NUPD 701 Week 5 Respiratory PDF

WEEK 5 - RESPIRATORY NUPD 701 Airway Anatomy & Physiology  WHAT IS AN AIRWAY OBSTRUCTION? WHAT TYPES OF AIRWAY OBSTRUCTIONS ARE THERE? VARYING DEGREES FROM MILD TO SEVERE 3 Airway Obstruction Mild, Moderate, Severe  PATIENT CAN...

WEEK 5 - RESPIRATORY NUPD 701 Airway Anatomy & Physiology  WHAT IS AN AIRWAY OBSTRUCTION? WHAT TYPES OF AIRWAY OBSTRUCTIONS ARE THERE? VARYING DEGREES FROM MILD TO SEVERE 3 Airway Obstruction Mild, Moderate, Severe  PATIENT CAN STILL STILL COUGH RESPONDING TO AND GET SOME QUESTIONS Mild AIR IN. Obstructions MAY HAVE NOISY ENCOURAGE THEM TO BREATHING KEEP TRYING TO (WHEEZING) COUGH TO RID THE AIRWAY OF THE OBSTRUCTION (IF A FOREIGN BODY) Moderate Obstructions Wheezing is getting worse May not be having adequate gas exchange May not be able to elicit a cough or be able to speak Struggling more to breath Dyspnea, labored breathing, use of accessory muscles Changes in LOC  Severe Airway Obstruction Agitation, restlessness, confusion Cyanosis, or bluish-colored skin. Difficulty breathing. Gasping for air Panic High-pitched breathing sounds such as wheezing getting worse or no movement of air heard Unconsciousness. 7 Nursing Consider a nursing diagnosis or Diagnosis priority problem for a patient with an airway obstruction? 8 Tracheostomy What are Indications for use? Used to provide a safe and comfortable airway in patients requiring long-term airway support Tracheotomy: a surgical incision in the trachea just below the larynx Tracheostomy: The opening made for the tracheostomy tube 9 Airway Anatomy & Physiology Landmark  Cuffed Tracheostomy Tubes Un-cuffed Tracheostomy Tubes Types of Tracheostomy Tracheostomy Tubes with an Inner Cannula Tubes Fenestrated Tracheostomy Tubes Used for patients to talk 12 Types of Tracheostomy Tubes Cuffed Tracheostomy Tubes Un-cuffed Tracheostomy Tubes Types of Tracheostomy Tubes Tracheostomy Tubes with an Inner Cannula Fenestrated Tracheostomy Tubes  Indications for Use Important for patients especially when they have a lot of secretions 1. Easier to pull the inner cannula out and clean it to maintain hygiene of the airway Inner Cannula 2. If patients develop a mucus plug, you can pull the inner cannula out and have the outer cannula serve as the airway You can then either place a new inner cannula or clean the plug out of the old one and reuse it depending on whether the tube is disposable or not Maintaining hygiene and management of emergent cannula blockages can become difficult if you do not have the inner cannula as changing the whole tracheostomy tube is more work and often uncomfortable for the patients. Retrieved from http://www.ho pkinsmedicin e.org/tracheo stomy/faq.ht ml 15  Fenestrated tubes have a hole(s) in the tube which allows air to move around the trach and through the vocal cords More force may be needed to push the air out through the mouth. Fenestrated To speak: Patient takes a deep breath in. Tubes and Then they breathe out, using more force than they normally would to push the air out. They close off the trach tube opening with a clean finger Communication and then speak. This will help the air go out through the mouth to create a sound. May not hear much at first, and the patient will have to build up the strength to push the air out through their mouth, but the sounds will get louder with practice. Adaped from https://medlineplus.gov/ency/patientinstructions/000465.htm 16 What are some possible nursing diagnosis for a patient with a tracheostomy? 17 Nursing Care for a Patient with a Tracheostomy Tube 18  Decannulation: “describes the process of tracheostomy tube removal once the need for the tube has resolved” Decannulati Dislodgement/accidental on Complications: tracheal stenosis, bleeding, infection, aspiration pneumonia, and fistula formation from the trachea to esophagus Pleural Effusion Pleural Effusion 21 Chest Trauma Blunt Penetrating No break in the skin Wound caused by impalement or and More life-threatening as not as object passing through the tissue obvious and diagnosis is more Severity is based on organ tissue difficult damage Open and closed Pneumothorax / Hemothorax 24  Pneumotho rax: A Symptoms: chest pain, dyspnea, decrease in collection O2 saturation of air in the Caused by trauma, lung disease, invasive pleural procedure, spontaneous space Manifestations and treatment vary depending on the size of the pneumothorax & the signs and symptoms patient is experiencing. Can be caused by blunt/penetrating chest Manifestations Hemothorax trauma or chest surgery : Presence Pneumo/Hemothora of blood in Iatrogenic hemothorax can occur from complication of CVAD (central venous access x & Pleural Effusion the pleural space device) Post cardio-thoracic surgery Pleural effusion: Caused by pneumonia, left ventricular heart Excessive failure, pulmonary embolism, cancer or fluid in the complication of surgery pleural space 25 Pneumothorax  Respiratory & Cardiac Assessment & Findings Manifestations and treatment vary depending on the size of the pneumothorax & the signs and symptoms patient is experiencing Caring for a May be asymptomatic, symptomatic but Client with a medically stable, fragile clinically, or have life threatening manifestations. May have anxiety, restlessness, SOB Pneumothorax May have tachycardia, tachypnea May have an acute onset of chest pain. Chest pain is described as severe and/or stabbing, radiates to the ipsilateral shoulder and increases with inspiration (pleuritic) May have hyper-resonance (filled with air) & unequal chest expansion. 