Medical-Surgical-Nursing.pdf

Medical-Surgical Nursing PROBLEMS IN OXYGENATION Rules: 1. 15 minutes late is considered absent 2. 3 consecutive lates is considered 1 absent 3. 3 unexcused absences is considered drop-out 4. Special exam should only be taken within 3 days from the day of examination 5. Strictly no using of...

Medical-Surgical Nursing PROBLEMS IN OXYGENATION Rules: 1. 15 minutes late is considered absent 2. 3 consecutive lates is considered 1 absent 3. 3 unexcused absences is considered drop-out 4. Special exam should only be taken within 3 days from the day of examination 5. Strictly no using of cellphone during the class 6. No one is allowed to go out of the room when the class has started 7. Use the bathroom whatsoever before the class starts 8. Post test shall be given during the first 15 minutes of the class schedule 9. Strictly no picture taking of slides, students must copy from the power point provided. 10. I will be checking your notebook at the end of each period. This will be one of the graded requirements 11. One assignment notebook is also required Grading system: Long exam 50% Short exam 20% Participation/Requirements 25% Attendance/Behavior 5% Total 100%  Anatomy and Physiology of Respiratory System Composed of Upper and Lower respiratory tracts -responsible for ventilation ( movement of air in and out of the airways) Upper respiratory tract - Warms and filters inspired air so that the lower respiratory tract (lungs) can accomplish gas exchange or diffusion Upper respiratory system Consists of nose, paranasal sinuses, pharynx, tonsils, and adenoids, larynx and trachea Gas exchange- involves delivering oxygen to the tissues through the bloodstream and expelling waste gases such as carbon dioxide during expiration Nose - serves as passageway for air to pass to and from the lungs - It filters impurities and humidifies and warms the air as it is inhaled Paranasal sinusis - frontal, ethmoid, sphenoid, and maxillary - Serves as resonating chamber in speech - Common site of infection Pharynx - Or throat is a tubelike structure that connects the nasal and oral cavities to the larynx - Passageway for respiratory and digestive tracts Larynx - Or voicebox is an organ that connects the pharynx and the trachea - Functions in vocalization  Cont. - Protects the lower airway from foreign substances and facilitates coughing Trachea - Or windpipe serves as passageway between the larynx and the right and left main stem bronchi which enter the lungs through an opening called hilus The lower respiratory tract - Consists of lungs which contain the bronchial and alveolar structures needed for gas exchange  Lungs Paired elastic structures enclosed in the thoracic cage which is an airtight Lungs chamber with distensible walls Each lung is divided into lobes: right lung has upper, middle and lower lobes Left lung consists of upper and lower lobes  pleura The lungs and wall of the thoracic cavity are lined a serous membrane called pleura Visceral pleura-covers the lungs Parietal pleura- lines the thoracic cavity Visceral and parietal pleura and the small amount of pleural fluid serve to lubricate the thorax and the lungs and permit smooth motion of the lungs within the thoracic cavity during inspiration and expiration Mediastinum- is in the middle of the thorax, between the pleural sacs that contain the 2 lungs Bronchi – main airways into the lungs Air enters your body through your mouth or nose and it passes through the larynx and trachea. The trachea, also called the windpipe, branches into a bronchus in each lung. bronchioles- tiny air passages that deliver oxygen to the alveoli in the lungs. Bronchi ALVEOLI -are tiny, balloon-shaped air sacs located at the end of the bronchioles, the branch-like tubes in the lungs. The alveoli move oxygen and carbon dioxide (CO2) molecules into and out of your bloodstream.  Function of the Respiratory System Oxygen transport-Oxygen is supplied to, and carbon dioxide is removed from cells by way of the circulating blood through the thin walls of the capillaries Respiration- process of gas exchange between the atmospheric air and the blood and between the blood and cells of the body Ventilation- Ventilation is the movement of air through the respiratory tract into (inspiration) and out of (expiration) the respiratory zone (lungs) Pulmonary Diffusion- is the process by which oxygen and carbon dioxide are exchanged from an area of higher concentration to areas of lower concentration at the air Pulmonary perfusion- is the actual blood flow through the pulmonary vasculature. The blood is pumped into the lungs by the RV through the PA Gas Exchange  ASSESSMENT HEALTH HISTORY COMMON SYMPTOMS - DYSPNEA - COUGH - SPUTUM PRODUCTION - CHEST PAIN - WHEEZING - HEMOPTYSIS PAST HEALTH SOCIAL AND FAMILY HISTORY  DIAGNOSTIC EVALUATION 1. PULMONARY FUNCTION TEST- (PFT) test to assess respiratory function and to determine the extend of dysfunction 2. ARTERIAL BLOOD GAS- (ABG) aid in assessing the ability of the lungs to provide adequate oxygen and remove carbon dioxide which reflects ventilation, and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body ph, which reflects metabolic