Medical Surgical Nursing - Module-1.pdf

1 NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC  UNIT I. INTRODUCTION TO CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATION IN THE RESPIRATORY SYSTEM Nurses encounter different respiratory system disorde...

1 NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC  UNIT I. INTRODUCTION TO CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATION IN THE RESPIRATORY SYSTEM Nurses encounter different respiratory system disorders in many healthcare settings, ranging from community care to critical care units. To evaluate the respiratory system, the nurse must possess the ability to distinguish between normal evaluation results and abnormal ones. Developing and using sound evaluation techniques is essential for providing care for patients with both acute and long-term respiratory issues. Furthermore, an understanding of respiratory function and the importance of abnormal diagnostic test outcomes is important CHAPTER 1. ASSESSMENT OF THE RESPIRATORY SYSTEM Respiratory System ▪ It is composed of the upper and lower respiratory tracts, which are responsible for ventilation - movement of air in and out of the airways. ▪ The upper tract, known as the upper airway, warms and filters inspired air so that the lower respiratory tract (the lungs) can accomplish gas exchange. NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC ▪ Gas exchange involves delivering oxygen to the tissues through the bloodstream and expelling waste gases, such as carbon dioxide, during expiration. ▪ Primary functions of the respiratory system ✓ Provides oxygen for metabolism in the tissues ✓ Removes carbon dioxide – the waste product of metabolism ▪ Secondary functions of the respiratory system ✓ Facilitates sense of smell ✓ Produces speech ✓ Maintains acid – base balance ✓ Maintains body water levels ✓ Maintains heat balance ▪ Upper respiratory airway – filters, moistens and warms air during inspiration. 1. Nose – Humidifies, warms, and filters inspired air 2. Sinuses – Air-filled cavities within the hollow bones that surround the nasal passages and provide resonance during speech 3. Pharynx ✓ Passageway for the respiratory and digestive tracts located behind the oral and nasal cavities ✓ Divided into the nasopharynx, oropharynx, and laryngopharynx 4. Larynx ✓ Located just below the pharynx at the root of the tongue; commonly called the voice box ✓ Contains 2 pairs of vocal cords, the false and true cords ✓ The opening between the true vocal cords is the glottis. ✓ The glottis plays an important role in coughing, which is the most fundamental defense mechanism of the lungs. 5. Epiglottis ✓ Leaf-shaped elastic flap structure at the top of the larynx ✓ Prevents food from entering the tracheobronchial tree by closing over the glottis during swallowing ▪ Lower respiratory airway – enables the exchange of gases to regulate PaO2, PaCO2 and Ph 1. Trachea – Located in front of the esophagus; branches into the right and left mainstem bronchi at the carina 2. Mainstem bronchi ✓ Begin at the carina ✓ The right bronchus is slightly wider, shorter, and more vertical than the left bronchus. ✓ Divide into secondary or lobar bronchi that enter each of the 5 lobes of the lung ✓ The bronchi are lined with cilia, which propel mucus up and away from the lower airway to the trachea, where it can be expectorated or swallowed. 3. Bronchioles ✓ Branch from the secondary bronchi and subdivide into the small terminal and respiratory bronchioles ✓ Contain no cartilage and depend on the elastic recoil of the lung for patency ✓ The terminal bronchioles contain no cilia and do not participate in gas exchange. 2  4. Alveolar ducts and alveoli ✓ Acinus (plural, acini) is a term used to indicate all structures distal to the terminal bronchiole. ✓ Branch from the respiratory bronchioles ✓ Alveolar sacs, which arise from the ducts, contain clusters of alveoli, which are the basic units of gas exchange. ✓ Type II alveolar cells in the walls of the alveoli secrete surfactant, a phospholipid protein that reduces the surface tension in the alveoli; without surfactant, the alveoli would collapse 5. Lungs ✓ Located in the pleural cavity in the thorax ✓ Extend from just above the clavicles to the diaphragm, the major muscle of inspiration ✓ The right lung, which is larger than the left, is divided into 3 lobes: the upper, middle, and lower lobes. ✓ The left lung, which is narrower than the right lung to accommodate the heart, is divided into 2 lobes. ✓ The respiratory structures are innervated by the phrenic nerve, the vagus nerve, and the thoracic nerves. ✓ The parietal pleura lines the inside of the thoracic cavity, including the upper surface of the diaphragm. NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC ✓ The visceral pleura covers the pulmonary surfaces. ✓ A thin fluid layer, which is produced by the cells lining the pleura, lubricates the visceral pleura and the parietal pleura, allowing them to glide smoothly and painlessly during respiration. ✓ Blood flows throughout the lungs via the pulmonary circulation system. ✓ Lung function – reflects the mechanics of ventilation, is viewed in terms of lung volumes and lung capacities. Lung volumes – categorized as tidal volume, inspiratory reserve volume, expiratory reserve volume, and residual volume. Lung capacity – evaluated in terms of vital capacity, inspiratory capacity, functional residual capacity, and total lung capacity. ▪ Accessory muscles of respiration include: ✓ Scalene muscles – which elevate the first 2 ribs ✓ Sternocleidomastoid muscles – which raise the sternum ✓ Trapezius and pectoralis muscles – which fix the shoulders. ▪ The respiratory process 1. The diaphragm descends into the abdominal cavity during inspiration, causing negative pressure in the lungs. 2. The negative pressure draws air from the area of greater pressure, the atmosphere, into the area of lesser pressure, the lungs. 3. In the lungs, air passes through the terminal bronchioles into the alveoli and diffuses into surrounding capillaries, then travels to the rest of the body to oxygenate the body tissues. 3  4. At the end of inspiration, the diaphragm and intercostal muscles relax and the lungs recoil. 5. As the lungs recoil, pressure within the lungs becomes higher than atmospheric pressure, causing the air, which now contains the cellular waste products carbon dioxide and water, to move from the alveoli in the lungs to the atmosphere. 6. Effective gas exchange depends on distribution of gas (ventilation) and blood (perfusion) in all portions of the lungs Assessment of Diffusion and Perfusion ▪ Understanding and evaluating diffusion and perfusion is critical in assessing a patient's respiratory and circulatory health. ▪ These processes play key roles in maintaining the body's internal environment, ensuring that tissues receive adequate oxygen while waste products are efficiently removed. ▪ The respiratory process consists of three components. Ventilation, diffusion and perfusion. Ventilation consists of two parts Ventilation ▪ It is the process by which air moves in and out of the lungs ▪ Ventilation consists of two parts: a. Inspiration – which is the expansion of the chest with a negative intrapulmonary pressure when air flows into the thorax b. Expiration – when the intrapulmonary pressure is higher than the atmosphere, air will flow NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC out of the lungs. Diffusion ▪ It is the process by which oxygen and carbon dioxide are exchanged at the air–blood interface. ▪ It is the spontaneous movement of gases, without the use of any energy or effort by the body, between the alveoli and the capillaries in the lungs ▪ It is the process whereby gases move from an area of high pressure to low pressure. ▪ This includes during: ✓ Internal respiration – the movement in the internal tissues between cells and capillaries, ✓ External respiration – when gas is exchanged between the alveoli and lung capillaries. ▪ The role of Diffusion in Respiration Diffusion is the process by which molecules move from an area of higher concentration to an area of lower concentration. In the respiratory system, this principle facilitates the exchange of gases in the lungs. Oxygen is transferred from the alveoli, the tiny air sacs in the lungs, into the bloodstream and carried to the tissues. Conversely, carbon dioxide, a waste product of cellular metabolism, moves from the blood into the alveoli to be exhaled. The efficiency of this gas exchange process is vital for maintaining healthy cellular function and is a primary focus in respiratory assessments. ▪ The alveolar–capillary membrane is ideal for diffusion because of its large surface area and thin membrane. ▪ In the normal healthy adult, oxygen and carbon dioxide travel across the alveolar–capillary membrane without difficulty because of differences in gas concentrations in the alveoli and capillaries Perfusion ▪ It involves blood circulation through tissues and organs, essential for delivering oxygen and nutrients. ▪ Role of Perfusion in Respiration In