STUDïENT Chapter 49-Respiratory System.ppt

Care of the Patient with a Respiratory Disorder All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.  Differentiate...

Care of the Patient with a Respiratory Disorder All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.  Differentiate between external and internal respiration.  Describe the purpose of the respiratory system and list and define the parts of the upper and lower respiratory tracts.  List the ways in which oxygen and carbon dioxide are transported in the blood.  Discuss the mechanisms that regulate respirations.  Identify those signs and symptoms that indicate a patient is experiencing hypoxia.  Differentiate among sonorous wheezes, sibilant wheezes, crackles, and pleural friction rub. All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 2  Describe the purpose, significance of results, and nursing interventions related to diagnostic examinations of the respiratory system.  Describe the significance of arterial blood gas values and differentiate between arterial oxygen tension (PaO2) and arterial oxygen saturation (SaO2).  Discuss the etiology and pathophysiology, clinical manifestations, assessment, diagnostic tests, medical management, nursing interventions, and prognosis of the patient with disorders of the upper airway.  Discuss nursing interventions for the patient with a laryngectomy. All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 3  Discuss the etiology and pathophysiology, clinical manifestations, assessment, diagnostic tests, medical management, nursing interventions, and prognosis of the patient with disorders of the lower airway.  Differentiate between tuberculosis infection and tuberculosis disease.  List five nursing assessments or interventions pertaining to the care of the patient with closed-chest drainage. All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 4  Compare and contrast the etiology and pathophysiology, clinical manifestations, assessment, diagnostic tests, medical management, nursing interventions, and prognosis for the patient with chronic obstructive pulmonary disease, including chronic bronchitis. All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 5  Compare and contrast the etiology and pathophysiology, clinical manifestations, assessment, diagnostic tests, medical management, nursing interventions, and prognosis for the patient with chronic obstructive pulmonary disease, including emphysema, asthma, and bronchiectasis.  State three possible nursing diagnoses for the patient with altered respiratory function. All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 6  Auscultate lung sounds. Identify abnormal breathing patterns.  Monitor a client receiving oxygen.  Assist the client with incentive spirometry use.  Perform: tracheostomy care, collar care and suctioning  Perform: oropharyngeal suctioning.  Obtain a sputum specimen  Perform postural drainage.  Provide nursing care for a client with underwater seal drainage.  Provide care for a client with chronic obstructive pulmonary disease (COPD). 7  Respiration:  External and Internal  Purpose of Respiratory System  Works with cardiac system to deliver oxygen to cells  for energy  for metabolism  Upper respiratory tract  Nose, Pharynx, Larynx  Trachea – Cilia and purpose?  Lower respiratory tract  Bronchial tree  Bronchi, Bronchioles, Alveolar ducts, Alveoli All items and derived items © 2015, 2011, 2006 by Mosby, Inc., 8 an imprint of Elsevier Inc. All rights reserved.  Oxygen(O2) enters the body via the lungs  O2 binds to Hgb in the alveoli  O2 is delivered to cells where it is exchanged for carbon dioxide (CO2)  CO2 is carried back the lungs where it is exhaled Copyright © 2019, 2015, 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, an imprint of Elsevier Inc. All rights reserved. 9 All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 10 Regulation of respiration – Nervous Control 1) Medulla oblongata and pons of the brain 2) Chemoreceptors—in carotid artery and aorta modify respiratory rates Chemoreceptors regulate breathing level and rate according to amount of CO2 in the blood Carbon dioxide is the chemical stimulant CO2 present in blood as carbonic acid Increase in CO2 = increase in acidity Eliminating CO2 via exhalation = more alkaline Normal pH 7.35 to 7.45 < 7.35 is acidic and > 7.45 is alkaline All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.  