states. These are obtained through an arterial puncture at the radial, brachial, or femoral artery or through an indwelling arterial catheter VENOUS BLOOD GAS STUDIES- provide additional data on oxygen delivery and consumption. Reflects the balance between the amount of oxygen used by tissues and organs and the amount of oxygen returning to the right side of the heart in the blood 4. PULSE OXIMETRY- is a non invasive method of continuously monitoring the oxygen saturation of hemoglobin 5. END TIDAL CARBON DIOXIDE- (ETCO2) is a non invasive method of monitoring partial pressure of carbon dioxide at end exhalation. It is considered to be a reliable tool for detecting and monitoring of life threatening conditions because it provides immediate information about ventilation, perfusion, and metabolism by determining the concentration of CO2. 6. CULTURES- throat, nasal and nasopharyngeal cultures can identify pathogens responsible for respiratory infections 7. SPUTUM STUDIES- is obtained for analysis to identify pathogenic organisms and to determine whether malignant cells are present 8. IMAGING STUDIES- including x-rays, computed tomography (CT), magnetic resonance imaging (MRI), and radioisotope or nuclear scanning may be part of any diagnostic work up ranging from extent of the infection of sinusitis to tumor growth in cancer 9. COMPUTED TOMOGRAPHY- CT in the chest is an imaging method in which the lungs, mediastinum, and vascular structures within the chest are scanned in successive layers by a narrow beam x-ray 10. PULMONARY ANGIOGRAPHY- is use to investigate congenital abnormalities of the pulmonary vasculature tree. To visualize the pulmonary vessels, a radiopaque agent is injected through a catheter inserted into a vein and then threaded into the pulmonary artery 11. MAGNETIC RESONANCE IMAGING- is similar to CT scan except the magnetic fields and radiofrequency signals are used instead of radiation. MRI is able to better distinguish between normal and abnormal tissues than CT and therefore yields a much more detailed diagnostic image. 12. FLUOROSCOPIC STUDIES- allows live x-ray images to be generated via a camera to a video screen, is used to assist with invasive procedures such as needle biopsy or transbronchial biopsy, that are used to identify lesions. 13. RADIOISOTOPE DIAGNOSTIC PROCEDURES (LUNG SCAN)- V/Q scan, gallium scan, and positron emission tomography (PET) are performed to assess normal lung functioning, pulmonary vascular supply, and gas exchange * V/Q scan- performed by injecting a radioactive agent into a peripheral vein and then obtaining a scan of the chest to detect radiation. It is usually done if your healthcare provider thinks you have a pulmonary embolism (blood clot). 14. ENDOSCOPIC PROCEDURES BRONCHOSCOPY- is a direct inspection and examination of the larynx, trachea, and bronchi through either a flexible fiberoptic bronchoscope or a rigid bronchoscope. The bronchoscope is advanced into bronchial structures orally. THORACOSCOPY- is diagnostic procedure in which the pleural cavity is examined with an endoscope and fluid and tissues can be obtained for analysis. The fiberoptic mediastinoscope is inserted into the pleural cavity, any fluid is aspirated and the pleural cavity is inspected through the instrument THORACENTESIS- the aspiration of fluid and air from the pleural space for diagnostic or therapeutic reasons. The purpose of the procedure include removal of the fluid, very rarely air from pleural cavity; aspiration of pleural fluid for analysis; pleural biopsy, and instillation of medication into the pleural space 15. BIOPSY- excision of the small amount of tissue PLEURAL BIOPSY- is accomplished by needle biopsy of the pleura, thoracoscopy, or pleuroscopy, a visual exploration through a fiberoptic pleuroscope inserted into the pleural space or through a throracotomy LUNG BIOPSY PROCEDURES- performed to obtain tissue for examination when other diagnostic testing indicates potential interstitial lung disease, such as cancer, infection or sarcoidosis LYMPH NODE BIOPSY- A needle biopsy removes a small sample of cells from your lymph node. Part I. Upper Respiratory Problems  RHINITIS- Is an inflammation and irritation of the mucous membrane of the nose  A. Assessment  Subjective Data  a. History of indoor allergens (molds, dust mite) outdoor allergens (trees, weeds, grasses, molds)  Objective Data  a. Physical assessment- rhinorrhea (runny nose), nasal congestion, nasal discharge, sneezing, pruritus of the nose, roof of the mouth, throat, eyes, and ears  b. Diagnostic studies/procedures- allergy test may be perform  B. Analysis/Nursing Diagnosis Rhinitis C. Planning D. Implementation of Care of Clients MEDICAL MANAGEMNT Desensitizing immunizations and corticosteroids may be required, antimicrobial agent Pharmacologic therapy- Antihistamine Nasal spray Antihistamine/decongestant (brompheniramine/pseudoephedrine, cromolyn Oral decongestant agents Intranasal ipratropium NURSING MANAGEMNT - instruct the patient to avoid or reduce exposure to allergens and irritants such as dusts, molds, animals, fumes, odors, powders, sprays, and tobacco smoke - Instruct patient to read drug