the respiratory system, perfusion is necessary to deliver oxygen-rich blood to all body parts and carry carbon dioxide-laden blood back to the lungs for exhalation. Pulmonary Perfusion ▪ It is the actual blood flow through the pulmonary circulation. ▪ It is the process by which the cardiovascular system pumps blood throughout the lungs ▪ The blood is pumped into the lungs by the right ventricle through the pulmonary artery. ▪ The pulmonary artery divides into the right and left branches to supply both lungs. These two branches divide further to supply all parts of each lung. Normally about 2% of the blood pumped by the right ventricle does not perfuse the alveolar capillaries. This shunted blood drains into the left side of the heart without participating in alveolar gas exchange. ▪ The pulmonary circulation is considered a low-pressure system because the systolic blood pressure in the pulmonary artery is 20 to 30 mmHg, and the diastolic pressure is 5 to 15 mmHg. Gas Exchange ▪ Gas exchange occurs at two sites in the body: in the lungs, where oxygen is picked up and carbon dioxide is released at the respiratory membrane, and at the tissues, where oxygen is released, and carbon dioxide is picked up. ▪ External respiration ✓ The exchange of gases with the external environment and occurs in the alveoli of the lungs. ✓ It occurs as a function of partial pressure differences in oxygen and carbon dioxide between the alveoli and the blood in the pulmonary capillaries. 4  ✓ In external respiration, oxygen diffuses across the respiratory membrane from the alveolus to the capillary, whereas carbon dioxide diffuses out of the capillary into the alveolus. Note: As the solubility of oxygen in blood is relatively low, there is a significant difference in the partial pressure of oxygen between the alveoli and the blood in the pulmonary capillaries. The discrepancy amounts to around 64 millimeters of mercury (mm Hg). The alveoli have an oxygen partial pressure of around 104 mm Hg, whereas the capillary blood has a partial pressure of about 40 mm Hg. The significant difference in partial pressure generates a very pronounced pressure gradient, which facilitates the fast diffusion of oxygen over the respiratory membrane, from the alveoli into the bloodstream. Note: The carbon dioxide partial pressure differs between the alveolar air and the capillary blood. However, the disparity in partial pressure is smaller compared to oxygen, around 5 mm Hg. The carbon dioxide partial pressure in the capillary blood is around 45 mm Hg, whereas in the alveoli it is around 40 mm Hg. Nevertheless, carbon dioxide has far higher solubility compared to oxygen, with a ratio of around 20 times larger, in both blood and alveolar fluids. Therefore, the concentrations of oxygen and carbon dioxide that pass through the respiratory membrane are comparable. NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC ▪ Internal respiration ✓ It is the exchange of gases with the internal environment and occurs in the tissues. ✓ The gas exchange that occurs at the level of body tissues. Like external respiration, internal respiration also occurs as simple diffusion due to a partial pressure gradient. However, the partial pressure gradients are opposite of those present at the respiratory membrane. ✓ Oxygen is transported from the capillary to the cells by diffusion, whereas carbon dioxide is transported from the cells to the capillary through diffusion. Note: For effective gas exchange to occur, alveoli must be ventilated and perfused. V/Q Ratio ▪ Ventilation (V) refers to the flow of air throughout the lungs, whereas perfusion (Q) refers to the flow of blood in the pulmonary capillaries. ▪ Individual alveoli have variable degrees of ventilation and perfusion in different regions of the lungs. ▪ Collective changes in ventilation and perfusion in the lungs are measured clinically using the ratio of ventilation to perfusion (V/Q). ▪ V/Q imbalance occurs when there is inadequate ventilation and/or perfusion (imbalance occurs from inadequate ventilation, inadequate perfusion, or both) ▪ V/Q imbalance can result in shunting, in which the blood is not oxygenated and remains high in carbon dioxide. ▪ Changes in the V/Q ratio can affect gas exchange and can contribute to hypoxemia. ▪ Causes of V/Q imbalance ✓ Inadequate ventilation: Airway blockages, low compliance, increased airway resistance, pulmonary edema, atelectasis ✓ Inadequate perfusion: Increase alveolar pressure, increased pulmonary artery pressure, pulmonary embolism Note: The air we breathe is a gaseous mixture consisting mainly of nitrogen (78.62%) and oxygen (20.84%), with traces of carbon dioxide (0.04%), water vapor (0.05%), helium, and 5  argon. The atmospheric pressure at sea level is about 760 mm Hg. Partial pressure is the pressure exerted by each type of gas in a mixture of gases. Summary of Physiology of the Respiratory System 1. Basic gas-exchange unit of the respiratory system is the alveoli. 2. Alveolar stretch receptors respond to inspiration by sending signals to inhibit inspiratory neurons in the brain stem to prevent lung over distention. 3. During expiration stretch receptors stop sending signals to inspiratory neurons and inspiration is ready to start again. 4. Oxygen and carbon dioxide are exchanged across the alveolar capillary membrane by process of diffusion. 5. Neural control of respirations is in the medulla. The respiratory center in the medulla is stimulated by the concentration of carbon dioxide in the blood. 6. Chemoreceptors, a secondary feedback system, located in the carotid arteries and aortic arch respond to hypoxemia. These chemoreceptors also stimulate the medulla. 7. Ph regulation Blood Ph (partial pressure of hydrogen in blood): a decrease in blood Ph stimulates respiration hyperventilation, both through the neurons of the brain's respiratory center and through the chemoreceptors in carotid arteries and aortic arch. Blood PaCO2 (partial pressure of carbon dioxide in arterial blood): an increase in the NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC PaCO2 results in decreased blood Ph and stimulates respiration. Blood PaO2 (partial pressure of oxygen in arterial blood): a decrease in the PaO2 results in a decreased blood Ph, stimulating respiration. When arterial Ph rises or the arterial PaCO2 falls, hypoventilation occurs CHAPTER 2. RESPIRATORY CARE MODALITIES, PROCEDURES AND TREATMENTS Essential Diagnostic Procedures 1. Chest x-ray film (radiograph) ▪ Description: Provides information regarding the anatomical location and appearance of the lungs ▪ Nursing responsibility Pre-procedure: ✓ Remove all jewelry and other metal objects from the chest area. ✓ Assess the client’s ability to inhale and hold his or her breath. Post-procedure: ✓ Help the client to get dressed. Note: Ask women regarding pregnancy or the possibility of pregnancy before performing radiography studies. 2. Sputum specimen ▪ Description: Specimen obtained by expectoration or tracheal suctioning to assist in the identification of organisms or abnormal cells ▪ Nursing Responsibility Pre-procedure: ✓ Determine the specific purpose of collection and check institutional policy for the appropriate method for collection. ✓ Obtain an early morning sterile specimen by suctioning or expectoration after a respiratory treatment if a treatment is prescribed. ✓ Instruct the client to rinse the mouth with water before collection. ✓ Obtain 15 mL of sputum. ✓ Instruct the client to take several deep breaths and then cough deeply to obtain sputum. ✓ Always collect the specimen before the client begins antibiotic therapy. Post-procedure ✓ If a culture of sputum is prescribed, transport the specimen to the laboratory immediately. ✓ Assist the client with mouth care. Ensure that an informed consent was obtained for any invasive procedure. Vital signs are measured before the procedure and monitored post procedure to detect signs of complications 6 3. Laryngoscopy and bronchoscopy ▪ Description: Direct visual examination of the larynx, trachea, and bronchi with a fiberoptic bronchoscope ▪ The purposes of diagnostic bronchoscopy are: ✓ To examine tissues or collect secretions ✓ To determine the location and extent of the pathologic process and to obtain a tissue sample for diagnosis (by biting or cutting forceps, curettage, or brush biopsy) ✓ To determine if a tumor can be resected surgically ✓ To diagnose bleeding sites (source of hemoptysis) NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC ▪ Therapeutic bronchoscopy is used to: ✓ Remove foreign bodies from the tracheobronchial tree ✓ Remove secretions obstructing the tracheobronchial tree when the patient cannot clear them ✓ Treat postoperative atelectasis ✓ Destroy and excise lesions. ▪ Nursing Responsibility: Pre-procedure ✓ Maintain NPO (nothing by mouth) status as prescribed. ✓ Assess the results of coagulation studies. ✓ Remove dentures and eyeglasses. ✓ Establish an intravenous (IV) access as necessary and administer medication for sedation as prescribed. ✓ Have emergency resuscitation equipment readily available. Post-procedure ✓ Maintain the client in a semi-Fowler’s position. ✓ Assess for the return of the gag reflex. ✓ Maintain NPO status until the gag reflex returns. ✓ Monitor for bloody sputum. ✓ Monitor respiratory status, particularly if sedation has been administered. ✓ Monitor for complications, such as bronchospasm or bronchial perforation, indicated by facial or neck crepitus, dysrhythmias, hemorrhage, hypoxemia, and pneumothorax. ✓ Notify the health care provider (HCP) if signs of complications occur. 