Sonorous wheezes  Formerly known as rhonchi  Low-pitched, loud, coarse, snoring sounds  Sibilant wheezes  Formerly known as wheezes  Musical, high-pitched, squeaking, or whistling sounds BECAUSE of air moving through narrowed bronchioles  Crackles  Short, discrete crackling or bubbling sounds heard during inspiration  Pleural friction rub  Low pitched, grating or creaking sounds All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 12  Chest X-ray Provides visualization of the lungs, ribs, clavicles, humeri, scapulae, vertebrae, heart, and major thoracic vessels Identifies lesions, infiltrates, foreign bodies, or fluid  Helical or Spiral CT Chest Scan Faster than CT If contrast is used – check for allergies to??. All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 13  Pulmonary Angiography  Contrast material is injected into pulmonary arteries to visualize pulmonary vasculature  Used to detect and definitively diagnose pulmonary embolism  Nursing interventions include:  Assessing allergies  Assess renal function labs  Ventilation-perfusion scan (V/Q scan)  Ventilation – Radioactive gas is used  Perfusion - IV radioisotope to check perfusion  Used to diagnose pulmonary embolism All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 14  Pulmonary function testing Assess disease in large and small airways  Mediastinoscopy  Surgical endoscopic procedure that allows for visualization of mediastinum Visual examination of chest cavity Obtain biopsies  Nursing interventions include performing postoperative care All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 15  Laryngoscopy Can be used for biopsy or polyp excision Nursing interventions include monitoring the patient’s airway  Bronchoscopy Performed by passing a bronchoscope into the trachea and bronchi Nursing interventions  Monitor airway  Conscious sedation is used All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 16  Sputum specimen Allows sputum to be tested for culture and sensitivity Guidelines for Collection Range of Sputum Characteristics  Yellow refers to????  Malodorous refers to????  Frothy refers to????  Occasionally refers to???? All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 17  Thoracentesis Purpose? Nursing Interventions? All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 18  Indicates ability of lungs to oxygenate arterial blood  PaO2  SaO2  Acid-base balance (pH)  CO2 – Respiratory  Bicarbonate (HCO3) – metabolic/kidneys  Sample from radial artery Place direct pressure on site for 5 minutes What if patient is taking anticoagulants? All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 19  1st - What are normal ABG values? pH: PaCO2 PaO2 HCO3 SaO2  Respiratory Alkalosis Nursing Interventions  Respiratory Acidosis Nursing Interventions All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 23 Epistaxis Etiology/pathophysiology Bleeding from the nose Clinical manifestations/assessment Bright red bleeding from one or both nostrils Diagnostics  Hemoglobin & Hematocrit  PT/INR  Rhinoscopy  CHECK BP Epistaxis  Treatment options Nasal packing with epinephrine Electrical or chemical cautery Posterior packing of the nasal cavity  Nursing interventions Keep pt. quiet; Fowler’s position with head FORWARD Direct pressure; ice compresses, suck on ice  Prognosis  Good with proper treatment  Did anyone have epistaxis as a child? What did you do? Antigen-Antibody Allergic Rhinitis and Allergic Conjunctivitis (Hay Fever)  Etiology/pathophysiology Antigen/antibody reactions due to allergens Allergic rhinitis and allergic conjunctivitis  Clinical manifestations/assessment Photophobia Nasal secretions and/or congestion Diagnostics Skin test; IgE Allergic rhinitis and allergic conjunctivitis  Medical management/nursing interventions Avoid allergen Antihistamines Topical or nasal corticosteroids Prognosis??  Discussion on OSA All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 27 Upper airway obstruction  Etiology/Pathophysiology Dentures Aspiration Diagnostics Medical emergency Foreign bodies identified via radiographic studies – Clinical manifestations/assessment Hypoxia; cyanosis Wheezing; stridor Show me the UNIVERSAL SIGN of ASPIRATION  As you are doing hourly rounds, you, the nurse, hears stertorous respirations, and wheezing for patient 2B. What are your 2 priority nursing interventions?  Note – You are able to identify the obstruction All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 29 Upper airway obstruction – Medical management/nursing interventions Open the airway Remove obstruction Artificial airway; tracheostomy Prognosis Good with immediate interventions; CAN BE FATAL Does anyone have real life clinical examples? What age group? Cancer of the larynx  Etiology/pathophysiology Heavy smoking and alcohol use  Diagnostics  Biopsy of lesions Cancer of the larynx  Clinical manifestations/assessment Progressive or persistent hoarseness – EARLY SIGN Pain radiating to the ear Difficulty swallowing Hemoptysis  Medical management Radiation Surgery Partial or total laryngectomy  Nursing interventions for the laryngectomy patient  Airway maintenance  Thorough assessments  Monitor I&O  Assist with nutrition  Develop communication strategies with patient  Prevent infection Copyright © 2019, 2015, 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, an imprint of Elsevier Inc. All rights reserved. 