week 2 exapt Respiratory.pdf

Pneumothorax Overview Definition: Air trapped in the pleural space, causing lung collapse. Pleural Space: Space between the lungs and chest cavity; normally contains 50 mL of fluid for lubrication and negative pressure. Effect: Air buildup prevents...

Pneumothorax Overview Definition: Air trapped in the pleural space, causing lung collapse. Pleural Space: Space between the lungs and chest cavity; normally contains 50 mL of fluid for lubrication and negative pressure. Effect: Air buildup prevents lung expansion, leading to partial or full collapse. Symptoms Small Pneumothorax: o May be asymptomatic (no symptoms). Large Pneumothorax: o Shortness of breath (dyspnea) o Chest pain o Hypoxia (low oxygen) o Absent or reduced breath sounds o Tachycardia (fast heart rate) Risk Factors Smoking Tall, thin body type Family history of pneumothorax Chronic lung diseases (e.g., asthma, COPD) Pregnancy Lung infections (e.g., pneumonia) Mechanical ventilation Previous pneumothorax Causes Medical Procedures: Puncture or laceration during procedures (e.g., needle aspiration, subclavian catheter insertion). Trauma: Rib fractures, penetrating wounds, blunt trauma. Lung Disease: Underlying diseases can increase risk of spontaneous pneumothorax (e.g., COPD, asthma).  Types of Pneumothorax 1. Spontaneous Pneumothorax Cause: Rupture of small air-filled sacs (blebs) on the lung surface. Air Location: Air becomes trapped in the pleural cavity, often rising to the top. Associated Lung Diseases: o Chronic obstructive pulmonary disease (COPD) o Asthma o Cystic fibrosis o Pneumonia Risk Factors: o Smoking o Tall and thin frame o Male gender o Personal or family history of spontaneous pneumothorax Symptoms: May vary based on lung involvement, commonly includes shortness of breath and chest pain. 2. Iatrogenic Pneumothorax Cause: Occurs due to medical procedures. o Lung puncture or laceration during procedures like transthoracic needle aspiration or subclavian catheter insertion. o Mechanical ventilation: High-pressure settings can cause barotrauma, rupturing alveoli. Mechanism: Air enters the pleural space due to damage during procedures, leading to lung collapse. Examples: o Subclavian catheter insertion (lungs are near subclavian veins) o Needle aspirations 3. Traumatic Pneumothorax Cause: Trauma to the chest, resulting in air entering the pleural space. o Rib fractures o Penetrating chest wounds (e.g., stab wounds)  o Blunt trauma to the chest Effect: The trauma causes a break in the pleura, allowing air to enter the pleural cavity and collapse the lung. 4. Tension Pneumothorax Cause: Air enters the pleural cavity but cannot escape. o May result from penetrating wounds or burst blebs due to high-pressure mechanical ventilation. Mechanism: o With each breath, more air enters the pleural cavity, increasing pressure. o This pressure collapses the lung and shifts the contents of the mediastinum (heart, great vessels) to the opposite side. o Compression of the unaffected lung, heart, and great vessels leads to reduced cardiac output and venous return. Medical Emergency: Requires immediate treatment to relieve pressure. o Needle or chest tube insertion is needed to allow air to escape and decompress the pleural cavity. Symptoms: Severe respiratory distress, tracheal deviation, decreased cardiac output, and potentially life-threatening cardiovascular collapse. 5. Hemothorax (Related Condition) Cause: Accumulation of blood in the pleural space, leading to lung collapse. Symptoms: o Chest pain due to blood irritating the parietal pleura. o Shallow, rapid breathing; wheezing or coughing. Common Cause: Traumatic injury to the chest. 6. Chylothorax (Related Condition) Cause: Accumulation of chyle (milky, lipid-rich fluid) in the pleural cavity due to damage to the thoracic duct of the lymphatic system. Types: o Spontaneous (non-traumatic) o Traumatic o Idiopathic (unknown cause) Nursing Diagnosis for Pneumothorax Assessment: o Sudden chest pain and shortness of breath. o Mild symptoms: tachycardia, dyspnea (small pneumothorax). o Severe symptoms: shallow rapid breathing, respiratory distress, air hunger, hypoxia (large pneumothorax). o Hyperresonance on percussion (pneumothorax) or dullness (hemothorax). o Absent or faint breath sounds, unequal chest expansion. Diagnosis: o Acute pain due to positive pressure in the pleural space. o Impaired gas exchange from decreased alveolar surface area. o Ineffective breathing pattern from respiratory distress. o Ineffective tissue perfusion due to hypoxia. Treatment & Management Emergency Management: o Open Wound: Cover with an occlusive dressing (secured on 3 sides) to