4. Endobronchial ultrasound (EBUS) ▪ Description: Tissue samples are obtained from central lung masses and lymph nodes, using a bronchoscope with the help of ultrasound guidance. Tissue samples are used for diagnosing and staging lung cancer, detecting infections, and identifying inflammatory diseases that affect the lungs, such as sarcoidosis. ▪ Nursing Responsibility: Post-procedure: ✓ The client is monitored for signs of bleeding and respiratory distress. 7 5. Pulmonary angiography ▪ Description: It is most used to investigate thromboembolic disease of the lungs, such as pulmonary emboli and congenital abnormalities of the pulmonary vascular tree. It involves the rapid injection of a radiopaque agent into the vasculature of the lungs for radiographic study of the pulmonary vessels Involves an injection of iodine or radiopaque contrast material ▪ Nursing Responsibility: Pre-procedure ✓ Assess for allergies to iodine, seafood, or other radiopaque dyes. ✓ Maintain NPO status as prescribed. ✓ Assess results of coagulation studies. ✓ Establish an IV access. ✓ Administer sedation as prescribed. ✓ Instruct the client to lie still during the procedure. ✓ Instruct the client that he or she may feel an urge to cough, flushing, nausea, or a salty taste following injection of the dye. ✓ Have emergency resuscitation equipment available. Post-procedure ✓ Avoid taking blood pressures for 24 hours in the extremity used for the injection. NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC ✓ Monitor peripheral neurovascular status of the affected extremity. ✓ Assess insertion site for bleeding. ✓ Monitor for reaction to the dye. These reactions can be mild (nausea, vomiting, mild urticaria, pallor), moderate (severe vomiting, extensive urticaria, dyspnea, rigor, laryngeal edema) or severe (pulmonary edema, cardiac arrhythmias or arrest, circulatory collapse). 6. Fluoroscopic Studies ▪ Description: Fluoroscopy is used to assist with invasive procedures, such as a chest needle biopsy or transbronchial biopsy, performed to identify lesions. It also may be used to study the movement of the chest wall, mediastinum, heart, and diaphragm, to detect diaphragm paralysis, and to locate lung masses. 7. Thoracentesis ▪ Description: Removal of fluid or air from the pleural space via transthoracic aspiration. Thoracentesis drains fluid from your chest during the procedure, which usually lasts about 15 minutes. ▪ Nursing Responsibility: Pre-procedure ✓ Prepare the client for ultrasound or chest radiograph, if prescribed, before procedure. ✓ Assess results of coagulation studies. ✓ Note that the client is positioned sitting upright, with the arms and shoulders supported by a table at the bedside during the procedure. ✓ If the client cannot sit up, the client is placed lying in bed toward the unaffected side, with the head of the bed elevated. ✓ Instruct the client not to cough, breathe deeply, or move during the procedure. Post-procedure ✓ Monitor respiratory status. ✓ Apply a pressure dressing and assess the puncture site for bleeding and crepitus. ✓ Monitor for signs of pneumothorax, air embolism, and pulmonary edema. 8 8. Pulmonary function tests ▪ Description: Tests used to evaluate lung mechanics, gas exchange, and acid-base disturbance through spirometric measurements, lung volumes, and arterial blood gas levels. ▪ Nursing Responsibility: Pre-procedure ✓ Determine whether an analgesic that may depress the respiratory function is being administered. ✓ Consult with the HCP regarding withholding bronchodilators before testing. ✓ Instruct the client to void before the procedure and to wear loose clothing. ✓ Remove dentures. ✓ Instruct the client to refrain from smoking or eating a heavy meal for 4 to 6 hours before the test Post-procedure: ✓ Client may resume a normal diet and any bronchodilators and respiratory treatments that were withheld before the procedure. NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC 9. Pleural biopsy ▪ Description: is accomplished by needle biopsy of the pleura or by pleuroscopy, a visual exploration through a fiberoptic bronchoscope inserted into the pleural space. Pleural biopsy is performed when there is pleural exudate of undetermined origin and when there is a need to culture or stain the tissue to identify tuberculosis or fungi 10. Lung biopsy ▪ Description: A transbronchial biopsy and a transbronchial needle aspiration may be performed to obtain tissue for analysis by culture or cytological examination. An open lung biopsy is performed in the operating room. ▪ Nursing Responsibility: Pre-procedure ✓ Maintain NPO status as prescribed. ✓ Inform the client that a local anesthetic will be used for a needle biopsy but a sensation of pressure during needle insertion and aspiration may be felt. ✓ Administer analgesics and sedatives as prescribed. Post-procedure ✓ Apply a dressing to the biopsy site and monitor for drainage or bleeding. ✓ Monitor for signs of respiratory distress and notify the HCP if they occur. ✓ Monitor for signs of pneumothorax and air emboli and notify the HCP if they occur. ✓ Prepare the client for chest radiography if prescribed 11. Spiral (helical) computed tomography (CT) scan ▪ Description: Frequently used test to diagnose pulmonary embolism IV injection of contrast medium is used; if the client cannot have contrast medium, a ventilation perfusion (V/Q) scan will be done. The scanner rotates around the body, allowing for a 3-dimensional picture of all regions of the lungs 12. Ventilation-perfusion (V/Q) lung scan ▪ Description The perfusion scan evaluates blood flow to the lungs. The ventilation scan determines the patency of the pulmonary airways and detects abnormalities in ventilation. A radionuclide may be injected for the procedure. 9  ▪ Nursing Responsibility: Pre-procedure ✓ Assess the client for allergies to dye, iodine, or seafood. ✓ Remove jewelry around the chest area. ✓ Review breathing methods that may be required during testing. ✓ Establish an IV access. ✓ Administer sedation if prescribed. ✓ Have emergency resuscitation equipment available. Post-procedure ✓ Monitor the client for reaction to the radionuclide. ✓ Instruct the client that the radionuclide clears from the body in about 8 hours. 13. D-dimer ▪ Description: A blood test that measures clot formation and lysis that results from the degradation of fibrin Helps to diagnose (a positive test result) the presence of thrombus in conditions such as deep vein thrombosis, pulmonary embolism, or stroke The normal D-dimer level is less than or equal to 250 ng/mL (250 mcg/L) D-dimer units (DDU); normal fibrinogen is 200 to 400 mg/dL (2 to 4 g/L) NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC 14. Pulse Oximetry ▪ Description Pulse oximetry is a noninvasive test that registers the oxygen saturation of the client’s hemoglobin. The capillary oxygen saturation (SaO2) is recorded as a percentage. The normal value is 95% to 100%. After a hypoxic client uses up the readily available oxygen (measured as the arterial oxygen pressure, PaO2, on arterial blood gas [ABG] testing), the reserve oxygen, that oxygen attached to the hemoglobin (SaO2), is drawn on to provide oxygen to the tissues. A pulse oximeter reading can alert the nurse to hypoxemia before clinical signs occur. If pulse oximetry readings are below normal, instruct the client in deep breathing technique and recheck the pulse oximetry. ▪ Procedure ✓ A sensor is placed on the client’s finger, toe, nose, earlobe, or forehead to measure oxygen saturation, which then is displayed on a monitor. ✓ Maintain the transducer at heart level. ✓ Do not select an extremity with an impediment to blood flow 15. Arterial Blood Gases (ABGs) ▪ Description: Measurement of the dissolved oxygen and carbon dioxide in the arterial blood helps to indicate the acid-base state and how well oxygen is being carried to the body. ▪ Nursing Responsibility: Pre-procedure: Collection of an ABG specimen ✓ Obtain vital signs. ✓ Determine whether the client has an arterial line in place (allows for arterial blood sampling without further puncture to the client). ✓ Perform the Allen’s test to determine the presence of collateral circulation Note: The Allen’s test is performed before obtaining an arterial blood specimen from the radial artery to determine the presence of collateral circulation and the adequacy of the ulnar artery. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. ✓ Assess factors that may affect the accuracy of the results, such as changes in the O2 settings, suctioning within the past 20 minutes, and client’s activities. ✓ Provide emotional support to the client. 