Respiratory Patient Assessment and Care Nursing Notes PDF

Assessment and Care of the Respiratory Patient **VENTILATION, PERFUSION, AND RESPIRATION** - The respiratory system is responsible for ventilation (air movement), in combination with the cardiovascular system which provides profusion (blood flow) at the alveolar capillary level, so t...

Assessment and Care of the Respiratory Patient **VENTILATION, PERFUSION, AND RESPIRATION** - The respiratory system is responsible for ventilation (air movement), in combination with the cardiovascular system which provides profusion (blood flow) at the alveolar capillary level, so the process of external respiration (or gas exchange) can occur. In the lungs gas exchange is based on adequate ventilation and perfusion. - Cellular respiration (gas exchange inside the body) occurs between the capillaries and the cells based on hydrostatic and oncotic pressures. **History** - Current complaints - S/S - Needs Closer Evaluation: A patient who reports coughing, nasal or sinus symptoms, pain, discolored mucus, blood from the mouth or nose, dyspnea at any time, fatigue, or unexplained weight loss - Needs Emergent Medical Care: A patient with a respiratory complaint who experiences limitations in speaking, use of accessory muscles or retractions (assess from back), head bobbing, pursed lip breathing, has adventitious breath sounds, tachypnea or bradypnea with altered mental status, hypoxia or cyanosis should be considered an emergency - Pediatrics: grunting, retractions - Cough: sputum colors: - Yellow: - White: - Green: - Bloody: - Foamy: - Onset - Provokes/palliates - Quality - Region/radiates - Severity - Timing - U: What do you think it is? **Past medical history** - Smoking and drug use - For infants and pediatrics being exposed to second hand smoke is part of the assessment, as well as feeding and sleeping habits. SUIDI/SIDS is most common during sleep up to 6 months of age and is a diagnosis of exclusion (rule out other possibilities) such as congenital defects, suffocation, injury, etc. - Allergies - Medications - Past medical, surgical hx - Family hx - Travel, work, residence, exposures - A thorough history including risk factors for respiratory disease is important to uncovering the need for further evaluation or testing. - **Assessment** - Inspect - General impression, tone, appearance, mental status - Patency of the airway, nares, neck/trachea - Are they managing secretions - Rate, depth, effort of breathing, shape of thorax - Tachycardia = early sign of hypoxia - Skin color, turgor, mucus membranes - Nails for clubbing, fingers for tobacco staining - Infant: neutral to open airway - Adult: head tilt unless trauma, jaw tilt instead - Palpate - Trachea --midline - Thorax- crepitus, pain, masses, deformities, expansion. **Auscultate** - Lung sounds - Upper lobes are best heard anteriorly - Right middle lobe and lower lobes are best heard posteriorly - Note sounds inspiration, expiration, or both - Adventitious Lung Sounds - Adventitious lung sounds are considered abnormal, however, may be a "normal" finding for the patient with chronic disease. - **Stridor:** - high-pitched inspiratory sound of the upper airway caused by airway obstruction, glottic edema, trauma, or spasms. - **Ex.** It is found in croup, epiglottitis, laryngitis, allergic reactions, FBAO, and vocal cord injuries. Patients who have had thyroidectomy may develop stridor after surgery from nerve injury or edema. - **Rhonchi**: - low-pitched "junky" or snoring sound from thick mucus in the upper/large airways. - **Ex.** It can be heard with inspiration and exhalation and often clears (at least partially) with coughing. Conditions like COPD, pneumonia, bronchitis, foreign bodies, and tumors may cause rhonchi. - Reassess rhonchi after clearing - **Wheezes:** are musical, violin-like sounds in the smaller airways due to bronchoconstriction (bronchioles), mucosal edema, and excessive mucus production. - They can be present on exhalation, both exhalation and inhalation, or just inhalation (in order of getting worse). - "Silent Chest" = respiratory arrest - **Ex.** Wheezes are present with asthma, COPD, and allergic reactions. - **Crackles**: are fine (soft like hair rubbing together) or coarse (slightly louder popping sound) from recruitment of atelectic alveoli or fluid in the alveoli or terminal bronchioles. - Monitor the location (dependent, how high) and if they clear with deep breathing (atelectasis). - **Ex.