prevent air entry and allow air to escape, avoiding tension pneumothorax. o Penetrating Wound: Stabilize any object in place, do not remove it. o Other: ▪ Assess respiratory function (O2 saturation, signs of dyspnea, air hunger). ▪ Elevate the head of the bed and position patient on the affected side. ▪ Administer oxygen if hypoxic. Long-Term Management: o May require chest tube insertion or surgery. o Educate the patient about risk factors and prevention. o Encourage smoking cessation. Expected Outcomes Establish effective respiratory pattern with normal arterial blood gas (ABGs). Absence of cyanosis or other hypoxic symptoms. Controlled pain at a level acceptable to the patient. Evaluation Pneumothorax resolved (verified by X-ray). Normal respiratory pattern restored. Adequate tissue perfusion and controlled pain. Nursing Management of a Client with a Chest Tube Client Assessment Position: Upright Fowler's position to promote drainage. Documentation: Comprehensive pulmonary assessment, including respiratory rate, heart rate, blood pressure, and temperature. o Monitor breath sounds, pulse oximetry (SpO2), and work of breathing. o Pain assessment and response to pain relief measures. Dressing & Insertion Site: Inspect for drainage, signs of infection, or subcutaneous emphysema. o If subcutaneous emphysema is spreading, notify the doctor. Chest Tube and Drainage System Assessment Position: Keep drainage unit below the client’s chest. Drainage Inspection: Check drainage (color, consistency, and amount) and monitor water seal and suction hourly. o Tidaling: Fluctuation in the water seal chamber with respiratory effort is normal. ▪ If absent, check for kinks, clamping, or fluid in the tubing. o Bubbling: Continuous bubbling may indicate a system leak. Check the connections. o Sudden changes: No bubbling or tidaling may suggest tube occlusion— assess the client and the system. Documenting: Record drainage characteristics every 8 hours. Report sudden changes, such as a sharp increase in drainage, especially if it is bright red or free- flowing (may indicate hemorrhage).  Avoid Manipulation: Do not milk, strip, or clamp the tube unless necessary, as it can cause extreme negative pressure and complications like tension pneumothorax. Bedside Equipment Always have: 1. Two padded drain clamps for emergencies (e.g., accidental disconnection). 2. Two sources of suction: One for the chest tube and one for airway management. 3. Bottle of sterile water or saline to use as a water seal if the drainage system breaks. Care of the Chest Tube Drainage System Key Safety Measures Keep the drainage system below the level of the client’s chest at all times. Ensure tubing has no kinks or obstructions. Secure all connections between the chest tube and drainage system with tape or ties. Ensure the chest tube is secured to the client’s skin a few inches below the insertion site. Keep the water seal chamber filled with sterile water or saline to maintain suction. Client Activity Bedrest Clients: o Frequent position changes to prevent respiratory complications (e.g., atelectasis, pneumonia). o Encourage coughing, deep breathing, or using an incentive spirometer hourly to help expand the collapsed lung. Ambulatory Clients: o Teach them how to carry and protect the drainage system during mobility. Suction: o Only discontinue suction if ordered by the healthcare provider. o Use portable suction if necessary during client transportation.  o Ensure the drainage system remains below chest level during all activities. Mechanical Ventilation Terminology: Assist-Control (AC) Ventilation: o A mode of mechanical ventilation that delivers a preset tidal volume (TV) and respiratory rate. o Client can trigger a breath, but each breath is delivered with the preset volume. o Used primarily for sedated or unconscious clients. Extubating: o Removal of an endotracheal tube. o Can be intentional (weaning) or accidental. High-Frequency Oscillatory Ventilation (HFOV): o Small tidal volumes (1-5 ml/kg) at high respiratory rates (100-300 breaths/min). o Used in critically ill ARDS patients when traditional ventilation is ineffective. o Clients need to be paralyzed and sedated during HFOV. Positive End-Expiratory Pressure (PEEP): o Positive pressure applied at the end of expiration. o Increases lung capacity and improves oxygenation. o Avoid in clients with increased intracranial pressure, low cardiac output, or hypovolemia. Pressure Support Ventilation (PSV): o Client initiates all breaths and determines the tidal volume, rate, and inspiratory time. o Pressurized gas reduces the work of breathing. o Monitor for hypercapnia. Synchronized Intermittent Mandatory