10  ✓ Assist with the specimen draw; prepare a heparinized syringe (if not already prepackaged). Post-procedure ✓ Apply pressure immediately to the puncture site following the blood draw; maintain pressure for 5 minutes or for 10 minutes if the client is taking an anticoagulant ✓ Appropriately label the specimen and transport it on ice to the laboratory. ✓ On the laboratory form, record the client’s temperature and the type of supplemental O2 that the client is receiving NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC ▪ Causes of Acid – Based Imbalance Respiratory Acidosis ✓ Asthma: Spasms resulting from allergens, irritants, or emotions cause the smooth muscles of the bronchioles to constrict, resulting in ineffective gas exchange. ✓ Atelectasis: Excessive mucus collection, with the collapse of alveolar sacs caused by mucous plugs, infectious drainage, or anesthetic medications, results in ineffective gas exchange. ✓ Brain trauma: Excessive pressure on the respiratory center or medulla oblongata depresses respirations ✓ Bronchiectasis: Bronchi become dilated because of inflammation, and destructive changes and weakness in the walls of the bronchi occur ✓ Bronchitis: Inflammation causes airway obstruction, resulting in inadequate gas exchange. ✓ Central nervous system depressants: Depressants such as sedatives, opioids, and anesthetics depress the respiratory center, leading to hypoventilation (excessive sedation from medications may require reversal by opioid antagonist medications); carbon dioxide (CO2) is retained and the hydrogen ion concentration increases ✓ Emphysema and COPD: Loss of elasticity of alveolar sacs restricts air flow in and out, primarily out, leading to an increased CO2 level. ✓ Administering high oxygen levels per nasal cannula to clients who are CO2 retainers (example: emphysema and COPD). ✓ Hypoventilation: Carbon dioxide is retained and the hydrogen ion concentration increases, leading to the acidotic state; carbonic acid is retained and the pH decreases. ✓ Pneumonia: Excess mucus production and lung congestion cause airway obstruction, resulting in inadequate gas exchange. ✓ Pulmonary edema: Extracellular accumulation of fluid in pulmonary tissue causes disturbances in alveolar diffusion and perfusion. ✓ Pulmonary emboli: Emboli cause obstruction in a pulmonary artery resulting in airway obstruction and inadequate gas exchange Respiratory Alkalosis ✓ Fever: Causes increased metabolism, resulting in overstimulation of the respiratory system. ✓ Hyperventilation: Rapid respirations cause the blowing off of carbon dioxide (CO2), leading to a decrease in carbonic acid. ✓ Hypoxia: Stimulates the respiratory center in the brainstem, which causes an increase in the respiratory rate to increase oxygen (O2); this causes hyperventilation, which results in a decrease in the CO2 level. ✓ Hysteria: Often is neurogenic and related to a psychoneurosis; however, this condition leads to vigorous breathing and excessive exhaling of CO2. ✓ Overventilation by mechanical ventilators: The administration of O2 and the depletion of CO2 can occur from mechanical ventilation, causing the client to be hyperventilated. ✓ Pain: Overstimulation of the respiratory center in the brainstem results in a carbonic acid deficit 11  Metabolic Acidosis ✓ Diabetes mellitus or diabetic ketoacidosis: An insufficient supply of insulin causes increased fat metabolism, leading to an excess accumulation of ketones or other acids; the bicarbonate then ends up being depleted. ✓ Excessive ingestion of acetylsalicylic acid: Causes an increase in the hydrogen ion concentration. ✓ High-fat diet: Causes a much too rapid accumulation of the waste products of fat metabolism, leading to a buildup of ketones and acids. ✓ Insufficient metabolism of carbohydrates: When the oxygen supply is not sufficient for the metabolism of carbohydrates, lactic acid is produced and lactic acidosis results. ✓ Malnutrition: Improper metabolism of nutrients causes fat catabolism, leading to an excess buildup of ketones and acids. ✓ Renal insufficiency, acute kidney injury, or chronic kidney disease: Increased waste products of protein metabolism are retained; acids increase, and bicarbonate is unable to maintain acid-base balance. ✓ Severe diarrhea: Intestinal and pancreatic secretions are normally alkaline; therefore, excessive loss of base leads to acidosis. Metabolic Alkalosis ✓ Diuretics: The loss of hydrogen ions and chloride from diuresis causes a compensatory increase in the amount of bicarbonate in the blood. NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC ✓ Excessive vomiting or gastrointestinal suctioning: Leads to an excessive loss of hydrochloric acid. ✓ Hyperaldosteronism: Increased renal tubular reabsorption of sodium occurs, with the resultant loss of hydrogen ions. ✓ Ingestion of and/ or infusion of excess sodium bicarbonate: Causes an increase in the amount of base in the blood. ✓ Massive transfusion of whole blood: The citrate anticoagulant used for the storage of blood is metabolized to bicarbonate 16. Chest Tube Drainage ▪ Description: This is used to restore the negative pressure within the thoracic cavity The system is used to remove abnormal accumulations of air and fluid from the pleural space The anterior chest tube is used to drain air The posterior chest tube is used to drain fluid A chest tube, or a smaller drain with a curled end (pigtail catheter), stays inside patient’s chest and drains fluid or air over a few days. ▪ Types of Chest Tube Drainage a. Drainage collection chamber ✓ The drainage collection chamber is located where the chest tube from the client connects to the system. ✓ Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. b. Water seal chamber ✓ The tip of the tube is underwater, allowing fluid and air to drain from the pleural space and preventing air from entering the pleural space. ✓ Water oscillates (moves up as the client inhales and moves down as the client exhales). ✓ Excessive bubbling indicates an air leak in the chest tube system. c. Suction control chamber ✓ The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest. ✓ This chamber is filled with various levels of water to achieve the desired level of suction; without this control, lung tissue could be sucked into the chest tube. ✓ Gentle bubbling in this chamber indicates that there is suction and does not indicate that air is escaping from the pleural space. d. Dry suction system ✓ This is another type of chest drainage system. Because this is a dry suction system, absence of bubbling is noted in the suction control chamber. ✓ A knob on the collection device is used to set the prescribed amount of suction; then the wall suction source dial is turned until a small orange floater valve appears in the window on the device (when the orange floater valve is in the window, the correct amount of suction is applied). e. Portable chest drainage system ✓ Small and portable chest drainage systems are also available and are dry systems that use a control flutter valve to prevent the backflow of air into the client’s lung. 12  ✓ Principles of gravity and pressure, and the nursing care involved, are the same for all types of systems, and these systems allow greater ambulation and allow the client to go home with the chest tubes in place ▪ Nursing Responsibility ✓ Collection chamber - Monitor drainage; notify the physician if drainage is more than 70 to 100 mL/hour or if drainage becomes bright red or increases suddenly. - Mark the chest tube drainage in the collection chamber at 1- to 4-hour intervals, using a piece of tape. ✓ Water seal chamber - Monitor for fluctuation of the fluid level in the water seal chamber. - Fluctuation in the water seal chamber stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has re- expanded. - If the client has a known pneumothorax, intermittent bubbling in the water seal chamber is expected as air is drained from the chest, but continuous bubbling indicates an air leak in the system. - Notify the physician if there is continuous bubbling in the water seal chamber. ✓ Suction control chamber - Gentle (not vigorous) bubbling should be noted in the suction control chamber NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC of a wet suction system. ✓ An occlusive sterile dressing is maintained at the insertion site. ✓ A chest radiograph assesses the position of the tube and determines whether the lung has re-expanded. ✓ Assess respiratory status and auscultate lung sounds. Assess chest tube dressing for drainage and palpate surrounding tissue for crepitus. ✓ Monitor for signs of extended pneumothorax or hemothorax. ✓ Keep the drainage system below the level of the chest and the tubes free of kinks, dependent loops, or other obstructions. ✓ Ensure that all connections are secure. ✓ Encourage coughing and deep breathing. ✓ Change the client’s position frequently to promote drainage and ventilation. ✓ Do not strip or milk a chest tube unless specifically directed to do so by the physician and if agency