32 Cancer of the larynx Nursing interventions I&O; Weight Psychosocial assessment Communication techniques Lost chord club or new voice club Prognosis 5 year survival rate is 65% Acute bronchitis – Etiology/pathophysiology Inflammation of the trachea and bronchial tree What is this usually secondary to? Exposure to inhaled irritants – Examples? – Clinical manifestations/assessment Productive cough; wheezes Dyspnea; chest pain Low-grade fever Malaise; headache Diagnostics CXR Sputum specimen Acute bronchitis Acute bronchitis Medical – Nursing management interventions – Need to complete Antitussives ALL antibiotics Antipyretics Monitor lung Bronchodilators sounds Antibiotics Encourage rest Encourage periods fluids Encourage fluids Prognosis Avoid smoking, or Good irritating fumes Anthrax –Etiology/pathophysiology Caused by spore forming bacillus “Bacillus Anthracis” Spread by direct contact Three Types: Cutaneous; GI; Inhalational –Clinical Manifestations/Assessment –Initial Symptoms – Like flu –Severe symptoms  –Diagnostic Tests Chest X-ray; Blood C & S –Medical Management Cipro is drug of choice -Nursing Interventions?? -Prognosis?? Tuberculosis- ANY REAL LIFE EXAMPLES?  Etiology/pathophysiology Inhalation of tubercle bacillus (Mycobacterium tuberculosis) Infection versus active disease Diagnostics  Mantoux tuberculin skin test; Sputum culture  Clinical manifestations/assessment Fever Weight loss; weakness HEMOPTYSIS AND NIGHT SWEATS  Medical management/nursing interventions Tuberculosis isolation (acid fast bacilli [AFB]) R stands for: I stands for: P stands for: E stands for:  Nursing Interventions Ensure patients are in AFB isolation Ensure patients are compliant with taking medications  Referral to community center if needed Teaching:  TAKE daily for 6-9 months – LONG TIME  Coughing and sneezing etiquette?  Proper hand washing frequently   Active TB  Infected TB  Symptomatic No  Requires 6-9 months symptoms of medication administration Positive  50% - tuberculin NONCOMPLIANT  Non-multiplying skin test tubercle bacilli can CXR survive more than negative 50 years in human tissue and REACTIVATED All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 39  Pneumonia – Etiology/pathophysiology Inflammatory process of the bronchioles Bacteria, viruses, EVEN ASPIRATION  High-risk people  Immune system? Type of feedings? Age groups? Clinical Manifestations  Productive cough  Soreness in chest when coughing  Chills, fever, tachypnea Diagnostics  Blood and sputum culture & sensitivity  CXR; WBC –Leukocytosis  PFT; ABGs  Pulse oximetry Medical Management Medications – I.e. antibiotics, analgesics, expectorants, antipyretics, bronchodilators Encourage to cough and deep-breathe Chest Physiotherapy All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 41 Nursing Interventions Conserve energy Place patient in high Fowler’s Assist the patient to expectorate secretions  Assist with coughing  Hydration, Positioning, Suctioning Prognosis  Improvement in 2-3 days with antibiotics  Major cause of death in severely ill or elder patients All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 42 Pleural effusion/empyema – Etiology/pathophysiology Accumulation of fluid in the pleural space Empyema—infection – color of fluid? – Clinical manifestations/assessment Dyspnea Respiratory distress Fever – Diagnostics CXR Thoracentesis – To diagnose pathogen AND to relieve SOB and discomfort Pleural effusion/empyema Medical management/nursing interventions Thoracentesis Chest tube with closed water-seal drainage system Antibiotics Cough and deep-breathe Prognosis VARIABLE depending on patient’s overall condition  No kinks in tubing  Observe for air bubbling in water-seal chamber and fluctuations  Bubbling in water seal may occur INTERMITTENTLY BUT CONTINOUS bubbling means air leak  Never elevate drainage system to level of chest- FLUID WILL DRAIN BACK into pleural space  DO NOT STRIP or MILK chest tubes  If drainage system breaks  place distal end of chest tubing in sterile water All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 45 What is the intervention if the chest tube comes out? Immediately apply pressure with occlusive dressing Immediately notify MD Pneumothorax – Etiology/pathophysiology Collection of air or gas in the pleural space, causing the lung to collapse – Clinical manifestations/assessment Decreased or NO breath sounds OVER AFFECTED AREA Sudden, sharp chest pain with dyspnea Diaphoresis; tachycardia; tachypnea No chest movement on affected side – Diagnostics CXR ABG  Respiratory Acidosis Pneumothorax  Medical management/nursing interventions Chest tube to water-seal drainage