Ventilation (SIMV): o Ventilator synchronizes with client’s spontaneous breathing to support it. o Reduces respiratory muscle fatigue. o Requires settings for rate, tidal volume, and PEEP. Weaning: o Gradually decreasing ventilator support before extubation. o Assess vital signs and work of breathing to determine readiness. Oropharyngeal Airway: Indications for Use: o Prevents the tongue from obstructing the airway. o Aids in oropharyngeal suctioning and ventilation of unconscious clients. o Protects the airway after anesthesia or seizures. Insertion Assistance: o Gather equipment (cotton-tipped applicator, oral airway, gloves, etc.). o Assess gag reflex before insertion. o Use tape or tube holder to secure, per facility policy. Care: o Assess mouth and lips for irritation or breakdown. o Reposition airway periodically to prevent breakdown. o Clean the airway with hydrogen peroxide if needed. Contraindications: o Presence of gag or cough reflex. o Loose or damaged teeth, recent oral surgery. Nasopharyngeal Airway: Indications for Use: o Protects nasal mucosa and assists in nasal-tracheal suctioning. o Useful when oral airways are not suitable due to limited mouth opening. Insertion Assistance: o Gather necessary equipment (correct size airway, gloves, lubricant, etc.). o No tape or tube holder required unless specified by facility. Care: o Rotate airway every 8 hours to prevent adhesion. o Lubricate suction catheter before use to prevent removal of the airway. Contraindications: o Facial trauma, bleeding disorders, nasal polyps. Bag-Valve-Mask (BVM) Ventilation Purpose: Provides effective ventilation and oxygenation for clients with respiratory distress. Procedure:  o Place face mask over client’s nose and mouth. o Manually squeeze the bag to push oxygen into the lungs. Airway Adjuncts: Use nasopharyngeal or oropharyngeal airways unless contraindicated. Positive End-Expiratory Pressure (PEEP) Valve: Can be attached to maintain pressure inside the lungs. Successful BVM Ventilation Factors Patent airway Adequate mask seal Proper ventilation technique PEEP valve as needed for oxygenation Continuous Positive Airway Pressure (CPAP) & Bilevel Positive Airway Pressure (BiPAP) CPAP: o Provides continuous pressure, client must breathe on their own. o Indications: obstructive sleep apnea (OSA), pulmonary edema, oxygenation improvement. BiPAP: o Two pressures: Higher during inhalation (IPAP), lower during exhalation (EPAP). o Provides ventilation like mechanical ventilation. o Indications: OSA, acute COPD exacerbation, ARDS, asthma exacerbation, pneumonia, post-extubation respiratory failure. Uses of CPAP vs BiPAP Continuous Positive Airway Pressure (CPAP) Uses: Obstructive Sleep Apnea (OSA): Keeps the airways open during sleep. Pulmonary Edema: Helps reduce fluid in the lungs and improve oxygenation. General Oxygenation Improvement: Used to support clients needing additional oxygen, especially when struggling with hypoxia. Bilevel Positive Airway Pressure (BiPAP) Uses:  Obstructive Sleep Apnea (OSA): Offers higher pressure during inhalation and lower during exhalation, making it easier for clients to breathe. Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD): Helps reduce the work of breathing and improve ventilation. Acute Respiratory Distress Syndrome (ARDS): Assists in delivering two levels of pressure to support breathing. Asthma Exacerbation: Reduces the effort required to inhale and exhale during an attack. Pneumonia: Supports breathing by helping maintain adequate oxygen levels. Post-Extubation in Respiratory Failure: Provides extra respiratory support after removal of an endotracheal tube to prevent reintubation. BiPAP is generally used when more intensive support is needed compared to CPAP, as it can deliver two levels of pressure and help with both inhalation and exhalation. Nursing Care for Noninvasive Positive Pressure Ventilation (NPPV) Interdisciplinary Care: Respiratory therapy (RT) sets up and monitors NPPV equipment. Assessment: o Level of consciousness, anxiety, ability to tolerate procedure. o Ability to protect airway (gag/cough reflex). o Vital signs, oxygen saturation, signs of inadequate oxygenation. Actions: o Collaborate with RT regarding interface, headgear, and device. o Monitor breathing pattern, synchrony with machine, mask fit, and leaks. Outcomes: o Improved oxygenation and ventilation, vital signs within normal limits. Contraindications: Claustrophobia, apnea, neuromuscular diseases, facial trauma, hypoventilation, uncontrolled vomiting. Endotracheal Intubation Purpose: Gold standard for securing the airway and providing oxygenation. Indications:  o Upper airway