** Conditions like hypoventilation, bronchitis, pneumonia, COPD, pulmonary edema, and congestive heart failure can lead to crackles. **Diagnostics** - Pulse oximetry - Estimates oxygen binding to hemoglobin - This is an estimated level and requires adequate ventilation and perfusion for respiration to occur. - Can be affected by nail polish, - Capnography, Capnometry - Measure exhaled CO2 - VBGs and ABGs - Respiratory acidosis - COPD, late finding in pneumonia, ARDS - Hypoventilation, respiratory failure - Respiratory alkalosis - Hyperventilation, early asthma or pneumonia, anxiety - Blood gasses are a more accurate measurement of gas levels and acid base balance but are invasive. - Allen's test should be performed prior to puncturing the radial artery to ensure blood flow to the hand. (pressure is held several minutes after arterial puncture to avoid bleeding). - Sputum analysis - Sputum analysis can confirm infection, organism, and sensitivity. - Chest x-ray - x-rays can identify problems with the heart, lungs, and pleural space. Masses, fluid or air collections in the pleural space, pneumonia, atelectasis, TB infections. - Pulmonary function testing - Pulmonary function testing evaluates lung function and helps evaluate if a disease, such as COPD, is stabilizing or progressing. - UA: urine struck pneumonia antigen test - Strep infection antigen floating in bloodstream **Diagnostics** **Awake** - Thoracentesis - Local anesthetic - Position, reassurance - Evaluate VS and LS - Risks: pain, bleeding, infection - HYPOTENSION, PNEUMOTHORAX **Sedation = NPO 8 hours** - Bronchoscopy - Flexible - Moderate sedation - Rigid - General anesthesia - GAG REFLEX PRIOR TO PO - Lung biopsy - Percutaneous - Moderate sedation - Open - General anesthesia - Chest tube **Chest tube management** - Management of the patient with a chest tube includes - Maintain a closed system - Keep the collection system below the level of the chest - Air vent: - Water Seal: - Drainage Canister: - Suction: - Frequent respiratory assessment (at least every 2 to 4 hours) - Check tubes for kinks or loops- no dependent loops - Check the water seal chamber for bubbling- initially there is bubbling on exhalation indicating reinflation of the lung, then tidaling/fluctuation in water level with respiration that decreases as the pleura heals. - Vigorous or continuous bubbling in the water seal chamber is a sign of a leak- check all the tubing and connections first. - Measure the amount of drainage (this is part of your I&O measurement) - WATER LEVEL IN WATER SEAL CHAMBER MUST BE FULL - Never clamp the chest tube - Assist with frequent position changes, ambulation, pain management, turn cough, deep breathe. - Apply an occlusive dressing after removal - Hemothorax: - Monitor H&H and WBC - If removed, Cover hole and call for help **AIRWAY** - Ventilation - We can divide problems with respiratory patients into AIRWAY or ventilation issues, BREATHING or respiration issues, and Circulation or perfusion issues. **AIRWAY** - Assessment and management - Open? - Position - If can't hold on own reposition airway with a head-tilt, chin-lift, or a jaw-thrust - If the tongue is falling back in the throat due to altered mental status, does the patient require an oral airway (no gag reflex) or a nasal airway (gag reflex)? - Are they going to require long-term airway management and ventilation, and an ET Tube should be placed? - Adjunct (NPA, OPA, ETT, BiPAP/CPAP) - BiPAP, CPAP and APAP support the patient with intermittent airway obstruction (such as sleep apnea) or who requires increased airway pressures (COPD exacerbation, heart failure). The mask and straps need to fit snugly to avoid leaks. These devices can sometimes cause anxiety, the patient should use relaxation techniques, or sometimes require small doses of benzodiazepines, to tolerate the mask. The air can be humidified to prevent drying of the airways. - Patent? - Suction, FBAO maneuvers - If there are adventitious sounds- the airway is not patent - Adventitious sounds? - Snoring- tongue - Snoring indicates a partial obstruction by the tongue, positioning and/or an adjunct (OPA) will alleviate this - Gurgling- secretions - Suction with a yankauer rigid suction catheter, insert to the posterior pharynx, occlude the hole, suction in a circular motion on the way out for no more than 10 seconds - Follow with oxygenation and continued assessment - Stridor- glottic area - Stridor is present when a foreign body, infection, or inflammation occurs at the level of the glottis (vocal cords). If a FB is suspected and the person can cough, speak or breath, encourage them to cough. If they cannot cough, speak, or breathe, initiate back blows/chest thrusts for an infant, and abdominal thrusts for a child/adult or CPR for an unresponsive victim. Only sweep an object out of the mouth that you can visualize. - Mucus, mucus plugs, secretions - Hydration, suction, mucolytics - Encourage TCDB, I/S - Chest PT, positioning **Tracheostomy** - Inner cannula - Stoma - Dressing - Ties - Document **URI & infections** - URI - Viral - Rhinitis/ Rhinosinusitis - Allergic or viral - intranasal steroids, antihistamines, decongestants, saline - Acute bacterial rhinosinusitis - Antibiotics (\>10 days, new symptoms after 5-6 days, acute symptoms for more than 3-4 days) - Pharyngitis - Viral or bacterial (or can be from irritation) - Strep