (Type and amount depends on severity) NP, Mask, Mechanical ventilation IV Line for drug therapy and fluids Emotional Support - it’s scary when you can’t breathe! Self care while on anticoags (next slide) Ongoing Monitoring: Resp status, VS, cardiac dysrhythmias, lung sounds, mental status, confusion https://www.carehome.co.uk/advice/is-a-care-home-cheaper-than-a-nursing-home DVTs Evidence of bleeding (could be gums, old IV sites, GI, brain) umanitoba.ca/nursing RFHS / College of Nursing Take Action: PE Discharge Teaching Can be discharged once hemodynamically stable, hypoxia is resolved, and adequate anticoagulation is achieved. May be on anticoag therapy for weeks, months, years. Teach the following: Importance of taking take anticoagulants at same time each day Will require frequent regular appointments to monitor INR. Vit K can alter effectiveness of anticoagulants (green leafy veggies) Teach to monitor for S&S of bleeding, bruising. Teach to use soft bristle toothbrush electric shaver. Non- contact sports, careful with ADLs If bleeding occurs and does not stop within 15 min call EMS https://www.mountsinai.on.ca/care/schwartz-reisman-emergency/ed-discharge umanitoba.ca/nursing  RFHS / College of Nursing Take Action: Pulmonary Embolus Surgical Therapy Embolectomy Surgical removal embolus when patient is not a candidate for tPA Inferior Vena Cava Filter Insertion of a filter to vena Cava that traps emboli travelling to lungs from other veins. Candidates are patients that: Can’t take anticoags (i.e. pregnancy) Have a DVT not responding to anticoags Have a PE and are at high risk for reoccurrence Post procedure monitor insertion site for bleeding (femoral site or jugular vein) umanitoba.ca/nursing RFHS / College of Nursing Exemplar: COPD (p 648 Lewis) umanitoba.ca/nursing RFHS / College of Nursing COPD- What is it? Airflow Limitations: loss of elasticity of alveoli (Emphysema) Airflow Obstruction: Mucous (Bronchitis) Risk Factors Cigarette smoking Occupational Chemicals, Dust Recurring Infection, Heredity (AAT gene) Asthma Aging umanitoba.ca/nursing RFHS / College of Nursing Recognize/ Analyze Cues: COPD umanitoba.ca/nursing RFHS / College of Nursing Recognize /Analyze Cues: COPD Lab Assessments ABGs Hypoxemia (low PA02) Hypercapnia (increase in PAC02) often chronically present if alveoli hyperinflated If chronic the body tries to compensate ( increase HC03) CBC Increased WBC (if infection present) Increased HGB and HCT (polycythemia –if body is trying to compensate for hypoxia https://fgintegrativemedicine.ca/service/functional-testing-laboratory-assessment/ Electrolytes Watch carefully because Resp acidosis can change electrolytes umanitoba.ca/nursing RFHS / College of Nursing Recognize/ Analyze Cues: Other Diagnostics Pulmonary Function Tests Breathing tests that measure how well the lungs are exchanging air. Spirometry measures how effective inhalation and exhalation is Diagnosis of severity based on FEV1 (Forced expiratory volume in 1st sec of exhalation) Chest x-rays Show hyperinflation and flattened diaphragm umanitoba.ca/nursing RFHS / College of Nursing Recognize/ Analyze Cues: COPD umanitoba.ca/nursing RFHS / College of Nursing Take Action: COPD Drug Therapy Focus is on long term control therapy with short and long acting inhaled drugs and combination drugs. Step system is used (step up for exacerbations and step down once under control again) SABA’s- (Ventolin) short acting g bronchodilator SAMA’s- (Atrovent) short acting muscarinic agonist LABA’s- (Servant) Long acting bronchodilator LAMA’s- (Spiriva) Long acting muscarinic agonist Combination Inhalers (Advair) ICS/ LABA, (Combivent) SABA and SAMA Oral or parenteral corticosteroids (Prednisone) for exacerbations of COPD Treat infections promptly with antibiotics umanitoba.ca/nursing RFHS / College of Nursing Take Action: COPD Pursed Lip Breathing Inhale slowly through nose Pucker lips as if whistling Exhale through lips while counting Exhale longer than inhale Coughing after 3rd breath Diaphragmatic Breathing Breath from abd while keeping chest still Positioning Upright position (tripod if possible) Elevating HOB allows for lung expansion Fluids to thin secretions https://www.facebook.com/SupportCOPDAwareness/photos/a.1076429202371917/2316209105060581/?type eater umanitoba.ca/nursing  RFHS / College of Nursing Take Action: COPD O2 therapy is used to Reduces work of breathing Maintain PaO2 Reduce workload on the heart Sats should be between 88-92% or as prescribed Aim is to raise