policy allows it. ✓ Keep a clamp (may be needed if the system needs to be changed) and a sterile occlusive dressing at the bedside at all times. ✓ Never clamp a chest tube without a written prescription from the physician; also, determine agency policy for clamping a chest tube. ✓ If the drainage system cracks or breaks, insert the chest tube into a bottle of sterile water, remove the cracked or broken system, and replace it with a new system. ✓ Depending on the physician’s preference, when the chest tube is removed, the client may be asked to take a deep breath and hold it, and the tube is removed. Or the client may be asked to take a deep breath, exhale, and bear down (Valsalva maneuver). A dry sterile dressing, petroleum gauze dressing, or Telfa dressing is taped in place after removal of the chest tube 13  NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC Respiratory Management and Mechanical Ventilation Chest physiotherapy (CPT) ▪ Description: Percussion, vibration, and postural drainage techniques are performed over the thorax to loosen secretions in the affected area of the lungs and move them into more central airways. ▪ Nursing Responsibility: ✓ Perform chest physiotherapy (CPT) in the morning on arising, 1 hour before meals, or 2 to 3 hours after meals. ✓ Stop CPT if pain occurs. ✓ If the client is receiving a tube feeding, stop the feeding and aspirate for residual before beginning CPT. ✓ Administer the bronchodilator (if prescribed) 15 minutes before the procedure. ✓ Place a layer of material (gown or pajamas) between the hands or percussion device and the client’s skin. ✓ Position the client for postural drainage based on assessment. ✓ Percuss the area for 1 to 2 minutes. ✓ Vibrate the same area while the client exhales 4 or 5 deep breaths. ✓ Monitor for respiratory tolerance to the procedure. ✓ Stop the procedure if cyanosis or exhaustion occurs. ✓ Maintain the position for 5 to 20 minutes after the procedure. ✓ Repeat in all necessary positions until the client no longer expectorates mucus. ✓ Dispose of sputum properly. ✓ Provide mouth care after the procedure. ▪ Contraindications: ✓ Unstable vital signs ✓ Increased intracranial pressure ✓ Bronchospasm ✓ History of pathological fractures ✓ Rib fractures f. Chest incisions Postural Drainage ▪ Description: A technique that involves positioning a patient in specific ways to assist in the mobilization and removal of secretions from different segments of the lungs. It utilizes gravity to aid in the drainage process, often complemented by additional exercises or techniques for better results ▪ Nursing Responsibility: ✓ Auscultate the chest to determine the areas of the chest that need drainage ✓ Administer appropriate pain relief if needed 14  ✓ Bronchodilators, nebulization of saline or mucolytic agents may be administered prior to repositioning if prescribed ✓ Position the patient with the affected lung segment positioned uppermost, utilize pillows to maintain patient’s position. Note: If this does not appear to be having benefit or the patient is desaturating in this position try lying on the other side as some patients will clear more secretions from the dependent lung. ✓ Encourage patient to cough or suction the patient’s airway to assist in secretion clearance. ✓ Monitor the patients HR, RR and Sp02. ✓ Discontinue postural drainage (or change the postural drainage position) if tachycardia, dyspnea or hypoxia occur. NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC Incentive Spirometry ▪ Description: It is used to facilitate a sustained slow deep breath. Incentive spirometry is performed using devices which provide visual cues to the patients that the desired flow or volume has been achieved. The basis of incentive spirometry involves having the patient take a sustained, maximal inspiration ▪ Nursing Responsibility: ✓ Instruct the client to assume a sitting or upright position. ✓ Instruct the client to place the mouth tightly around the mouthpiece of the device. ✓ Instruct the client to inhale slowly to raise and maintain the flow rate indicator between the 600 and 900 marks. ✓ Instruct the client to hold the breath for 5seconds and then to exhale through pursed lips. ✓ Instruct the client to repeat this process 10 times every hour while awake Breathing Retraining ▪ Description: This includes exercises to decrease use of the accessory muscles of breathing, to decrease fatigue, and to promote carbon dioxide (CO2) elimination. The main types of exercises include pursed-lip breathing and diaphragmatic breathing. Note: Huff Coughing – This is an effective coughing technique that conserves energy, reduces fatigue, and facilitates mobilization of secretions. The client should take 3 or 4 deep breaths using pursed-lip and diaphragmatic breathing. Leaning slightly forward, the client should cough 3- or 4-times during exhalation. ▪ Nursing Responsibility: ✓ Instruct the client to inhale slowly through the nose. ✓ Instruct client to place hand over the abdomen while inhaling; the abdomen should expand with inhalation and contract during exhalation. ✓ The client should exhale 3 times longer than inhalation by blowing through pursed lips. Oxygenation Supplemental oxygen delivery systems 1. Nasal cannula for low flow – Used for the client with chronic airflow limitation and for longterm oxygen use 2. Nasal high-flow (NHF) respiratory therapy – Used for hypoxemic clients in mild to moderate respiratory distress 3. Simple face mask – Used for short-term oxygen therapy or to deliver oxygen in an emergency 4. Venturi mask – Used for clients at risk for or experiencing acute respiratory failure 5. Partial rebreather mask – Useful when the oxygen concentration needs to be raised; not usually prescribed for a client with chronic obstructive pulmonary disease (COPD) 15  6. Nonrebreather mask – Most frequently used for the client with a deteriorating respiratory status who might require intubation 7. Tracheostomy collar and T-bar or T-piece – Tracheostomy collar is used to deliver high humidity and the desired oxygen to the client with a tracheostomy; the T-bar or T-piece is used to deliver the desired FiO2 to the client with a tracheostomy, laryngectomy, or endotracheal tube 8. Face tent – Used instead of a tight-fitting mask for the client who has facial trauma or burns. Continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) 1. CPAP ▪ It maintains a set positive airway pressure during inspiration and expiration ▪ It beneficial in clients who have obstructive sleep apnea or acute exacerbations of COPD 2. BiPAP ▪ Provides positive airway pressure during inspiration and ceases airway support during expiration; there is only enough pressure provided during expiration to keep the airways open ▪ It usually used if CPAP is ineffective. Both CPAP and BiPAP improve oxygenation through airway support. NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC 16  Supplemental Oxygen Delivery Systems Device Oxygen Delivered Nursing Consideration Nasal cannula 1-6 L/min for oxygen ▪ Easily tolerated and can dislodge easily. (nasal prongs) concentration (FiO2) of 24% ▪ Doesn’t get in the way of eating or talking (at 1 L/min) to 44% (at 6 L/min) ▪ Effective oxygen concentration can be delivered. ▪ Allows the client to breathe through the nose or mouth ▪ Ensure that prongs are in the nares with openings facing the client ▪ Assess nasal mucosa for irritation from drying effect of higher flow rates ▪ Assess skin integrity, as tubing can irritate skin ▪ Add humidification as prescribed and check water levels Simple Face 5-8 L/ min oxygen flow for ▪ Interferes with eating and talking Mask FiO2 of 40%-60% ▪ Can be warm and confining ▪ Ensure that mask fits securely over nose and Minimum flow of 5 L/ min mouth needed to flush CO2 from ▪ Remove saliva and mucus from the mask NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC mask ▪ Provide skin care to area covered by mask ▪ Provide emotional support to decrease anxiety in the client who feels claustrophobic ▪ Monitor for risk of aspiration from inability of client to clear mouth Venturi Mask 4-10 L/ min oxygen flow for ▪ Keep the air entrapment port for the adapter FiO2 of 24%-55% open and uncovered to ensure adequate oxygen delivery Delivers exact desired ▪ Keep mask snug on the face and ensure tubing selected concentrations of O2 is free of kinks because the FiO2 is altered if kinking occurs or if the mask fits poorly ▪ Assess nasal mucosa for irritation; humidity or aerosol can be added to the system as needed Partial 6-15 L/ min oxygen flow for ▪ The client rebreathes one-third of the exhaled rebreather FiO2 of 70%-90% tidal volume, which is high in oxygen, thus mask (mask providing a high FiO2 with reservoir ▪ Adjust flow rate to keep the reservoir bag two- bag) thirds full during inspiration ▪ Keep mask snug on face and make sure the reservoir bag does not twist or kink ▪ Deflation of the bag results in decreased oxygen delivered and rebreathing of exhaled air Nonrebreather FiO2 of 60%-100% at a rate of ▪ Adjust flow rate to keep the reservoir bag mask flow