Module 1B - Ventilation Disorders.pdf

UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory,...

UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture [TRANS] UNIT XX: VENTILATION DISORDERS The pharynx is a collapsible tube that can be compressed Module 1B by the soft tissues and structures surrounding it. Ventilation Disorders The tone of the muscles of the upper airway is reduced during sleep. Outline 1. Describe nursing management of patients with Mechanical factors such ventilation disorders. as reduced diameter of the 2. Compare and contrast ventilation disorders according to upper airway or dynamic cause, incidence, clinical manifestations, management, Reduced diameter changes in the upper and the significance of preventive health care. airway during sleep may result in obstruction. Respiration and Ventilation These sleep-related Respiration: The exchange of gases, oxygen and changes may predispose carbon dioxide, in the lungs, especially in alveoli. to upper airway collapse Ventilation: The mechanical drawing in and expelling Negative pressure when small amounts of negative pressure are out air via breathing. generated during o Movement of air in and out of the body. inspiration. o When you promote ventilation in a patient, you open Repetitive apneic events the windows so that air from the outside go inside the result in hypoxia room. (decreased oxygen Hypoxia saturation) and Upper Respiratory Airway Obstruction hypercapnia, which triggers a sympathetic 1. Obstructive Sleep Apnea (OSA) response. A disorder characterized by recurrent episodes of upper Patients with OSA have a airway obstruction and a reduction in ventilation. high prevalence of Cessation of breathing (apnea) during sleep usually caused HTN hypertension. by repetitive upper airway obstruction. MI OSA is associated with an o Apnea: absence of breathing Stroke increased risk of o Dyspnea: difficulty breathing myocardial infarction and o Eupnea: normal breathing stroke. o Hypercapnia: Layman’s term for MI: heart attack Obstructive Sleep Apnea Deficiency of oxygen in the heart muscle since nagkakaroon ng hypoxia. What happens in stroke? Clinical Manifestations Frequent and loud snoring with breathing cessation for 10 seconds or longer, for at least five episodes per hour, followed by awakening abruptly with a loud snort as the blood oxygen level drops. “3 S’s o Snoring o Sleepiness o Significant-other report of sleep apnea episodes Assessment and Diagnostic Findings CTTO: https://www.sleepcareonline.com Polysomnographic finding “sleep study” → definitive test for OSA. Risk Factors Obesity Medical Management Male Weight loss Postmenopausal status Avoidance of alcohol Advanced age o Leads to poor ventilatory process Associated factors include alterations in the upper airway, such as structural changes e.g., tonsillar hypertrophy Positional therapy and oral appliances (OA like CPAP Abnormal posterior positioning of one or both jaws machine - continuous positive Variations in craniofacial structures airway pressure) Pathophysiology o Keeping airway open to prevent airway collapse. Jopar Jose C. Ramos | Bachelor of Science in Nursing 3-A 1  UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture In more severe cases involving hypoxemia and severe Obstructive Sleep Apnea - Mayo Clinic hypercapnia, the treatment includes continuous positive https://www.youtube.com/watch?v=z12MEPiG4cg airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) therapy with supplemental oxygen via nasal 2. Epistaxis (Nosebleed) cannula. CPAP is used to prevent airway collapse, whereas Hemorrhage from the nose, is caused by the rupture of BiPAP makes breathing easier and results in a lower tiny, distended vessels in the mucous membrane of any average airway pressure. area of the nose. Administration of low-flow nasal oxygen at night can help Most common site is the anterior septum, where three major relieve hypoxemia in some patients but has little effect on blood vessels enter the nasal cavity: the frequency or severity of apnea. A. Anterior ethmoidal artery on the forward part of the roof (Kiesselbach’s plexus) CPAP vs. BiPAP Differences B. Sphenopalatine artery in the posterosuperior region C. Internal maxillary branches Epistaxis (Nosebleed) CTTO: https://www.cpap.com Surgical Management Simple tonsillectomy may be effective for patients with larger tonsils when deemed clinically necessary, or when other options have failed or are refused by patient. Uvulopalatopharyngoplasty is the resection of pharyngeal soft tissue and removal of approximately 15 mm of the free edge of the soft palate and uvula. o Pharynx will be repaired, i-e’enlarge ‘yung daluyan ng hangin. Nasal septoplasty may be performed for gross anatomic CTTO: https://emedicine.medscape.com nasal septal deformities. Management o Nasal septum – the bone that divides the two nostrils. Depends on its cause and the location of the bleeding site. o Plasty – surgical repair Nasal speculum, penlight, or headlight may be used to Maxillomandibular surgery may be performed to advance identify the site of bleeding in the nasal cavity. the maxilla and mandible forward in order to enlarge the Initial Treatment posterior pharyngeal region. Applying direct pressure. Tracheostomy relieves upper airway obstruction but has o Don’t extend to the back. numerous adverse effects, including speech difficulties and o Preventing blood clots inside the nose increased risk