PaO2 with just enough O2 Various methods of delivery Should be humidified (thins secretions) Home Delivery Systems Portable systems (Can be used at home or when out) https://www.inogen.com/oxygen-therapy/purchase-options/ 36 umanitoba.ca/nursing RFHS / College of Nursing Take Action: COPD Nutritional therapy Weight loss and malnutrition are common. Pressure on diaphragm from a full stomach causes dyspnea. Difficulty breathing while eating leads to inadequate consumption To decrease dyspnea and conserve energy Rest at least 30 minutes before eating. Use bronchodilator. Prepare foods in advance (4-6 small meals/day). High calorie high protein foods Hydration Therapy https://www.beachbodyondemand.com/blog/quick-and-simple-21-day-fix-meal-prep-for-every-calorie-leve Drink at least 2L/ day (thins thick secretions) Can use humidifiers if air is dry. umanitoba.ca/nursing  RFHS / College of Nursing Take Action: COPD Exercise Therapy Can improve function and performance significantly Start slowly and increase gradually. Walk daily until symptoms limit further exercise, stop and rest, continue on until 20 min has passed. Pulmonary Rehab Programs Involve education and monitored exercise Psychosocial considerations Support is really important umanitoba.ca/nursing RFHS / College of Nursing Take Action: COPD Surgical Management Lung Volume Reduction Surgery (LVRS) Removal of hyperinflated lung tissues containing stagnant air where no gas exchange occurs Results in increased forced expiratory volume (FEV) and improved oxygenation Must meet criteria (end stage emphysema but otherwise be in good health) Lung Transplant Less common because of cost and scarce availability Very difficult course of antirejection drugs to follow https://www.myupchar.com/en/surgery/lung-volume-reduction-surgery umanitoba.ca/nursing  RFHS / College of Nursing COPD: Acute Exacerbation What is it? COPD is a lifelong disease with remissions and exacerbations Acute exacerbation is a worsening of symptoms and decrease in ability to do ADLs Triggered by respiratory infections, unhealthy air quality Respiratory rate can be 40-50 breaths per minute Immediate medical attention required. Prevention of Exacerbations Avoid crowds Up to date pneumonia and flu vaccines Avoid triggers, stay indoors when air quality poor https://www.heartfailurematters.org/en_GB/Understanding-heart-failure/Shortness-of-bre umanitoba.ca/nursing RFHS / College of Nursing Take Action: Acute Exacerbation COPD Will require hospitalization and increased monitored care Medication will be “stepped up”until stable. o Increase Inhaled bronchodilators o Antibiotics if infection present o Oral systemic steroids Oxygen will be required and stepped up as needed Promote rest to allow energy for breathing and eating. Raise HOB Ventilation and intubation may be required if acute respiratory failure https://scilog.fwf.ac.at/en/tag/acute-respiratory-distress-syndrome umanitoba.ca/nursing RFHS / College of Nursing COPD: COR Pulmonale What is it? Air trapping and stiff alveolar walls increase lung tissue pressure and narrow blood vessels making blood flow and perfusion difficult This causes right side of heart to work harder to pump the blood to lungs. Right chamber of heart enlarges thickens and becomes inefficient. Causes blood to back of to central venous system Distended neck veins Peripheral swelling Cardiac Dysrhythmias Decreased oxygenation of heart muscle can cause dysrhythmias umanitoba.ca/nursing  RFHS / College of Nursing COPD: Depression/ Anxiety/ Panic High rates of depression anxiety (>40% report anxiety/ depression) Depression Related to loss associated with disease Related to guilt of smoking Convey understanding Support groups, counselling, meditation, hypnosis therapy etc to help. Anxiety Dyspnea causes anxiety- scary when can’t breathe. Pt should have a plan for when systems flare umanitoba.ca/nursing RFHS / College of Nursing Let’s Go Clinical https://www.medicalnewstoday.com/articles/323131.php 77-year-old man presents to the hospital complaining of shortness of breath, morning cough, and swelling in his lower extremities. He has difficulty breathing when he walks. States sleeping in a recliner to make it easier to breathe. Feels his shoes are tight at the end of the day. Has smoked one pack of cigarettes a day for the past 30 years His breathing is laboured.Breath sounds faint with prolonged expiration. Assessment His arterial blood gases show ↓ PaO2 and ↑ PaCO2 Chest x-rays show hyperinflation of the lungs. 