system Oxygen Analgesics Encourage fluids Prognosis  Lung reexpands within several days  When CXR shows lungs reexpanded – chest tube removed  occlusive dressing placed over site of chest tube removal  What is an important nursing intervention after removal of chest tube? Atelectasis – Etiology/pathophysiology Collapse of lung tissue – Clinical manifestations/assessment Dyspnea; tachypnea; Decreased breath sounds – Diagnostics CXR; CT scan; ABG’s; Pulse oximetry –%? – Medical management/nursing interventions Cough and deep-breathe Analgesia; Early ambulation Incentive spirometry; Oxygen; Bronchodilators Chest tube – Prognosis Depends on patient age and general condition – Etiology/Pathophysiology Primary tumor or metastasis  Approximately 87% of lung cancers are related to smoking  Clinical manifestations/assessment  Few early symptoms occur  Later symptoms – Weight loss, fatigue, hemoptysis, fever, and chills Diagnostic Exams  CT  MRI  Sputum specimen  Mediastinoscopy All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 50 Medical Management Surgery Radiation Chemotherapy Nursing Interventions Postsurgical interventions – ABCs IS; Oxygen Chest tube assessment Prognosis American Cancer Society:  5-year survival rate after diagnosis is 15.9%  10-year survival rate is 5% All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 51 Pulmonary edema – Etiology/pathophysiology Accumulation of fluid in alveoli Patients literally drown in their own secretions Causes: Left sided heart failure, hepatic disease, Rapid administration of IV fluids – Clinical manifestations/assessment Dyspnea; tachypnea; tachycardia Pink or blood-tinged, frothy sputum Wheezing; crackles; restlessness; agitation Sudden weight gain Diagnostics CXR Pulmonary edema Medical management Oxygen Diuretics Strict I&O; daily weight Low-sodium diet Nursing interventions ABCs Vital signs, pulse oximetry Administration of 02 High fowler’s position Prognosis Guarded If not treated early, leads to death  Etiology/pathophysiology  Caused by a TRAVELING CLOT into the pulmonary artery  Risk factors include?  List 2 things the nurse can teach a patient who has limited mobility to avoid pulmonary embolism.  Clinical manifestations/assessment Sudden, unexplained dyspnea, tachypnea Hemoptysis Chest pain REAL LIFE EXAMPLE ON 28 year-old female All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 54  Diagnostic tests??  Medical management Oxygen; HOB up 30 degrees Anticoagulants Umbrella filter  Nursing interventions Check ABGs, pulse oximetry Patient teaching Medications  Prognosis Early diagnosis and appropriate treatment reduce mortality Untreated PE – 30% mortality rate All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 55 56 Etiology & Pathophysiology Air trapped in alveoli during expiration This leads to a decrease in O 2 and an increase in CO2 in the blood – =ABG?? Risk factor? Can lead to cor pulmonale- Rt sided HF – edema & distended neck veins Clinical Manifestations/Assessment DOE Excessive sputum Barrel chest appearance? Weight loss DOE – Real Life Example of Smoker All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 57 Diagnostic Exams CXR ABGs show?? Medical Management Bronchodilators Low-flow oxygen  The hypoxic drive Diuretics – Especially when? Nursing Interventions O2; Rest periods; High-protein, high-calorie diet divided into 5-6 meals a day Cessation of cigarette smoking Pursed-lip breathing Prognosis Irreversible All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 58 Chronic bronchitis – Etiology/pathophysiology Recurrent/chronic productive cough Min. 3 months/year x at least 2 years Causes – Cigarette smoking What occurred in history that increased risk of COPD in firefighters? Clinical manifestations/assessment Productive cough – In AM Dyspnea Wheezing Complication – Cor Pulmonale – Rt sided HF Chronic bronchitis Nursing Diagnostics Interventions CXR Increase fluids ABGs - ? Info on  Medical management smoking Bronchodilators – cessation SABAs and LABAs Provide small Mucolytics frequent meals Antibiotics Promote Oxygen (low-flow)  Prognosis oxygenation Rest periods Irreversible  Etiology/Pathophysiology INFLAMMATORY PROCESS Clinical manifestations/assessment Mild asthma Acute asthma attack Diagnostics  Medical management/nursing interventions Maintenance therapy Acute or rescue therapy Prognosis Nursing Interventions – Real Life Clinical Example All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 61  Etiology/Pathophysiology  Clinical Manifestations/Assessment  Diagnostics  Medical Management  Nursing Interventions  Prognosis All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 62  Cyanosis????  Gray skin  Pale skin  Decreased O2 saturation????  Confusion????  Irritability???? All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 63