of infections. Application of nasal decongestants (phenylephrine, one or Pagod sila kahit kakatulog or kahit sapat naman tulog two sprays) to act as vasoconstrictors. nila. Other Measures Pharmacologic Therapy Illumination and suction to determine the site of bleeding. Modanil (Provigil) has been used to reduce daytime Visible bleeding sites may be cauterized with silver nitrate sleepiness. or electrocautery (high-frequency electrical current). Protriptyline (Triptil) given at bedtime may increase the Supplemental patch of Surgicel or Gelfoam. respiratory drive and improve upper airway muscle tone. o So that blood is absorbed. Medroxyprogesterone acetate (Provera) and Alternatively, a cotton tampon may be used to try to stop acetazolamide (Diamox) have been used for sleep apnea the bleeding. associated with chronic alveolar hypoventilation. Suction may be used to remove excess blood and clots Nursing Management from the field of inspection. Instruct the patient and family about treatments, including Search for the bleeding site should shift from the the correct and safe use of CPAP, BiPAP, and oxygen anteroinferior quadrant to the anterosuperior, then to therapy, if prescribed. the posterosuperior, and finally to the posteroinferior area Jopar Jose C. Ramos | Bachelor of Science in Nursing 3-A 2  UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture o Field is kept clear by using suction and by shifting the Nursing Management cotton tampon. Monitor the patient’s vital signs. Gauze packing is inserted, or a balloon-inflated catheter Assists in the control of bleeding. may be used. Alternatively, a compressed nasal sponge Provide tissues and an emesis basin to allow the patient to may be used. Once the sponge becomes saturated with expectorate any excess blood. blood or is moistened with a small amount of saline, it will Assure the patient in a calm, efficient manner that bleeding expand and produce tamponade to halt the bleeding. The can be controlled can help reduce anxiety. packing may remain in place for 3 to 4 days if necessary to Continuously assesses the patient’s airway and breathing control bleeding. as well as vital signs. o 1 nostril first only to let the patient breathe. ‘Wag Patient with significant hemorrhage requires IV infusions of pagsabayin. crystalloid solutions (normal saline) as well as cardiac and Figure 21.1: pulse oximetry monitoring. Once the bleeding is controlled, the nurse instructs the patient to avoid vigorous exercise for several days and to avoid hot or spicy foods and tobacco, because this may cause vasodilation and increase the risk of re-bleeding. Instruct to avoid forceful nose blowing, straining, high altitudes, and nasal trauma including nose picking. Adequate humidification may prevent drying of the nasal passages. o Once they become dry, it is prone to crack or lesion that may cause bleeding. Explain how to apply direct pressure to the nose with the thumb and the index finger for 15 minutes in the case of a recurrent nosebleed. If recurrent bleeding cannot be stopped, the patient is instructed to seek additional medical attention. 3. Nasal Obstruction The passage of air through the nostrils is frequently obstructed by: o Deviation of the nasal septum o Hypertrophy of the turbinate bones o Pressure of nasal polyps Nasal packing to control bleeding from the posterior nose, (A) On patient’s chart: catheter is inserted and packing is attached; (B) Packing drawn into position as the catheter is removed; (C) strip tied o Normal nasal septum right and left nostril over bolster to hold packing in place with anterior pack o External nose is symmetrical with no discoloration, installed "accordion pleat" style; (D) alternative method using swelling, or malformations. balloon catheter instead of gauze packing. o NS is midline / non deviated at the midline. Turbinate bones increase surface area for rapid warming Antibiotics may be prescribed because of the risk of and humidification of air. iatrogenic rhinosinusitis and toxic shock syndrome. Chronic nasal congestion forces the patient to breathe through the mouth, thus producing dryness of the oral mucosa and associated problems including persistent dry, cracked lips. Patients with chronic nasal congestion often suffer from sleep deprivation due to difficulty maintaining an adequate airway while lying at and during sleep. Persistent nasal obstruction also may lead to chronic infection of the nose and result in frequent episodes of nasopharyngitis. Frequently, the infection extends to the nasal sinuses. When rhinosinusitis develops and the drainage from these cavities is obstructed by deformity or swelling within the nose, pain is experienced in the region of the affected sinus. Jopar Jose C. Ramos | Bachelor of Science in Nursing 3-A 3  UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture Understanding Sinus Problems The larynx is a stiff box that will not stretch. It contains a narrow space between the vocal cords (glottis), through which air must pass. o Kapag ang isang tao ay nabulunan, pwedeng mag- lodge and object na na-obstruct d’yan at hindi na tayo makahinga. Swelling of the laryngeal mucous membranes may close off the opening tightly, leading to life-threatening hypoxia or suffocation. Edema of the glottis occurs rarely in patients with acute laryngitis, occasionally in patients with urticaria, and more frequently in patients with severe inflammation of the throat, as in