2+ peripheral edema bilateral lower extremities umanitoba.ca/nursing RFHS / College of Nursing Discuss with Neighbor 1. He is diagnosed with COPD. What is the basis for this diagnosis? 2. Why does he have swelling of his feet and ankles? 3. What important teaching measures should you incorporate into his plan of care once he is stable and ready for discharge? umanitoba.ca/nursing RFHS / College of Nursing COPD: Discharge Teaching Pace and plan ADLs with rest periods. Encourage smoking cessation Promote hand hygiene, stay away from crowds Encourage influenza, pneumonia vaccines Seek medical attention promptly if S&S of infection begin. Follow medication schedule, understand use, how to take inhalers properly. Take long-acting medications to prevent exacerbations. Take short acting inhalers before activity (exercise, eating) or when feeling SOB. Exercise using pursed lip breathing. Walking daily for 20 min is best. Home 0 2 if needed. umanitoba.ca/nursing RFHS / College of Nursing Questions welcome! umanitoba.ca/nursing RFHS / College of Nursing Altered Gas Exchange: Disorders of the Respiratory System By Linda Townsend RN, MN With some contributions from Lisa Banman umanitoba.ca/nursing RFHS / College of Nursing Territory Acknowledgement The University of Manitoba campuses are located on original lands of Anishinaabeg, Ininewuk, Anisininewuk, Dakota Oyate and Denesuline, and on the National Homeland of the Red River Métis. We respect the Treaties that were made on these territories, we acknowledge the harms and mistakes of the past, and we dedicate ourselves to move forward in partnership with Indigenous communities in a spirit of Reconciliation and collaboration. umanitoba.ca/nursing  RFHS / College of Nursing Learning Outcomes By the end of today’s class you will be able to: Explain the nursing interventions used to support a patient with altered gas exchange and identify nursing priorities for patients with the following respiratory conditions. Adult Respiratory COPD, Pulmonary Emboli, Head and Neck Ca, Pulmonary Lung Ca, Chest Trauma (hemo/pneumothorax, flail chest), Pediatric Respiratory, Respiratory Infections (General Aspects), RSV and Bronchiolitis, Asthma umanitoba.ca/nursing RFHS / College of Nursing What is Required for Adequate Gas Exchange? O2 is transported to the cells and C02 away from cells (Via the bloodstream). This requires: Normal functioning brain and spinal cord Normal diaphragm function and skeletal muscle contractility Intact Chest /Thorax with functioning alveoli and good blood flow in surrounding capillaries umanitoba.ca/nursing RFHS / College of Nursing Hypoxia and Hypercapnia Decreased Gas Exchange results in: Inadequate transportation of O2 to body cells (Hypoxia) Results in cell necrosis and death Build up of CO2 combines with H2O to produce carbonic acid. (Hypercapnia) Results in respiratory acidosis and acid base imbalance umanitoba.ca/nursing RFHS / College of Nursing Shunt vs Dead Space VQ mismatch https://www.sciencedirect.com/science/article/pii/S2049080122005805 umanitoba.ca/nursing  RFHS / College of Nursing Think Pair Share Think about why your patient is short of breath. What is happening that is causing this? Examples: pneumonia affects gas exchange because alveoli are filled with infectious fluid causing inadequate ventilation (shunt). High cervical spinal cord affects gas exchange because there is damage to the spinal nerves that control the diaphragm and this causes decreased ventilation (shunt). Pulmonary embolus affects gas exchange because there is inadequate perfusion because the emboli is causing an obstruction of bloodflow in the pulmonary vessels (dead space). What would be the cause of inadequate ventilation is in the following: MVA with chest being crushed by steering wheel COPD https://www.alamy.com/cartoon-character-with-shortness-of-breath-symptoms-illustration-image369551293.ht umanitoba.ca/nursing  RFHS / College of Nursing Gas Exchange Recognize Cues: Patient History Age, Race, Gender, Environment Women > risk than men, areas of high pollution, highly populated, extremes in weather, aging increases risk Respiratory Hx Smoking , Vaping, drug use, allergies Family Hx and Genetic risk Is their any respiratory illnesses that run in family cystic fibrosis and emphysema Current Health Problems Cough, sputum amount & color Any pain? What type? http://nurseadvisormagazine.com/wp-content/uploads/2021/04/AdobeStock_228644979-850x425.jpg Dyspnea at rest or on exertion umanitoba.ca/nursing