labels before taking any OTC medication - Instruct correct administration of the nasal medications to achieve maximum relief - Nasal container should be cleaned after each use and should never be shared with other people to avoid cross- contamination - Get flu vaccine each year - Documentation of patient’s response to treatment - Proper referral or collaboration with other health care team Pharyngitis- painful inflammation of the pharynx. Also referred to as sore throat A. Assessment Subjective Data a. History of environmental exposure to viral agents and poorly ventilated rooms b. peaks in cold and warm seasons Objective Data a. Physical assessment- inflammation of the pharynx, the back portion of the throat, that includes posterior portion of the tongue, soft palate, and tonsils Fiery red pharyngeal membrane and tonsils Lymphoid follicles that are swollen and flecked with white purple exudate Enlarged and tender cervical lymph nodes Fever Vomiting anorexia b. Diagnostic studies/procedures Rapid antigen detection test (RADT) to ensure viral or bacterial infection B. Mode of Transmission: droplet in coughs and sneezes, as well as clean hands that have been exposed to the contaminated fluids C. Planning D. Implementation of Care of Clients Medical Management - Antibiotic (Penicillin), cephalosphorins (cefpodoxime and cefuroxime) and macrolides (clarithromycin and azithromycin) - Analgesics, benzocaine (gurgle) E. Client Education/Nursing Management - Nutrition-liquid or soft diet , cool beverages, warm liquids, and flavored frozen dessert such as ice pops - IV fluids - Increase oral fluid intake - Instruct the patient to report promptly to the doctor the following: dyspnea, drooling, inability to swallow, and inability to open the mouth Used tissue should be disposed of properly to avoid spread of infection Warm gargles or throat irrigations Ice collar can relieve severe sore throats Instruct pt full course of therapy of ABO to avoid complications such as nephritis and rheumatic fever Replace toothbrush with new one - Proper reporting and documentation of care  Tonsillitis and Adenoiditis - is inflammation of the tonsils, two oval-shaped pads of tissue at the back of the throat — one tonsil on each side Adenoiditis- Adenoiditis is an inflammation of the adenoids caused by infection. Adenoids are masses of lymphatic tissue that help the body fight infection. Adenoids are found in the throat, also called the pharynx, just behind the nose. Along with the tonsils, adenoids are the first line of defense against bacteria and viruses. A. Assessment Subjective Data a. History- rule out related or systematic conditions Tonsillitis Objective Data a. Physical assessment Sore throat, fever, snoring, and difficulty swallowing, a scratchy muffled or throaty voice, bad breath, stomachache, neck pain or stiff neck, headache enlarged adenoids may cause mouth breathing, earache, draining ears, frequent head colds, bronchitis, foul smelling breath, voice impairment, and noisy respiration Infection can extend to the middle ear and cause mastoiditis Infection may reside in the middle ear as chronic that may cause permanent deafness b. Diagnostic studies/procedures- RADT, throat swab culture, comprehensive audiometric assessment is warranted B. Analysis/Nursing Diagnosis: - Impaired airway clearance, risk for impaired nutritional status, risk for constipation, anxiety associated with surgical procedure, acute pain associated with surgical incision, C. Planning - Major goal for the pt include optimal respiratory function, relief of pain, optimal cardiovascular function, increase activity tolerance, unimpaired healing, maintenance of body temperature, and maintenance of nutritional balance. Resumption of usual pattern of bowel and bladder elimination, identification of peri operative positioning injury, acquisition of sufficient knowledge to manage self care after discharge and absence of complications. Medical Management Increased fluid intake Antispasmodic agent Salt water gargles and rest Bacterial infections- penicillin or cephalosporin Viral infections- supportive therapy Tonsillectomy Adenoidectomy- for chronic nasal airway obstruction, chronic rhinorrhea, obstruction of the auditory tube with related ear infections and abnormal speech cefdinir or moxifloxacin given to patient undergoing tonsillectomy/adenoidectomy E. Client Education/Nursing Management Post operative management: - Continuous nursing observation post operatively and recovery periods due to risk of hemorrhage and compromise airway - Post op position is prone with patient’s head turned to the sides to allow drainage from the mouth and pharynx - Do not remove oral airway until the patient’s gag and swallowing reflexes have returned - Place ice collar on the neck - Watch for post op complications such as fever, throat pain, ear pain and bleeding - Report to surgeon immediately if the patient vomits large amount of dark blood or bright red blood at frequent intervals - If there’s no bleeding water and ice chips may be given as soon as desired - Instruct patient to refrain from too much talking and coughing - The family must be instructed to report immediately