that inflated. maintains the bag two-thirds ▪ Keep mask snug on the face full ▪ Remove mucus and saliva from the mask ▪ Provide emotional support to decrease anxiety in the client who feels claustrophobic ▪ Ensure that the valves and flaps are intact and functional during each breath ▪ Make sure the reservoir bag does not twist or kink or that the oxygen source does not disconnect; otherwise, the client will suffocate Tracheostomy ✓ The tracheostomy collar ▪ Ensure that aerosol mist escapes from the vents collar and T-bar can be used to deliver the of the delivery system during inspiration and or T-piece (face desired amount of oxygen expiration tent; face to a client with a ▪ Empty condensation from the tubing to prevent shield) tracheostomy the client from being lavaged with water and to ✓ Aspecial adaptor (T-bar or promote an adequate oxygen flow rate (remove T-piece) can be used to and clean the tubing at least every 4 hours) deliver any desired FiO2 to ▪ Keep the exhalation port in the T-piece open and client with tracheostomy, uncovered (if the port is occluded, the client can laryngectomy, or suffocate) endotracheal tube ▪ Position the T-piece so that it does not pull on ✓ The face tent provides 8-12 the tracheostomy or endotracheal tube and L/ min and the FiO2 varies cause erosion of the skin at the tracheostomy due to environmental loss insertion site 17 Mechanical Ventilation Types of Mechanical Ventilation 1. Pressure-cycled ventilator ▪ The ventilator pushes air into the lungs until a specific airway pressure is reached; it is used for short periods, as in the post anesthesia care unit. 2. Time-cycled ventilator ▪ The ventilator pushes air into the lungs until a preset time has elapsed; it is used for the pediatric or neonatal client. 3. Volume-cycled ventilator ▪ The ventilator pushes air into the lungs until a preset volume is delivered. ▪ A constant tidal volume is delivered regardless of the changing compliance of the lungs and chest wall or the airway resistance in the client or ventilator. 4. Microprocessor ventilator ▪ A computer or microprocessor is built into the ventilator to allow continuous monitoring of ventilatory functions, alarms, and client parameters. ▪ This type of ventilator is more responsive to clients who have severe lung disease or require prolonged weaning. Note: resuscitation bag should be available at the bedside for all clients receiving mechanical ventilation. Modes of ventilation NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC 1. Noninvasive positive pressure ventilation or BiPAP ▪ Ventilatory support given without using an invasive artificial airway (endotracheal tube or tracheostomy tube); orofacial masks and nasal masks are used instead. ▪ An inspiratory positive airway pressure (IPAP) and an expiratory positive airway pressure (EPAP) are set on a large ventilator or a small flow generator ventilator with a desired pressure support and positive end-expiratory pressure (PEEP) level. Note: This allows more air to move into and out of the lungs without the normal muscular activity needed to do so. ▪ Can be used in certain situations of COPD distress, heart failure, asthma, pulmonary edema, and hypercapnic respiratory failure 2. Controlled Mode ▪ The client receives a set tidal volume at a set rate. ▪ Used for clients who cannot initiate respiratory effort. ▪ Least used mode if the client attempts to initiate a breath. 3. Assist-control Mode ▪ Most used mode of MV ▪ Tidal volume and ventilatory rate are preset on the ventilator. ▪ The ventilator takes over the work of breathing for the client. ▪ The ventilator is programmed to respond to the client’s inspiratory effort if the client does initiate a breath. ▪ The ventilator delivers the preset tidal volume when the client initiates a breath while allowing the client to control the rate of breathing. ▪ If the client’s spontaneous ventilatory rate increases, the ventilator continues to deliver a preset tidal volume with each breath, which may cause hyperventilation and respiratory alkalosis 18  4. Synchronized intermittent mandatory ventilation (SIMV) ▪ Like assist-control ventilation in that the tidal volume and ventilatory rate are preset on the ventilator ▪ Allows the client to breathe spontaneously at her or his own rate and tidal volume between the ventilator breaths ▪ Can be used as a primary ventilatory mode or as a weaning mode ▪ When SIMV is used as a weaning mode, the number of SIMV breaths is decreased gradually, and the client gradually resumes spontaneous breathing Ventilator Alarms ▪ Causes of Alarms ✓ High-Pressure Alarm Increased secretions are in the airway. Wheezing or bronchospasm is causing decreased airway size. The endotracheal tube is displaced. The ventilator tube is obstructed because of water or a kink in the tubing. Client coughs, gags, or bites on the oral endotracheal tube. Client is anxious or fights the ventilator. ✓ Low-Pressure Alarm Disconnection or leak in the ventilator or in the client’s airway cuff occurs. The client stops spontaneous breathing NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC ▪ Alarm safety and alarm fatigue ▪ It is the responsibility of the nurse to be alert to the sound of an alarm because this signals a client problem. ▪ The nurse needs to respond promptly to an alarm and immediately assess the client. ▪ According to The Joint Commission (TJC), the most common contributing factor related to alarm- related sentinel events is alarm fatigue, which results when the numerous alarms and the resulting noise tends to desensitize the nursing staff and cause them to ignore alarms or even disable them. Complications ▪ Hypotension caused by the application of positive pressure, which increases intrathoracic pressure and inhibits blood return to the heart ▪ Respiratory complications such as pneumothorax or subcutaneous emphysema because of positive pressure ▪ Gastrointestinal alterations such as stress ulcers ▪ Malnutrition if nutrition is not maintained ▪ Infections ▪ Muscular deconditioning ▪ Ventilator dependence or inability to wean Nursing Responsibilities: ▪ Assess vital signs, lung sounds, respiratory status, and breathing patterns (the client will never breathe at a rate lower than the rate set on the ventilator). ▪ Monitor skin color, particularly in the lips and nail beds. ▪ Monitor the chest for bilateral expansion. ▪ Obtain pulse oximetry readings. ▪ Monitor ABG results. ▪ Assess the need for suctioning and observe the type, color, and amount of secretions. ▪ Assess ventilator settings. ▪ Assess the level of water in the humidifier and the temperature of the humidification system because extremes in temperature can damage the mucosa in the airway. ▪ Ensure that the alarms are set. ▪ If a cause for an alarm cannot be determined, ventilate the client manually with a resuscitation bag until the problem is corrected. ▪ Empty the ventilator tubing when moisture collects. ▪ Turn the client at least every 2 hours or get the client out of bed, as prescribed, to prevent complications of immobility. ▪ Have resuscitation equipment available at the bedside Essential Drugs Used in Clients with Respiratory Disorders Common Medication for Respiratory Disorders Drug Classifications Purpose and Nursing Consideration Medication Inhalation ▪ Metered-dose inhaler (MDI): Uses a chemical propellant to push the medication out of the inhaler ▪ Dry powder inhaler (DPI): Delivers medication without using chemical propellants, but it requires strong and fast inhalation ▪ Nebulizer: Delivers fine liquid mists of medication through a tube or a mask that fits over the nose and mouth, using air or oxygen under pressure. 19  Note: If 2 different inhaled medications are prescribed and 1 of the medications contains a glucocorticoid (corticosteroid), administer the bronchodilator first and the corticosteroid second. Bronchodilators ▪ Assess lung sounds. ▪ Monitor for cardiac dysrhythmias ▪ Assess for cough, wheezing, decreased breath sounds, and sputum production. ▪ Monitor for restlessness and confusion. ▪ Provide adequate hydration. ▪ Administer the medication at regular intervals around the clock to maintain a sustained therapeutic level. ▪ Administer oral medications with or after meals to decrease gastrointestinal irritation. ▪ Monitor for a therapeutic serum theophylline level of10 to 20 mcg/mL(55.5 to 111 mcmol/L) Anticholinergics ▪ Inhaled medications that improve lung function by blocking muscarinic receptors in the bronchi, which results in bronchodilation ▪ Effective for treating chronic obstructive pulmonary disease, allergy- induced asthma, and exercise, induced bronchospasm ▪ Side effects include dry mouth and irritation of the pharynx; sucking on NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC sugarless candy will help to relieve symptoms. ▪ Systemic anticholinergic effects rarely occur but can include increased intraocular pressure, blurred vision, tachycardia, cardiovascular events, urinary retention, and constipation Glucocorticoids ▪ Glucocorticoids act as antiinflammatory agents and reduce edema of the (Corticosteroids) airways; they are used to treat asthma and other inflammatory respiratory conditions Leukotriene Modifiers ▪ Used in the prophylaxis and treatment of chronic bronchial asthma (not used for acute asthma episodes) ▪ Assess lung sounds for rhonchi and wheezing. ▪ Assess liver function laboratory values. ▪ Monitor for cyanosis. ▪ Client education - To take medication 1 hour before or 2 hours after meal - To increase fluid intake - Not to discontinue the medication and to take it as prescribed, even during symptom-free periods Inhaled Nonsteroidal ▪ Monitor respirations and assess lung sounds for rhonchi or wheezing Antiallergy Agent ▪ Client education - To administer oral capsules at least 30 minutes before meals - Not to discontinue the medication abruptly, because a rebound asthmatic attack can occur Monoclonal Antibody ▪ Assess respiratory rate, rhythm, and depth, and auscultate lung sounds ▪ Assess for allergies and/or allergic reaction symptoms such as rash or urticaria. ▪ Have medications for the treatment of severe hypersensitivity reactions available during initial administration in case anaphylaxis occurs. ▪ Client education - That respiratory improvement will not be immediate. - Not to stop taking or decrease the currently prescribed asthma medications unless instructed - To avoid receiving live virus vaccines for the duration of treatment Antihistamines ▪ Monitor for signs of urinary dysfunction. ▪ Administer with food or milk. ▪ Avoid subcutaneous injection and administer by intramuscular injection in a large muscle if the intramuscular route is prescribed. ▪ Client education - To avoid hazardous activities, alcohol, and other CNS depressants - If the medication is being taken for motion sickness, take it 30 minutes before the event and then before meals and at bedtime during the event as prescribed. - To suck on hard candy or ice chips for dry mouth Nasal Decongestants ▪ Monitor for cardiac dysrhythmias. ▪ Monitor blood glucose levels. ▪ Client education - To avoid consuming caffeine in large amounts because it can increase restlessness and palpitations 20  - About the importance of limiting the use of nasal sprays and drops to prevent rebound nasal congestion Expectorants and ▪ Acetylcysteine, administered by nebulization, should not be mixed with Mucolytic Agents another medication. ▪ If acetylcysteine is administered with a bronchodilator, the bronchodilator should be administered 5 minutes before the acetylcysteine. ▪ Monitor for side effects of acetylcysteine such as nausea and vomiting, stomatitis, and runny nose. ▪ Client education - To take the medication with a full glass of water to loosen mucus - To maintain adequate fluid intake - To cough and deep breathe Antitussives ▪ Encourage the client to take adequate fluids with the medication. ▪ Encourage the client to sleep with the head of the bed elevated. ▪ Note that medication dependency can occur. ▪ Avoid administration to the client with a head injury or a postoperative cranial surgery client. Opioid Antagonists ▪ Assess vital signs, especially respirations. ▪ For intravenous administration, the dose is titrated every 2 to 5 minutes as prescribed NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC ▪ Have oxygen and resuscitative equipment available during administration Tuberculosis ▪ General client education points for tuberculosis medications Medications - Not to skip doses and to take medication for the full length of the prescribed therapy - Not to take any other medication without consulting with the HCP About the importance of follow-up HCP visits and laboratory tests - To avoid alcohol - To take medication on an empty stomach with 8 oz of water 1 hour before or 2 hours after meals and to avoid taking antacids with the medication - About the adverse effects that require HCP notification 21  UNIT II. CARE OF CLIENT WITH DISORDERS IN OXYGENATION AND VENTILATION CHAPTER 3. MANAGEMENT FOR CLIENTS WITH UPPER RESPIRATORY TRACT DISORDERS Many upper airway disorders are relatively minor, and their effects are limited to mild and temporary discomfort and inconvenience for the patient. However, other upper airway disorders are acute, severe, and life-threatening and may require permanent alterations in breathing and speaking. Thus, the nurse must have good assessment skills, an understanding of the wide variety of disorders that may affect the upper airway, and an awareness of the impact of these alterations on patients Upper respiratory tract infections are prevalent diseases that sometimes afflict the majority of individuals. Certain infections have an acute nature, characterized by symptoms that last for a few days, while others display a chronic one, with symptoms that endure for a prolonged period or reoccur. Patients afflicted with these illnesses seldom need hospitalization. Nevertheless, nurses working in community settings or long-term care institutions may come across patients who are afflicted with these illnesses. Therefore, it is crucial for the nurse to identify the indications and manifestations and provide suitable treatment. UPPER AIRWAY INFECTIONS Rhinitis NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC ▪ The word rhinitis means “inflammation of the nose.” ▪ It is an inflammation of the nasal mucosa and often the mucosa in the sinuses that can be caused by infection (viral or bacterial) or allergens. ▪ This is a condition characterized by inflammation and swelling of the mucous membrane in the nose. It is typically accompanied by a runny nose and congestion and is commonly caused by the common cold or seasonal allergies. ▪ Rhinitis is most often caused by colds and allergies, and the diagnosis is generally made by evaluating the symptoms. ▪ Rhinitis may be categorized as either acute, which refers to a brief duration, or chronic, which indicates a long-lasting condition. Acute rhinitis is often caused by viral infections; however, it may also be caused by allergies, bacteria, or other factors. Chronic rhinitis often coexists with chronic sinusitis, also known as chronic rhinosinusitis. ▪ It is classified as allergic or nonallergic rhinitis ▪ Allergic Rhinitis Called hay fever, causes congestion, sneezing, sore throat and itchy nose. It results from the immune system of the body responding to an external stimulus. Common environmental triggers include dust, molds, pollens, grasses, trees, and animals. Allergic rhinitis may be caused by both seasonal allergies and year-round allergies. Allergic rhinitis is the most common type of chronic rhinitis, affecting 10–20% of the population Pathophysiology: ✓ The presence of an allergen causes histamine and leukotrienes release (responsible for arteriolar dilation, increased vascular permeability, itching, rhinorrhea, mucous secretion, and smooth muscle contraction in the lung) and other mediators in the nasal mucosa. ✓ The mediators bind to blood vessel receptors causing capillary leakage, which leads to local edema and swelling. ✓ The release of mediators and cytokines at the first stage of an immune response to an allergen leads to a subsequent cellular inflammatory response during the following 4- 8 hours. This late-phase inflammatory response causes recurring symptoms, often nasal congestion, which frequently persist. Clinical Manifestations: Common symptoms of allergic rhinitis include pruritus (itching), frequent sneezing, rhinorrhea (runny nose), nasal congestion, and pruritus and lacrimation (itchy, watery eyes). Some patients may also have headaches, periorbital edema (swollen eyelids), coughing, and wheezing, particularly if sinusitis is also present. It is a common disorder that is strongly linked to asthma and conjunctivitis. Diagnosis of allergic rhinitis is based on a patient’s history of symptoms. Diagnostic Procedures: 1. Skin-prick testing - It is considered the primary method for identifying specific allergic triggers of rhinitis. - It involves placing a drop of a commercial extract of a specific allergen on the skin of the forearms or back, then pricking the skin through the drop to introduce the extract into the epidermis. Within 15–20 min, a wheal-and-flare response (an irregular blanched wheal surrounded by an area of redness) will occur if the test is positive. - Testing is typically performed using the allergens relevant to the patient’s environment (example: pollen, animal dander, and house dust mites) 2. Allergen-specific IgE tests 22  - Immunosorbent assay—previously performed by radioallergosorbent tests (RASTs) - This test will measure the amount of immunoglobulin E antibodies produced when a particular allergen is introduced into the blood Medical – Surgical and Pharmacological Management: 1. The treatment goal for allergic rhinitis is relief of symptoms. 2. Second-generation oral antihistamines and intranasal corticosteroids are the mainstay of treatment. 