throat - Tonsillitis - Lymphatic tissue, often inflamed with pharyngitis - Tonsillectomy - Monitor airway, gag, bleeding **Upper airway disorders** - Obstructive sleep apnea - CPAP, weight loss, surgery - Laryngitis - Smoking cessation, URI treatment, GERD management - Screen for cancer - Laryngeal cancer - Smoking, tobacco, toxin exposures, GERD - Hoarseness for \>2 weeks **Croup Syndromes** - Laryngotracheobronchitis - Brassy or barking cough - Stridor - Supportive care (hydration, steroids, nebs) - Bronchiolitis and RSV - Viral inflammation, leads to wheezing, dyspnea - Vaccine and an antiviral treatment - Acute epiglottitis - Tripod, sniffing position, drooling, muffled voice - Acute onset = bacterial - Antibiotics - NOTHING IN THE MOUTH/THROAT - Can cause laryngospasm and obstruct the airway **Influenza** - Influenza is a viral infection of the respiratory tract - It is spread through droplets PRECAUTIONS! - Antiviral agents may be started within 24-48 of onset of symptoms to decrease the severity of symptoms and shorten the duration by 1 day - The biggest concern is development of a secondary infection - Elderly, young, immunocompromised - Watch for s/s of pneumonia - Lingering cough, nighttime cough - Fever after getting better - Lack of energy, appetite, etc., after initial improvement **BREATHING** - Respiration and Gas Exchange - Lower airway disorders impact below the glottis, alveolar ventilation, and respiration (gas exchange) **BREATHING assessment & management** Assessment and management - Rate - Too fast or too slow for age? - Consider current condition (pain, fear, fever, sleep/activity, meds) - Depth - Deep, shallow, normal - Is it constant or fluctuating - Effort - Normal, increased, decreased - Adventitious sounds? - Lower airway disorders impact airflow below the glottis, alveolar ventilation, **and respiration (gas exchange).** **Asthma** - Asthma is a reactive airway disease that is defined as "intermittent and reversible" airway obstruction caused by an exaggerated immune response with resulting smooth muscle constriction. - Inflammation/edema, bronchoconstriction, and mucus production decrease the internal diameter of the airways leading to air trapping and a prolonged expiratory phase and wheezing. - Asthma is an inflammatory response: cumulative of the exposures of the past 7 days, that can exacerbate quickly when exposed to a strong allergen stimulus such as: - Cigarette smoke, mold, pollen, animal dander, roaches, air pollutants, occupational irritants, and dust - Illness (Viral infections and bacterial infections) as well as allergic responses lead to increased inflammation and edema and can set off the inflammatory response. - Nasal polyps are part of the allergic triad (asthma, nasal polyps and aspirin allergy) - Food and drug allergies, and even emotional responses can trigger an asthma attack. - Control mediations are taken daily. Rescue medications (SABA) bronchodilators are used for asthma exacerbation. Ensure the patient has a rescue inhaler and spacer and knows how to use them. **Chronic Bronchitis & Emphysema** **Chronic Bronchitis** - Chronic inflammation of the bronchi and goblet cells leading to narrowing of the airways and thick mucous production. **Emphysema** - Damage to the alveolar walls leads to a loss of elasticity and decreased gas exchange. Air trapping in the damaged alveoli is common. - Treatment: Bronchodilators, mucolytics, steroidal anti-inflammatories. Oxygen as needed to maintain a normal saturation (mental status). In patients with a true hypoxic drive, "CO2 retainers" high flow O2 can cause hypoventilation and respiratory acidosis. Use oxygen appropriately and be prepared to provide ventilations to someone who is hypoxic and hypoventilating. - Watch for signs and symptoms of hypoxia - bronchodilators, such as albuterol, work by stimulating the sympathetic nervous system. If the patient is tachycardic from hypoxia, the heart rate may slow down with administration. However, if the patient is using a SABA as a control medication they may experience tachycardia as a side effect. Look for other signs such as increased work of breathing, decreased word count, accessory muscle use, positioning, pursed lip breathing, and changes in skin color and condition. - Watch for signs and symptoms of pneumonia or infection such as loss of appetite, back pain, fever or chills, increasing shortness of breath, a change in the sputum from white to yellow, or an increased productive cough. - Patients with COPD should be seen as soon as possible for possible infections given their risk for impaired gas exchange. **Cystic Fibrosis** - Autosomal recessive genetic disorder that impairs chloride transport resulting in thick, tenacious secretions. The respiratory tract, sweat glands, GI tract/pancreas, and reproductive secretions are impacted. - The person with CF has salty skin/sweat, frequent constipation, bulky