for any signs and symptoms of hemorrhage/bleeding. Bleeding may occur 8 days post op - Alkaline mouthwash and warm saline solutions are used for thick mucus and halitosis - Explain to pt that sore throat, stiff neck, minor ear pain and vomiting may occur after 24 hours - The pt should eat an adequate diet with soft diet - Pt should avoid spicy, hot, acidic, or rough food - Milk and milk products (ice cream and yogurt) may be restricted because they make removal of mucus more difficult - Avoid vigorous toothbrushing or gargling to avoid bleeding - Pt should avoid smoking and heavy lifting or exertion for 10 days Laryngitis- inflammation of the larynx - Often caused by pathogens caused by the pathogen that caused common cold and pharyngitis caused by virus. Also associated with allergic rhinitis or pharyngitis - Viral laryngitis is common in winter and is easily transmitted to others A. Assessment - Hoarseness or aphonia (loss of voice) - Severe cough - Worsen with cold or dry wind B. Diagnosis - Laryngoscopy and biopsy C. Medical Management - Resting the voice, avoiding irritants (smoking), resting and inhaling cool steam, or an aerosol - Antibiotic therapy - Cortecosteriod (beclomethasone) Nursing Intervention: - Rest and maintain a well humidified environment - Expectorant - Increase OFI to 2 to 3 to thin the secretions - Contact physician if with loss of voice, sore throat that makes swallowing saliva difficult, hemoptysis, and noisy respirations - Continued hoarseness after a voice rest that persists for more than 5 days should be reported because of the possibility of malignancy Peritonsillar abscess -is a complication of acute pharyngitis or acute tonsillitis when bacterial infection invades one or both tonsils -tonsils may enlarge sufficiently to threaten airway patency Clinical Manifestations: - High fever - Leukocytosis - “hot potatoe voice” - Chills Interventions: - Intravenous antibiotic therapy is given - Needle aspiration or incision or drainage of the abscess - An emergency tonsillectomy, or an elective tonsillectomy may be done after the infection has subsided Part II. Lower Respiratory Problems Chronic Obstructive Pulmonary Disease/Chronic Airflow Limitation (COPD/CAL - COPD is characterized by airflow limitation that is not fully reversible. The airflow limitation is progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by smoking 2 types of obstructive airway disease in COPD are: 1. Chronic bronchitis 2. Emphysema ASSESSMENT IN COPD Cough, adventitious breath sounds (wheezing) Dyspnea, chest pain, sputum production, purse lip breathing CHRONIC BRONCHITIS - A PRODUCTIVE COUGH THAT LASTS 3 MONTHS IN EACH OF 2 CONSECUTIVE YEARS, IN PT IN WHOM OTHER CAUSES OF COUGH ARE EXCLUDED EMPHYSEMA PRESENCE OF OVER DISTENDED, NON FUNCTIONAL ALVEOLI, WHICH MAY RUPTURE, RESULTING TO LOSS OF AERATING SURFACE Tends to assume upright, leaning forward position Alteration in LOC Alteration in skin color (pallor to cyanosis) Alteration in skin temperature (cold to touch) - Voice changes - Decrease metabolism (weakness, fatigue, anorexia, weight loss, alteration in thoracic anatomy, clubbing of fingers, polycythemia Management Rest to reduce O2 demand Increase OFI  Good oral care Diet: high calorie, high protein, low carbohydrates, O2 therapy 1 to 3 liters per minute. The safest is 2 lpm Do not give high concentration of oxygen to COPD. The drive of breathing may be depressed Avoid cigarette smoking, alcohol, environmental pollutants Chest physiotherapy (percussion, vibration, postural drainage) Bronchial hygiene measures Steam inhalation, aerosol inhalation, medimist inhalation Pharmacotherapy Expectorants (guaiafenessin/mucomyst/mucosolvan) Antitussives (best given during the night to prevent sleep pattern disturbance due to persistent cough) ex. Dextromethorphan, codeine, Øobserve drowsiness, avoid activities that involve mental alertness ex. Driving, operating electrical machines ØCauses decrease of peristalsis thereby constipation Bronchodilators ØAminophylline (theophyline), Ventolin (Salbutamol), bricanyl (terbutaline), Spiriva (tiotropium) ØXopenex (levalbuterol), brethine (terbutaline) Watched for the following while taking bronchodilators: ØObserve for tachycardia and palpitations- these are the most common side effects of bronchodilators ØAdminister bronchodilator inhalation before steroid inhalation to open airways and ensure adequate absorption of drugs Long acting anticholinergic – Spiriva can be used for daily therapy of bronchospasm and dyspnea in COPD Steroids Ø Administered for anti inflammatory effect ex. Beclovent (beclomethasome), Solu Medrol (methylprednisone) Ø Rinse mouth after steroid inhalation to prevent oral thrush Ø Antimicrobials as ordered, if infection is present Ø Leukotriene antagonists- prevent bronchoconstriction, decrease mucosal edema and mucus production ex. Singulair/montelukast ØCor pulmonale Is hypertrophy of the right side of the heart with or without heart failure, resulting from pulmonary hypertension It is caused by diseases affecting the lungs or pulmonary blood vessels ASTHMA  ASTHMA ØA chronic inflammatory disease of the respiratory system resulting in