obstruction, apnea, ineffective secretion clearance, risk of aspiration, muscle weakness/paralysis, respiratory distress. Procedure: Inserted through mouth, ETT passes through pharynx and larynx, cuff inflated to seal trachea. Preparing for Endotracheal Intubation Contact rapid response team (RRT). Remove dentures, position supine, monitor vital signs, ensure venous access. Gather equipment and medications (sedation, paralytic). Rapid-Sequence Intubation (RSI) Rapid IV administration of sedative and paralytic for intubation. Medications: o Sedative-hypnotic: Propofol, etomidate. o Opioid: Fentanyl. o Neuromuscular blocker: Succinylcholine, rocuronium. Mechanical Ventilation Care Interprofessional Care: Nurse monitors client response; RT adjusts ventilator settings. Nursing Responsibilities: o Conduct hourly assessments, monitor ABGs, vital signs, and suction as needed. o Maintain proper ETT cuff inflation and suction equipment. o Assure availability of a bag-valve-mask. Ventilator-Associated Pneumonia (VAP) Prevention: o Upright position to reduce aspiration. o Continuous aspiration of subglottic secretions. o Oral care every 2-4 hours, change oral suction equipment daily. Endotracheal Tube Displacement Recognition: Low-pressure ventilator alarm, decreased breath sounds, respiratory distress. Response: o Stay with client, provide oxygen manually. o Notify healthcare provider and RT, prepare for reintubation if needed. Ventilator Settings Modes of Ventilation: o Volume Mode: Delivers set volume based on client size. o Pressure Mode: Pressure Support Ventilation (PSV), client controls rate and volume. PEEP: Keeps alveoli open at the end of exhalation, typically set at 5-10 mmHg. Fraction of Inspired Oxygen (FiO2): Adjusted to maintain oxygen levels above 60- 80 mmHg or saturation >92%. Respiratory Rate (f): Typically set between 12-20 breaths per minute. Nursing Response to Ventilator Alarms High-Pressure Alarm Causes: Secretions, excessive coughing, bronchospasm, ventilator asynchrony. o Actions: Suction, provide sedation, adjust tubing. Low-Pressure Alarm Causes: Disconnection, unplanned extubation, ETT cuff leak. o Actions: Reattach connections, inflate cuff or replace ETT. Apnea Alarm Causes: Respiratory arrest, over-sedation, unplanned extubation. o Actions: Change ventilator mode, adjust sedation, confirm ETT position. Ventilator Weaning and Extubation Weaning: Gradual reduction of ventilator support, use of spontaneous breathing trials (SBT). o Nursing Care: Monitor sedation, communicate with client, resume ventilation if needed. Extubation: o Prior to Extubation: Confirm orders, collaborate with RT, support client.  o After Extubation: Monitor for complications (oxygenation changes, breathing rate, PaO2/PaCO2 levels). Complications of Noninvasive Positive Pressure Ventilation (NPPV) Claustrophobia: Discomfort or anxiety due to the mask can affect compliance. Apnea (Respiratory Arrest): Ineffective breathing can make NPPV unsuitable. Neuromuscular Diseases: Reduced ability to maintain spontaneous breathing may necessitate more invasive ventilation. Facial/Airway Trauma: Physical injuries can prevent effective mask fitting or ventilation. Hypoventilation Syndrome: Inadequate ventilation may lead to buildup of carbon dioxide. Uncontrolled Vomiting: Risk of aspiration when using NPPV. Absence of Upper-Airway Reflexes: Lack of gag or cough reflex increases risk of aspiration. These complications can limit the use of NPPV and may indicate the need for endotracheal intubation for more effective management of the airway and ventilation. Nursing Actions for Noninvasive Positive Pressure Ventilation (NPPV) 1. Collaboration and Equipment Setup: o Collaborate with the respiratory therapist (RT) to determine the appropriate interface, headgear, and NPPV device for the prescribed therapy. o Ensure the mask is the correct size and fits the client well. 2. Monitoring: o Breathing Pattern: ▪ Continuously monitor the client’s breathing pattern, including synchrony with the machine. o Mask Fit and Leaks: ▪ Verify and adjust the fit of the mask interface and headgear as needed. ▪ Monitor for leaks around the mask and adjust straps to minimize leakage. o Vital Signs and Oxygenation:  ▪ Continuously monitor vital signs, oxygen saturation, breath sounds, and the breathing pattern to assess changes in oxygenation and ventilation. 3. Client Comfort and Safety: o Ensure that the client can quickly remove the mask in case of vomiting or other emergencies. o Assess the client's level of consciousness, anxiety, and ability to tolerate the procedure. o Evaluate the client’s ability to protect their airway (i.e., gag and cough reflexes).