frothy foul-smelling stools (steatorrhea), and infants are prone to meconium ileus. The thick GI secretions plug up the pancreas causing failure and requiring enzyme replacement therapy. The respiratory secretions are difficult to clear, leading to an increased risk of infection. - Treatment: - Bronchodilators, mucolytics, and chest pt with postural drainage are control therapies for the respiratory symptoms of CF. If the person develops any s/s of an infection, antibiotics are started. **Lung cancer** - Most commonly related to smoking. - Biopsy to determine type- small cell has the poorest outcome due to rapid metastases. - Smoking cessation - Surgery, chemotherapy, radiation. **Pneumonia** - Position of comfort, rest, monitor vital signs. - Respiratory isolation as indicated (fever, cough, flu) - Cluster care - Humidified O2 - Hydration - Antipyretics and Analgesics - Antibiotics - Bronchodilators - Monitor respiratory status and condition **Tuberculosis** A diagram of a human lungs Description automatically generated - PPD or QuantiFERON gold blood testing (if positive confirm with ppd then cxr) - Confirm with chest x-ray - Treatment based on risk and ppd size - 4-medications for 2 months, then 2 for 4 more months. It is critical that they take the entire course of medications to prevent drug resistant TB and clear the infection. - Discuss liver complications, monitor blood work, rifampin turns secretions red-orange and we are attempting to monitor for jaundice. Labs are important. **CIRCULATION** **Perfusion** - Certain conditions can impact blood flow through the pulmonary vessels, impacting the ability of respiratory system to perform gas exchange. **Pulmonary Embolus** - Pleuritic chest pain, dyspnea and/or tachypnea, hypoxia. There may be non-specific T wave changes on the EKG (not a STEMI) - These can be fatal. If you have a patient with a DVT or a known PE who suddenly complains of CP or dyspnea, assess them immediately. If there are any signs of hypoxia or tachycardia call for help. - Anticoagulants are used to prevent the clot from growing (or further clots from forming). - Embolectomy is the surgical removal of a clot - Patients at high risk may have a IVC filter placed to prevent future clots from reaching the lungs. **ARDS** **Pulmonary inflammation and edema** - Overwhelming inflammatory response that leads to capillary leaking, massive fluids shift into the alveoli and bronchioles with progressive dyspnea and hypoxia. - Hypoxia despite aggressive oxygenation and/or ventilation - Most commonly related to sepsis. Also seen after pneumonia, overdose, aspiration, trauma, etc. - Treatment includes antibiotics to treat any infection, steroids to decrease inflammation. Paralytics and sedation/pain management, intubation and mechanical ventilation. **COVID-19** - The novel corona virus that emerged in 2019 (known as COVID-19) - The virus binds with high affinity to the angiotensin-converting enzyme 2 (ACE2) receptor in humans. The ACE2 enzyme is expressed in type II alveolar cells in the lungs. - **Severe disease and poor outcomes** (i.e. ICU level of care and mortality) currently appear to occur in patients with chronic pulmonary disease, smoking, chronic medical conditions (i.e. hypertension, diabetes, or cardiovascular disease), or advanced age while kids and healthy younger adults seem to have milder courses - The infection leads to inflammation, especially of the bronchial lining and vasculature. Patients are at risk for ARDS-like respiratory failure as well as thrombus formation in the lungs (or VTE and PE). - Labs that should be monitored include ABGs, D-Dimer, CRP (inflammatory markers), and WBCs as patients can easily develop secondary infections like pneumonias. AST/ALT, Lactate, and Serum iron levels are also monitored in patients- as these are indicators of the severity of disease (hemolysis and anemia make oxygen carrying more difficult and contribute to greater hypoxia). - Currently most hospitalized patients are treated with the antiviral drug Remdesivir intravenously for 4-10 days depending on the severity of their symptoms. **Chest trauma** - Pain medication is critical for the chest trauma patient: they will breathe shallowly to avoid painful inspiration and not ventilate the alveoli. - Flail chest- 3 or more ribs in 2 or more places allows for paradoxical movement of the chest wall, decreases intrathoracic pressure (vacuum) and inspiratory volumes. Painful. - Pneumothorax- air in pleural space - Hemothorax- blood in pleural space - Hemopneumothorax- both - If hemothorax monitor H&H for decrease- blood loss. - Tension pneumothorax (pictured)- mediastinal shift from increasing pneumothorax causes compression of the heart: JVD, tachycardia, hypoxia, narrowing pulse pressure (obstructive shock), hypotension, absent lung sounds on affected side, tracheal deviation. Rescue is needle-chest decompression followed by chest tube insertion.