airway hyperresponsiveness, mucosal edema, and mucus production. It is largely a reversible process ØAllergy is the strongest factor for the development of asthma ØCommon allergens are; tree, weeds, pollens, mold, dust, roaches, cat/dog danders, histamine rich foods like eggs, sea foods, snack foods Triggers of acute asthma attacks Allergen inhalation (animal danders, house dust mite, cockroaches, pollens, molds Air pollutants (exhaust fumes, perfumes, oxidants, sulfur dioxides, cigarette smoke, aerosol sprays) ØViral upper respiratory infection ØSinusitis ØExercise and cold dry air ØDrugs (ex. ASA, NSAIDS, beta adrenergic blockers ØOccupational exposure  Metal salts, wood and vegetable dust, industrial chemicals ØFood additives (sulfites, beer, wine, dried fruit, shrimps, processed potatoes, chips, monosodium glutamate, tartrazine (yellow dye no. 5) ØHormonal, menses ØGERD ØStress (psychologic, emotional) crying, laughing, anger, fear, Clinical manifestations: Wheezing (due to narrowed airway) Cough (thick, tenacious, white, gelatinous mucus) Chest tightness Prolong expiration  Sit upright or slightly bend forward using the accessory muscles of respiration to get enough air (feeling of suffocation) Signs of hypoxemia (restlessness, increased anxiety, inappropriate paradoxus, Difficulty to speak in complete sentences Increased respiratory rate (more 30 bpm) with the use of accessory muscles Hyperresonance on percussion of the chest Cough initially is nonproductive, and as the episodes resolves coughing produces thick, stingy mucus  Diminished or absent breath sounds Severely diminished breath sounds (silent chest) indicates severe obstruction and impending respiratory failure Diminished breath sounds may also indicate atelectasis or pneumothorax Diagnostic studies: 1. History and physical exam 2. Pulmonary function studies including response to bronchodilator therapy 3. Peak expiratory flow rate (PEFR) 4. Chest x-ray 5. ABG analysis or oximetry 6. Allergy skin testing 7. Nitric oxide levels 8. Eosinophil count and IgE blood level Collaborative Care for Asthma 1. Mild intermittent and persistent Asthma Identification and avoidance/elimination of triggers Desensitization Drug therapy 2. Acute asthma episode Oxygen therapy Beta 2 adrenergic agonist administered by metered dose inhaler (MDI) using spacer device or nebulizer ( given every 20 mins to 1 hour) For severe exacerbation, anticholinergic medication (Atrovent) is nebulized with beta 2 adrenergic agonist every 20 mins or continuous for 1 hour Systemic corticosteroid (oral, IM, IV) for impending respiratory arrest IV administration is needed Drug Therapy 1. Anti inflammatory agents (corticosteroids) ex. Fluticasone, budesonide, mometasone, methylprednisolone (oral, IV prednisone) Mast cells stabilizer (cromolyn, nedocromil MDI) Anticholinergics short acting ex ipratropium nebulizer, MDI IgE antagonist 2. Leukotriene modifiers Leukotriene receptor blocker ex. Zafirlukast oral tablets, montelokust oral tablets Leukotriene inhibitor ex. Zileuton oral tablets 3. Beta 2 adrenergic agonists Inhaled short acting ex. Albuterol (neb, oral, rotahaler), levalbuterol (neb, MDI)terbutaline (oral, nebulizer, subcutaneous, MDI Inhaled long acting Ex. Salmeterol, folmoterol 3. Immediate acting Epinephrine subqutaneous 4. Methylxanthine IV agent ex. Aminophyline oral tablets, IV, elixir sustained release tablets Oral ex. Elixophyllin, quibron, slo-bid Drug alert theophylline Instruct pt to report signs of toxicity: nausea, vomiting, seizures, insomnia Avoid caffeine to prevent intensifying adverse effects Serum blood levels should be monitored regularly to determine if the drug is within therapeutic range (10-20 mcg/dl Combination agents Ipratropium and albuterol (combivent, DuoNeb) MDI, nebulizer Fluticasone/Salmeterol (Advair) DPI Budesonide/Formoterol (Symbicort) MDI Patient Teaching on the Use of inhaler Steps for using inhaler A. Getting ready 1. Take off the cap and shake the inhaler 2. Breath out all the way 3. Hold your inhaler as follows: a. Hold inhaler 1-2 in in front of your mouth b. Use spacer/holding chamber c. Put the inhaler in your mouth B. Breath in slowly 1. As you start breathing in slowly through your mouth, press down on the inhaler one time 2. Keep on breathing in slowly, as deeply as you can C. Hold your breath 1. Hold your breath as you count to 10 slowly, if you can 2. For inhaled quick relief medicine wait about 1 minute between puffs D. Clean your inhaler as needed Status asthmaticus Ø severe persistent asthma that does not respond to conventional therapy. The attack lasts longer than 24 hours. It is life threatening and places the patient at risk for developing respiratory failure Causes: Viral illnesses Ingestion of NSAIDS or ASA Emotional stress Abrupt discontinuation of drug therapy (specially corticosteroid) Overuse of aerosol medication Ø It is characterized by a history of poorly controlled asthma progressing over days or weeks Ø The clinical manifestation of status asthmaticus result from increased airway resistance as a consequence of edema, mucous plugging, severe bronchospasm, and subsequently, air trapping, hyperinflation, hypoxemia, and