scarlet fever. Foreign bodies frequently are aspirated into the pharynx, the larynx, or the trachea and cause a twofold problem. o First, they obstruct the air passages and cause difficulty in breathing, which may lead to asphyxia. o Later, they may be drawn farther down, entering the bronchi or a bronchial branch and causing symptoms of irritation, such as a croupy cough, expectoration of blood or mucus, or labored breathing. CTTO: https://www.saintlukeskc.org Medical Management Requires the removal of the obstruction, followed by measures to treat whatever chronic infection exists. In many patients, an underlying allergy also requires treatment. Nasal corticosteroids as well as oral leukotriene inhibitors, such as montelukast. Treatment with nasal corticosteroids for 1 to 3 months is usually successful for treatment of small polyps and may even reduce the need for surgical intervention. A short course of oral corticosteroids. (6-day course of prednisone) may be beneficial in the treatment of nasal obstruction due to polyps Antibiotics (bacterial) Antihistamines (allergies) Hypertrophied turbinates may be treated by applying an astringent agent to shrink them. Causes Surgical Management Swelling of mucous membranes Surgical reduction of the turbinate Edeme of glottis hypertrophy. Aspiration (foreign objects) Surgical procedures used to treat Tumors obstructive nasal conditions are collectively known as functional Pathophysiology rhinoplasty. Inflammation and edema ↓ Nursing Management Upper airway obstruction Postoperatively, the nurse elevates the head of the bed to ↓ promote drainage and to alleviate discomfort from edema. Increased resistance to airflow Frequent oral hygiene is encouraged to overcome dryness ↓ caused by breathing through the mouth. Increased intrathoracic negative pressure Instruct to avoid blowing the nose with force during the ↓ postoperative recovery period. Collapse of upper airway Instruct about the signs and symptoms of bleeding and ↓ infection and when to contact the primary provider. Respiratory failure 4. Laryngeal Obstruction Aspiration (foreign objects) Edema is a serious, often fatal, condition. ↓ Jopar Jose C. Ramos | Bachelor of Science in Nursing 3-A 4  UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture Obsruct the air passages and cause difficulty in breathing, o Subcutaneous epinephrine and corticosteroid which may lead to asphyxia o Continuous pulse oximetry ↓ Drawn farther down, entering the bronchi or a bronchial branch Note: and causing symptoms of irritation, such as a croupy cough, Nagkaroon ng anaphylactic reaction to something that they expectoration of blood or mucus, or labored breathing eaten (hypersensitivity reaction) kapag lumalala na. Clinical Manifestations Epinephrine and corticosteroid to help reduce the edema of X-ray findings confirm the diagnosis of laryngeal the larynx immediately. obstruction. o Allergies are crucial. Baka pati yung breathing is Lowered oxygen saturation; however, normal oxygen compromised. saturation should not be interpreted as a sign that the obstruction is not significant. Attempt to Open the Airway Use of accessory muscles to maximize airflow may occur Perform the head-tilt/chin-lift maneuver by placing one hand and is often manifested by retractions in the neck or on the forehead and placing the fingers of the other hand abdomen during inspirations. Patients who demonstrate underneath the jaw and lifting upward and forward. This these symptoms are at an immediate risk of collapse, and action pulls the tongue away from the back of the pharynx. respiratory support (i.e., mechanical ventilation or positive- pressure ventilation) is considered. Clear the Airway Assess the patient by observing the chest and listening and Laryngeal Obstruction feeling for the movement of air. Use a cross-finger technique to open the mouth and observe for obvious obstructions such as secretions, blood clots, or food particles. If no passage of air is detected, begin cardiopulmonary resuscitation (CPR). If all efforts are unsuccessful, an immediate tracheotomy is necessary. If the obstruction is caused by edema resulting from an allergic reaction, treatment may include immediate administration of subcutaneous epinephrine and a corticosteroid. Ice may be applied to the neck in an effort to reduce edema. Continuous pulse oximetry is essential in the patient who has experienced acute upper airway obstruction. Opening an Airway in an Adult or Child CTTO: thnm.adam.com Assessment and Diagnostic Findings History Emergency measures to secure the patient’s airway should not be delayed to obtain a history or perform tests. Obtains a history from the patient or family about heavy alcohol or tobacco consumption, current medications, history of airway problems, recent infections, pain or fever, dental pain or poor dentition, and any previous surgeries, radiation therapy, or trauma. Medical Management CTTO: https://www.msdmanuals.com Based on the initial evaluation of the patient and the need to ensure a patent airway. Take Time to Watch o If the airway is obstructed by a foreign body and signs https://www.youtube.com/watch?v=2fnS8mtqzms of asphyxia are apparent, immediate treatment is necessary. Emergent maneuvers to clear an airway obstruction. o Open airway using the head-tilt-chin lift maneuver. Clear the airway o Cardiopulmonary resuscitation (CPR) Jopar Jose C. Ramos | Bachelor of Science in Nursing 3-A 5