RFHS / College of Nursing Gas Exchange Recognize Cues: Physical Assessment Nose, Pharynx, Larynx, Trachea, Thorax Any lumps asymmetry, hoarse throat? Lungs and Thorax Auscultate for abnormal sounds. Other Observations Skin color, nail beds, weight loss, dyspnea when walking or talking? Psychological assessment Is patient anxious or depressed? http://nursing.uokerbala.edu.iq/wp/wp-content/uploads/2018/06/respiratory-assessment.pdf umanitoba.ca/nursing RFHS / College of Nursing Recognize Cues: Analyze Data Physical Assessment ABGs CBC (RBC, Hgb) Sputum culture https://en.wikipedia.org/wiki/Chest_radiograph umanitoba.ca/nursing  RFHS / College of Nursing Radiology Imaging Chest X-ray, CT scan, MRI images used to diagnose/ show progression or response to treatment. Pre- procedure Remove metal objects (jewelry) IV contrast can be nephrotoxic https://www.theguardian.com/society/2021/feb/14/ct-scan-catches-70-of-lung-cancers-at-early-stage-nhs-study-finds If using contrast dye check for allergies May check creatinine level first to assess kidney function If on Metformin drug is stopped before and held after procedure for 24-48 h. https://www.news-medical.net/news/20201218/Transfer-learning-exploits-chest-Xray-to-diagnose-COVID-19-pneumonia.aspx umanitoba.ca/nursing RFHS / College of Nursing Bronchoscopy Pre-procedure: Insertion of a tube in the CBC, Plt, PTT, Lytes, CXR airways NPO 8 hrs (depends on doctor) View airway structures and obtain tissue samples Post-Procedure: Monitor until sedation wears off Diagnose and manage Ensure gag prior to eating/drinking pulmonary diseases Risk of bleeding, infection, hypoxemia umanitoba.ca/nursing  RFHS / College of Nursing Thoracentesis Needle aspiration of pleural fluid or air from the pleural space. Pre- Procedure Patient teaching important will feel a sting when local anesthetic injected and pressure when needle pushing through the chest. Do not move cough or deep breath during procedure Need to sign consent Post Procedure Apply pressure to puncture site and sterile drsg Chest x-ray to rule out pneumothorax Monitor for s&s of pneumothorax (mediastinal shift, trachea moves to unaffected side, air hunger, rapid heart rate, pain on inspiration and expiration, cyanosis, cough umanitoba.ca/nursing https://jigsaw.vitalsource.com/books/9780323654050/epub/OEBPS/IMAGES/B9780323612425000245/main.assets/f24-13-9780323612425.jpg  RFHS / College of Nursing Pulmonary Function Tests Used to evaluate lung function by measuring strength of air movement. Can determine presence of disease and establish a baseline to evaluate improvement or decline. Pre- Procedure May be asked to hold bronchodilator 6 hrs before Post procedure Monitor for dyspnea, bronchospasm umanitoba.ca/nursing  RFHS / College of Nursing Percutaneous Lung Biopsy Needle inserted to aspirate tissue sample using CT or fluoroscopy to guide placement of needle Local anesthetic used before needle inserted Pre- Procedure teaching of what will happen to reduce anxiety Post Procedure Monitor for pneumothorax (same as post thoracentesis) umanitoba.ca/nursing  RFHS / College of Nursing Altered Gas Exchange: Take Action 1. Optimize oxygenation O2 as needed 2. Optimize ventilation positioning 3. Administer medication Appropriate to problem 4. Manage secretions Fluids, suction 5. Optimize nutrition Image from creative commons 6 small meals, increased protein, calories umanitoba.ca/nursing RFHS / College of Nursing Practice Question The nurse is caring for a client with a possible pulmonary embolism who has symptoms of chest pain and difficulty breathing. The nurse assesses a heart rate of 142, BP 100/60 mm Hg, and respirations of 42 breaths/minute. Which of the following actions should the nurse implement first? a. Elevate the head of the bed to 45–60 degrees. b. Administer the ordered pain medication. c. Notify the client’s health care provider. d. Offer emotional support and reassurance. umanitoba.ca/nursing  RFHS / College of Nursing Gas Exchange Pediatrics: Respiratory Disorders Linda Townsend RN, MN University of Manitoba© umanitoba.ca/nursing RFHS / College of Nursing Learning Outcomes By the end of the class you should be able to: 1. Know how to recognize and analyze cues of abnormal breath sounds in a pediatric patient. 2. Understand what nursing care is appropriate for a pediatric patient with a respiratory disorder (general rules for any). 