respiratory acidosis Nurse alert- if the patient had been wheezing, yet is visibly uncomfortable, the absence of a wheeze (silent chest) is life threatening situation that may require mechanical ventilation. (wheeze that suddenly disappears indicate complete airway obstruction) Collaborative Care for a Patient with Status asthmaticus: 1. SaO2 monitoring 2. ABG’s 3. Inhaled beta 2-adrenergic agonists or anti cholinergic agents 4. Oxygen by mask or nasal prongs (cannula) 5. IV or oral corticosteroids (IV corticosteroids: methylprednisolone 6. IV fluids 7. IV magnesium (bronchodilator) 8. Intubation and assisted ventilation NOTE: If epinephrine is administered monitor patient’s BP and ECG closely Indication of mechanical ventilator in patients with severe asthma attacks 1. Persistent or progressive carbon dioxide retention 2. Clinical deterioration 3. Declining mental clarity 4. Hypoxemia ( PaO2 less than 60 mmhg) despite supplemental oxygen 5. Cardiopulmonary arrest Pneumothorax and Pleural Effusion Øpneumothorax- is the accumulation of air in the pleural space ØPleural effusion- is the accumulation of fluids in the pleural space ØPneumothorax and pleural effusion disrupt the negative pressure in the lungs and my cause atelectasis (collapse of the lungs) ØTypes of pleural effusion hemothorax- blood in the pleural space Pyothorax/empyema- pus in the pleural space. This is due to pneumonia, TB, lung abscess, infection of surgical wound of the chest Hydrothorax- water in the pleural space Chylothorax- lymphatic fluid in the pleural space due to leak in the thoracic duct Types of Pneumothorax 1. Closed pneumothorax ØCauses of closed pneumothorax are as follows: Injury to the lungs from mechanical ventilation Injury to the lungs from subclavian catheter insertion Perforation of the esophagus Injury to the lungs from broken ribs Ruptured blebs or bullae in a patient with COPD 2. Open pneumothorax ØIt occurs when air enters the pleural space through an opening in the chest wall ØEx. Stab or gunshot wounds and surgical thoracotomy. A penetrating chest wound is often referred to as sucking chest wound  Vented dressing An open pneumothorax should be covered with nonporous vented dressing. This allows air to escape from the vent and decreases likelihood of tension pneumothorax developing ØIf the object that caused the open chest wound is still in place, it should not be removed until the physician is present. The impaled object should be stabilized with bulky dressing. 3. Tension Pneumothorax Ø Is a pneumothorax with rapid accumulation of air in the pleural space, causing severely high intrapleural pressures with resultant tension on the heart and great vessels Ø Results from either open or closed pneumothorax Ø In an open chest wound, a flap may act as a one way valve, thus the air can enter on inspiration but cannot escape Ø The intrathoracic pressure increases, the lung collapses, the mediastinum shifts toward the unaffected side, which is subsequently compressed Causes of tension pneumothorax are as follows: 1. Mechanical ventilation and resuscitative efforts 2. Chest tubes are clamped or become blocked in a patient with pneumothorax. 3. Tension pneumothorax is a medical emergency, with both the respiratory and circulatory systems affected 4. If the tension in the pleural space is not relieved, the patient is likely to die from inadequate cardiac output or severe hypoxemia 5. Emergency management : insertion of a large bore needle into the chest wall to release the trapped air Causes: trauma, thoracic surgery, positive pressure ventilation thoracentesis, CVP line insertion, emphysema, cancer, infection Assessment in pneumothorax and pleural effusion: Sudden, sharp chest pain SOB Anxiety Tachycardia Diminished breath sounds Increased RR Chest tightness Chest asymmetry (there is no movement on the side of atelactasis Deviation of larynx/trachea towards unaffected side Cyanosis ØHyperresonance on the chest percussion (pneumothorax) ; dullness (hemothorax) Collaborative management for pneumothorax and pleural effusion: Remain with patient, stay calm Place the client in high fowler’s position Pain management O2 therapy (high flow 10-15 lpm)  Chest tube/thoracentesis. Usually only 1000 to 1200ml of pleural fluid are removed at a time because if high volumes are removed, rapid removal can result in hypotension, hypoxemia, or pulmonary edema may occur. Chest x –ray ABG’s ØMonitor for shock ØFor tension pneumothorax, needle thoracentesis is done if chest tube insertion is not immediately available ØFor open pneumothorax, cover wound with sterile, non- porous dressing and tape on three sides; one side is left open to vent excess pressure ØFor hemothorax, prepare for blood transfusion to prevent hypovolemic shock Bronchiectasis ØIs characterized by permanent abnormal dilation of one or more large bronchi ØThis is due to the destruction of the elastic and muscular structures supporting the bronchial wall ØThe disease process results in a reduced ability to clear mucus from the lungs and decrease expiratory flow ØIt is classified as an obstructive lung disease Clinical manifestations: 1. Persistent or recurrent