3. Allergen immunotherapy (also called desensitization immunotherapy) is an effective immune-modulating treatment that is used if pharmacologic therapy for allergic rhinitis is not effective. It helps to build long-term tolerance to specific environmental triggers, but they may take months or years to become fully effective 4. Therapeutic options available to achieve the goal includes avoidance measures, use of nasal saline irrigation, oral antihistamines (prevent the allergic reaction), intranasal corticosteroids (decrease nasal inflammation), combination intranasal corticosteroid/ antihistamine sprays; leukotriene receptor antagonists (LTRAs), and allergen immunotherapy (also called desensitization immunotherapy -). Note: Antibiotics do not relieve the symptoms of allergic rhinitis. ▪ Nonallergic Rhinitis Also known as Vasomotor rhinitis It is described a syndrome of chronic symptoms of nasal congestion and rhinorrhea, NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC unrelated to a specific allergen. It can be a long-term problem, and it has no clear cause. Pathophysiology: It is partly due to an imbalance between parasympathetic and sympathetic inputs on the nasal mucosa. Note: The most critical factor in attaining a proper diagnosis of vasomotor rhinitis is a comprehensive history and physical. Etiology: The cause of vasomotor rhinitis is not well understood, it is thought to be associated with the dysregulation of sympathetic, parasympathetic, and nociceptive nerves innervating the nasal mucosa. - The imbalance among mediators results in increased vascular permeability and mucus secretion from the submucosal nasal glands. - Mucous secretion is regulated primarily by the parasympathetic nervous system, whereas the sympathetic nervous system controls vascular tone. - Acetylcholine is the primary parasympathetic neurotransmitter that regulates mucus secretion and rhinorrhea. - Norepinephrine and neuropeptide Y are sympathetic neurotransmitters that control the vascular tone of vessels in the nasal mucosa and modulate the parasympathetic system-initiated secretions. - Sensory neuropeptides and nociceptive type C fibers of the trigeminal nerve contribute to mast cell degranulation as well as the itching/sneezing reflexes. Clinical Manifestations: The symptoms are like those of hay fever, but it is not caused by allergies. The exact cause of nonallergic rhinitis is unknown Nonallergic rhinitis can affect children and adults. But it's more common after age 20. The condition is marked by periods of remission and exacerbation. Triggering factors of nonallergic rhinitis include: - Irritants in the air. These include dust, smog, cigarette smoke and strong odors such as perfumes - Weather. Changes in temperature or humidity can trigger swelling in the lining of the nose. This can cause a runny or stuffy nose. - Infections. Illnesses caused by a virus often cause nonallergic rhinitis. These include a cold or the flu. - Foods and drinks. Eating hot or spicy foods are the main triggers. Drinking alcohol also can cause the tissue that lines the inside of the nose to swell. This can lead to a stuffy nose. - Some medicines. These include aspirin and ibuprofen (Advil, Motrin IB, others). High blood pressure medicines such as beta blockers also can cause symptoms. Medicines that have a calming effect such as sedatives. So can medicines for depression. - Hormonal changes. These can be due to pregnancy, periods or birth control use. Hormone problems that may trigger nonallergic rhinitis include a condition that happens when the thyroid gland does not make enough thyroid hormone. This is called hypothyroidism. Nonallergic rhinitis might be linked to: Nasal polyps and Sinusitis (swelling of the sinuses) Diagnostics Procedures: 1. Nasal cytology - It provides information about cell types composing the mucosa and helps to identify the presence of inflammatory markers. 23  - Scrapings from the inferior turbinate, nasal lavage, or nose blowing can provide epithelial cells for analysis. - The presence of 5 to 25 eosinophils in high-powered fields is compatible with the diagnosis of nonallergic rhinitis with eosinophilia syndrome (NARES), a subset of nonallergic rhinitis. 2. Nasal provocation testing – involves exposing a patient to a respective allergen, assessing the clinical response, and collecting objective data with rhinomanometry and acoustic rhinometry Medical – Surgical and Pharmacological Management 1. Educating the patient on avoiding environmental triggers 2. Limiting exposure to inciting factors such as perfumes, tobacco smoke, and cleaning supplies. 3. Topical nasal corticosteroids – considered as first-line medication, especially for congestion and obstructive symptoms. Topical steroids work on the nasal mucosa resulting in decreased neutrophil and eosinophil chemotaxis, reduced mast cell and basophil mediator release, and ultimately decreased edema and inflammation. The most common side effects are nasal dryness, crusting, and septal irritation. 4. Fluticasone propionate and beclomethasone are currently the only topical steroid preparations approved by the FDA for vasomotor rhinitis. 5. Budesonide also shown to be efficacious and is currently the only topical steroid agent NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC with a pregnancy category B rating. 6. Anticholinergic medications can provide relief from unrelenting rhinorrhea. A topical anticholinergic like ipratropium bromide is the first choice for rhinorrhea. 7. Topical antihistamines such as azelastine have approval for both allergic and nonallergic rhinitis. Azelastine is an H1-receptor antagonist. It also inhibits the synthesis of leukotrienes, kinins, cytokines, and adhesion molecule expression, while providing anti- inflammatory effects unrelated to histamine 8. The therapeutic transection of the vidian nerve is a well-known surgical option for vasomotor rhinitis. The technique aims to disrupt the autonomic nerve supply of the nasal cavity, thus decreasing nasal secretions ▪ Acute viral rhinitis Also known as “common cold” “Common cold” is often used when referring to an upper respiratory tract infection that is self- limited and caused by a virus (viral rhinitis) Virus that invades the upper respiratory tract. Rhinoviruses is the causative factor of most common colds Clinical Manifestations: Symptoms consist of sore throat (about 50% of patients develop a sore throat, which is often the first symptom to appear because it can occur as early as 10 hours after infection), runny nose, sneezing, general malaise, congestion, postnasal drip, cough, and a low-grade fever. Complications: Laryngitis, sinusitis, otitis media, tonsillitis, and lung infection. Medical – Surgical and Pharmacological Management: 1. Providing adequate fluid intake, encouraging rest, preventing chilling 2. Instruct to increase intake of vitamin C 3. Warm salt-water gargles soothe the sore throat 4. Stuffiness is relieved by decongestants, such as oxymetazoline or phenylephrine as a nasal spray or pseudoephedrine by mouth. This causes the blood vessels of the nasal mucous membrane to narrow (constrict). Nasal sprays should be used for only 3 days because after that period of time when the effects of the medications wear off, the mucous membrane often swells even more than before. This phenomenon is called rebound congestion. 5. Antihistamines taken by mouth or as a nasal spray sometimes help control a runny nose, but some cause drowsiness and most cause other problems, especially in older people. Other medications such as mast-cell stabilizers, some of which also act as antihistamines, can control symptoms of allergic rhinitis. 6. Zinc lozenges is used to reduce the duration of cold symptoms if taken within the first 24 hours of onset 7. Amantadine (Symmetrel) or rimantadine (Flumadine) is prescribed prophylactically to decrease the signs and symptom of common colds Note: Antibiotics are not effective for acute viral rhinitis. ▪ Nursing Management: 1. Encourage rest (8 to 10 hour/day) and increased fluid intake (at least 2,000 mL/day). 2. Encourage the use of a home humidifier or breathing steamy air after running hot shower water 3. Promote proper disposal of tissues and use of cough etiquette (sneeze or cough into tissue, elbow or shoulder and not the hands). 4. Instruct the importance of hand hygiene as a measure to prevent transmission 5. Complementary therapies such as large doses of vitamin C, and zinc preparations (lozenges and nasal sprays) can be useful in promoting improved immune response 24 Sinusitis ▪ Often called “rhinosinusitis”, an inflammation of the mucous membranes of one or more of the sinuses, usually the maxillary or frontal sinus. ▪ Swelling of the mucosa can block the drainage of secretions, which can cause a sinus infection. ▪ It often occurs after rhinitis and can be associated with a deviated nasal septum, nasal polyps, inhaled air pollutants or cocaine, facial trauma, dental infections, or loss of immune function. ▪ Rhinosinusitis is classified as: ✓ Acute Sinusitis – symptoms lasting less than 4 weeks ✓ Subacute Sinusitis – symptoms last between 4 and 12 weeks ✓ Chronic Sinusitis – symptoms lasting more than 12 weeks NCM 112: MEDICAL – SURGICAL NURSING: CONCEPTS ON RESPIRATORY – CARDIOVASCULAR - HEMATOLOGIC ✓