3. Know how to recognize and analyze cues pediatric patient with RSV (Bronchiolitis) and the appropriate nursing care. 4. Know how to recognize the signs and symptoms of a patient with Asthma and the appropriate nursing care including an action plan for parents the child and caregivers. umanitoba.ca/nursing RFHS / College of Nursing Abnormal breath sounds in the Pediatric Patient Recognize Cues of a Baby in Respiratory Distress https://www.youtube.com/watch?v=IECGJiEyqFQ umanitoba.ca/nursing RFHS / College of Nursing Pediatric Respiratory Infections Some Facts Most infections are caused by viruses Anatomical differences put peds at higher risk Diameter of airways is smaller so inflammation and secretions cause narrowing Shorter respiratory tract so infection travels fast Short and open Eustachian tube allows pathogens easy access middle ear Immune system is not as strong (breastfeeding increases immunity) umanitoba.ca/nursing https://aneskey.com/differentiating-aspects-of-the-pediatric-airway-2/ RFHS / College of Nursing Take Action: Nursing Care (p1118 Perry) Easing Respiratory Efforts Can usually be managed at home Running a steamy shower (10-15 min) Hot steam or cool mist vaporizers not recommended Promoting Rest Encourage quiet play, rest umanitoba.ca/nursing https://www.kidspot.com.au/parenting/things-to-do/21-absorbing-quiet-games-for-quiet-times/news-story/4aa14a90f3a85ca1d886d71e81eec272 RFHS / College of Nursing Take Action: Nursing Care Promoting Comfort Clear nasal secretions with saline drops Bulb Suction (Babies that can't blow nose) Medicated drops not if 6 yrs no more that 2-3 days Reduce Spread of Infection Good handwashing, throw out tissues Sneeze/cough into arm Do not share cups/utensils Stay home when sick umanitoba.ca/nursing RFHS / College of Nursing Take Action: Nursing Care Reduce Temperature Monitor temp Acetaminophen or ibuprofen as directed Favorite fluids frequently (prevent dehydration) Dehydration Assess S&S Observe frequency and color of voids (older) Count diapers (home), weigh diapers (hospital) Continue breastfeeding if possible Oral rehydration fluids -Pedialyte Nutrition Do not force food, eat what they can Popsicles, pudding, soup Support for Parents https://medical-dictionary.thefreedictionary.com/dehydration Teaching re med admin Family friends umanitoba.ca/nursing RFHS / College of Nursing Exemplar Respiratory Synctial Virus (RSV) & Bronchiolitis(p1133 Perry) https://healthcare.utah.edu/healthfeed/2020/01/abcs-of-rsv-signs-symptoms umanitoba.ca/nursing RFHS / College of Nursing RSV & Bronchiolitis: Recognize Analyze Cues Bronchiolitis is a common viral illness most often caused by Respiratory Syncytial Virus (RSV) Moves from upper to lower airway Characterized by acute inflammation of airways, bronchospasm, and increased mucus production. Secretions are tested for RSV antigens to confirm RSV. umanitoba.ca/nursing https://www.rph.org.nz/public-health-topics/early-childhood-centres/fact-sheets/bronchiolitis/  RFHS / College of Nursing RSV & Bronchiolitis: Recognize Cues Initial Rhinorrhea ,Pharyngitis Coughing/sneezing/Wheezing Possible ear or eye drainage Intermittent fever With Progression of Illness Increased coughing and wheezing Tachypnea and retractions Cyanosis Severe Illness Tachypnea Listlessness Apneic spells Poor air exchange; decreased breath sounds umanitoba.ca/nursing RFHS / College of Nursing RSV & Bronchiolitis: Take Action If resp distress or poor hydration will be hospitalized Assign to separate rooms or grouped with other RSV patients Isolation (droplet contact -gloves, mask, gown) when entering room O2 to keep sats >90 (Humidified via N/C, mask, hood) umanitoba.ca/nursing RFHS / College of Nursing RSV & Bronchiolitis: Take Action Medications Nebulized Epinephrine ? Tylenol No abx - viral No OTC decongestants, cough/cold meds, etc. No steroids Hydration Check skin turgor, U/O Encourage Breastfeeding if tolerated Suction before feedings for babies that can’t blow nose (superficial suction or bulb suction) Small frequent as tolerated IV fluids or NG feeds umanitoba.ca/nursing  RFHS / College of Nursing RSV & Brochiolitis: Prevention Vaccine Palivizumab activates the immune system Given to high risk babies who are immunocompromised by underlying conditions umanitoba.ca/nursing  RFHS / College of Nursing Potential Complication of RSV: Otitis Media (p1126 Perry) Fluid /Inflammation of middle ear (majority preceded by virus) Recognize Cues Abrupt onset Earache, Fever, Purulent discharge If becomes chronic can cause hearing impairment Take Action Monitor without a/b for first 24-48 h Give if s&s 48 hrs or 3