cough with production of large amounts of purulent sputum that may exceed 500ml/day (hallmark sign of bronchiectasis) Dyspnea, wheezing, pleuritic chest pain, hemoptysis Crackles Diagnostic studies: Chest x-ray High resolution Ct scan (HRCT)- the gold standard for diagnosing bronchiectasis Øbronchoscopy, sputum studies ØPulmonary function studies Collaborative management 1. Antibiotics (usually associated with pneumonia, adenovirus, influenza virus, s. aureus, klebsiella, anaerobes 2. Bronchodilator therapy (to prevent bronchospasm) 3. Beta 2 agonists to stimulate mucociliary clearance 4. Mucolytic agent 5. Anti-inflammatory agents 6. Pneumococcal and influenza vaccinations 7. Rest, good nutrition, adequate hydration 8. Chest physiotherapy with postural drainage ACUTE RESPIRATORY DISTRESS SYNDROME/HYPERPERMEABLE PULMONARY EDEMA (ARDS/HPPE) - Is a sudden and progressive form of acute respiratory failure in which the alveolar capillary membrane becomes damaged and more permeable to intravascular fluid. - the most common cause of ARDS is sepsis ASSESSMENT - Increased RR- respiratory alkalosis - Dyspnea, retractions, central cyanosis, dry cough ØFine crackles, fever, alteration in LOC ØABG’S (decrease Pa O2) (increase in PaCO2) Collaborative Management: ØO2 therapy( high flow 8 to 10 lpm) to relieve hypoxia ØPosition semi fowler’s position. To enhance lung expansion. CPT ØMeticulous eye care ØMechanical ventilation on PEEP mode (Positive End expiratory Pressure) to open up collapsed alveoli ØAdminister pain medication as prescribed ØPromote comfort ØMonitor PEEP ventilation, PAP (pulmonary artery pressure) ØMechanical ventilation- mechanical support of ventilation is indicated for patients who are unable to maintain adequate ventilation on their own  - is an inflammation of the Pneumonia lung tissue Factors: Aging, air pollution, altered consciousness, alcoholism, head injury seizures, bedrest and prolong immobility, chronic lung disease, DM, HIV, Immunosuppressive drugs, intestinal and gastric feedings, malnutrition, smoking, tracheal intubation, URTI Acquisition of Organisms that cause pneumonia are as follows: 1. Aspiration from nasopharynx or oropharynx 2. Inhalation of microbes present in the air ex. Mycoplasma pneumoniae and fungal pneumonias 3. Hematogenous spread from a primary infection elsewhere in the body ex. Staphylococcus aureus Types of Pneumonia 1. Community-Acquired Pneumonia (CAP) Is a lower respiratory tract infection of lung tissues with the onset in the community or during the first 2 days of hospitalization 2. Hospital –Acquired Ventilator Associated and Health –Care Associated Pneumonia Hospital Acquired Pneumonia (HAP) is pneumonia occurring 48 hours or longer after hospitalization and not incubating at the time of hospitalization Ventilator –Associated Pneumonia (VAP) refers to pneumonia that occurs more than 48 to 72 hours after endotracheal intubation  Health Care-Associated Pneumonia (HCAP) includes any patient with new onset pneumonia who: a.Was hospitalized in an acute care hospital for 2 or more days within 90 days of infection b.Reside in a long term care facility c.Received recent intravenous antibiotic therapy, chemotherapy or wound care within the past 30 days of the current infection d.Attended a hospital or hemodialysis clinic The microorganism responsible for HAP, VAP, and HCAP are usually bacterial and rarely viral or fungal 3. Fungal Pneumonia- caused by fungi (ex. Histoplasma capsulatum, Coccidioides immitis, candida albicans) 4. Aspiration Pneumonia- refers to sequalae caused by abnormal entry of secretions or substances into the lower airway. It usually follows aspiration of material from the mouth or stomach into the trachea and subsequently into the lungs The person who has aspiration pneumonia usually has a history of loss of consciousness (ex. Anesthesia, head injury, seizure, stroke, or alcohol intake) Another risk factor is tube feeding The aspirated material (food, water, vomitus, or toxic fluids(gastric juices) 5. Opportunistic Pneumonia- patient with altered responses are at risk to respiratory infections Patients with altered immune responses are at risk (calorie malnutrition, immune deficiencies, received transplants and those who have been treated with immunosuppressive drugs, treated with radiation therapy, chemotherapy drugs, and prolonged corticosteroid therapy Causative agents that cause opportunistic pneumonia are bacteria (gram negative), virus, pneumocystis jiroveci (formerly carinii, fungus, cytomegalovirus (CMV)  Pneumocystis jiroveci pneumonia (PCP) – is the most common acquired immunodeficiency syndrome (AIDS)- defining opportunistic infection Cytomegalovirus (CMV)- is caused of viral pneumonia in the immunocompromised patients, particularly in transplant patients 6. Pneumococcal Pneumonia - Is the most common cause of bacterial pneumonia - Cased by streptococcus pneumoniae, also called pneumococcus Which is usually found in nose and throat Clinical Manifestations of Pneumococcal Pneumonia Ø fever, shacking, chills, SOB Ø Productive cough (rust colored sputum) Ø Pleuritic chest pain Ø Confusion, stupor Ø Pulmonary consolidation Collaborative Management of Pneumonia Promote rest Provide adequate fluids Incentive spirometry O2 therapy Semi fowler’s position Bronchial hygiene measures  Oral hygiene Humidifier Splint chest when coughing Monitor: sputum, chest x-ray, temperature Pharmacotherapy: antibiotics (blood culture should be done before starting antibiotic) Influenza and pneumococcal vaccine prior to discharge. Influenza vaccine is annual; pneumonia vaccine is every 5 years. These vaccines can be given at the same time but in different arms. Pulmonary Embolism - Obstruction of the pulmonary artery or one of its branches by a thrombus, that originates somewhere in the right side of the heart. It may also be due to other types of emboli like air, fat, amniotic fluid, and sepsis (due to bacterial invasion of the thrombus) Causes: Ø Fat embolism, multiple trauma, PVD’s (peripheral vascular disorders) Ø Abdominal surgery, immobility, hypercoagulability Assessment: Restlessness (cardinal sign) Dyspnea, tachycardia Stabbing chest pain Cyanosis, dilated pupils Apprehension, fear, diaphoresis Ødysrhythmias, hypotension, fever, hemoptysis, syncope Collaborative Management: ØOxygen therapy immediately (STAT) ØEarly ambulation post op ØMonitor obese patients ØDo not massage legs ØRelieve pain, elevate head of bed ØHeparin (2 weeks) then coumadin (3-6 months) as prescribed ØThrombolytic therapy as prescribed ØSurgical embolectomy ØPerfusion scan, hemodynamic measurements ØABG’s, pulmonary angiography, serum electrolytes, cbc, hematocrit ØSlow infusion of dobutamine as prescribed to treat hypotension ØSlow dose of morphine to relieve anxiety and alleviate chest pain Patient Teaching Do’s - Observe for bleeding (ex gum bleeding, nose bleeding, melena/black, tarry stool - Use soft toothbrush, electric razor - Evaluate use of contraceptives. Contraceptives may cause hyper coagulopathy of blood and thromboembolism - Use elastic stockings to promote venous return Don’t’s - Take ASA with coumadin. To prevent drug interaction that may lead to bleeding - Restrictive clothing’s on legs to prevent venous stasis - Prolong sitting/standing to prevent venous stasis - smoking to prevent vasoconstriction and endothelial injury - bruises, constipation, contact sports to prevent trauma that leads to bleeding Lung Abscess -is pus containing lesion of the lung parenchyma that gives rise to cavity. The cavity is formed by necrosis of the lung tissue - Causes of lung abscess are similar to those of pneumonia. Other causes are aspiration of material from the GI tract into the lungs, malignant growth, TB and various parasitic and fungal diseases of the lungs Clinical Manifestations: 1. Cough producing purulent sputum (often dark brown) that is foul smelling and foul tasting 2. Hemoptysis 3. Fever, chills, prostration, pleuritic pain 4. Dyspnea, weight loss 5. oral examination reveals dental caries, gingivitis, and periodontal infection Complications: Chronic pulmonary abscess Bronchiectasis Brain abscess as a result of the hematogenous spread of infection Bronchopleural fistula Empyema from abscess perforation into the pleural cavity Diagnostic studies for lung abscess Chest x-ray, CT scan, sputum culture Pleural fluid and blood cultures Bronchoscopy Collaborative Management of lung abscess 1. Antibiotics up to 2 to 4 months (penicillin, clindamycin) 2. Chest physiotherapy and postural drainage 3. Rest, good nutrition, adequate fluid intake 4. Dental care 5. Surgery (lobectomy, pneumonectomy, percutaneous drainage) Flail chest - Is fracture of 2 or more adjacent ribs due to crushing chest injury - Characterized by paradoxical breathing ( the chest is depressed during inhalation, it is elevated during exhalation). This causes hypercapnia (retention of carbon dioxide) Critical Facts about ABG Analysis Step 1. Remember the normal Values Blood ph 7.35-7.45 paO2 80-100 mmhg paCO2 35-45 mmhg HCO3 22-26 mEq/L O2 saturation 95-100% BE/BD -2 to +2 (Base excess/Base deficit) Step 2 Look at the ph pH low (below 7.35) ACIDOSIS pH high (above 7.45) ALKALOSIS Step 3 Look at the PaCO2 PaCO2 is the RESPIRATORY INDICATOR CO2 acts as an ACID. When CO2 combines with plasma, CARBONIC ACID is formed (CO2 + H2O = H2CO3) PaCO2 high(above 45mmHg) respiratory acidosis PaCO2 low (below 35 mmHg) respiratory alkalosis Step IV. Look at the (HCO3) (Bicarbonate) HCO3 high (above 26) metabolic alkalosis HCO3 low (below 22)metabolic acidosis Step V. Determine the primary ACID-BASE disturbance The change that matches the pH is the primary ACID- BASE DISTURBANCE 1. pH and PaCO2 match: Respiratory Acid- Base Imbalance a. pH ↓ ACIDOSIS = Respiratory pH ↑ ACIDOSIS Acidosis b. pH ↑ ALKALOSIS Respiratory pH ↓ ALKALOSIS = Alkalosis 2. pH and HCO3 match: Metabolic acid-Base balance a. pH ↑ ALKALOSIS METABOLIC HCO3 ↑ ALKALOSIS = ALKALOSIS b. pH ↓ ACIDOSIS METABOLIC HCO3 ↓ ACIDOSIS = ACIDOSIS Therefore: If pH PCO2 = are primarily affected (same interpretation) ↓ RESPIRATORY ACID-BASE IMBALANCE OCCURS Therefore: If pH HCO3= are primarily affected (same interpretation) ↓ METABOLIC ACID-BASE IMBALANCE OCCURS Or better yet, think about ROME! R-espiratory O-pposite M-etabolic E-qual Example: 1. pH 7.5 PaCO2 32 HCO2 26