29  Depending on the size of the pneumothorax or effusion and the S & S of the patient: May be left to heal on its own Treatment Oxygen therapy Thoracentesis with chest tube insertion to relieve the pressure Chest tube in place and hooked up to a collection device (pleurevac)  Tension Pneumothorax (considered a Medical Emergency) Occurs when air accumulates in the Complications pleural space more quickly than it can be evacuated of a Quickly becomes life threatening and must be relieved promptly Pneumothorax Pressure builds up, can collapse the lung, shift mediastinum, impede venous return and cardiac output. Tension Pneumothorax Tension pneumothorax is classically characterized by: Chest pain (90%), dyspnea (80%), anxiety, fatigue Hypotension and hypoxia On examination, breath sounds are absent on the affected side Trachea deviates away from the affected side Thorax may also be hyper-resonant Jugular venous distention Tachycardia may be present TENSION PNEUMOTHORAX 33 Chest Tubes – Care & Assessment Chest Tubes & Pleural Drainage What are the goals of therapy for a chest tube? Setting up the chest drainage unit (CDU) 36  PATIENT ASSESSMENT Vital signs Respiratory rate/pattern/depth Ease of respiration Oxygen saturation Check for subcutaneous emphysema (crackling sensation under the skin during palpation) Signs of Respiratory Distress Include tachypnea, dyspnea, shortness of breath Tachycardia Decreased or absent breath sounds Use of accessory muscles of respiration Restlessness Confusion  DO’S Keep system closed and below the patient’s chest level Make sure all connections are taped and the chest tube is secured to the patient’s chest wall. Ensure that the suction control chamber is filled Nursing with sterile water to the 20 cm level or as prescribed Management of If using suction, make sure the suction unit’s pressure level causes slow but steady bubbling in a Chest Tube: the suction control chamber Make sure the water seal chamber is filled with sterile water to the level specified by the manufacturer. You should see fluctuation (tidaling) of the fluid level in the water-seal chamber. If you don’t see tidaling then the system may not be patent or working properly, or the patient’s lung may have re- expanded.  DO’S Keep system closed and below the patient’s chest level Make sure all connections are taped, and the chest tube is secured to the patient’s chest wall. Ensure that the suction control chamber is filled Nursing with sterile water to the 20 cm level or as prescribed If using suction, make sure the suction unit’s Management of pressure level causes slow but steady bubbling in the suction control chamber a Chest Tube: Make sure the water seal chamber is filled with sterile water to the level specified by the manufacturer. You should see fluctuation (tidaling) of the fluid level in the water-seal chamber. If you don’t then the system may not be patent or working properly, or the patient’s lung may have re-expanded. (Rushing, 2007)  DO’S Look for constant or intermittent bubbling in the water seal chamber (which indicates leaks in the drainage system). Notify the physician/NP if you can’t Nursing identify an external leak or correct it. Assess the amount, color, and Management of consistency of drainage in the drainage tubing and in the collection chamber a Chest Tube: Mark the drainage level on the outside of the collection chamber (with date, time, initials every 8 hours)or more frequently if needed. Report drainage that is excessive, cloudy or unexpectedly bloody (Rushing, 2007)  DO’S Encourage the patient to perform DB&C, incentive spirometer Assist with ambulation as ordered Nursing Administer pain medication as indicated Assess vital signs, breath sounds, SpO2, Management of insertion site for subcutaneous emphysema. a Chest Tube: When chest tube is removed, administer analgesia & immediately apply occlusive petroleum gauze dressing over the site to prevent air from entering pleura space.  DO NOT Don’t let drainage tubing kink, loop or interfere with patient’s movement Don’t clamp except momentarily Nursing when replacing the chest drainage Management of unit (CDU), assessing for an air leak, or assessing patient’s tolerance of chest tube removal (medical order) a Chest Tube: Don’t aggressively manipulate the chest tube Don’t milk or strip tubing Complications of a Chest Tube What are some of the complications for a client with a chest tube? 44  If the chest tube gets pulled out: Have patient do the Valsalva maneuver on expiration Apply a Vaseline gauze (if hospital policy) then a dry, sterile gauze over the site and tape it on three sides. The Tube Notify the physician Dislodged… If chest tube disconnects from the drainage unit A temporary water seal can be established by What is your submerging the tube 2 to 4 cm below the surface of a 250-mL bottle of sterile water or saline solution until a new CDU is set up. intervention?? The end of the patient connector on the drainage system can be cleansed with alcohol if it has not been contaminated If it has been contaminated an entire new chest drainage system must be ordered. (Roman & Mercado, 2006)  If the drainage collection chamber is full, set up a new chest drainage unit: Instruct the patient to exhale and hold his or her breath (perform the valsalva maneuver). Clamp the chest tube with a padded Kelly Changing the clamp about one to two inches from the patient. Chest Drainage Place a second clamp distally. Aseptically, disconnect tubing from old chest drainage Unit (CDU) unit and connect to the new chest drainage unit. When completed, remove clamps within one minute and have your patient breath normally. At the end of changing the chest drainage unit, secure all connections with tape. (Atrium Med, 2013)  Gather supplies Administer pain medications Teach patient how to do the Valsalva Removing a maneuver (prevents air entering the pleural space during removal) Chest Tube Position patient in semi-Fowlers After: respiratory assessment, assess drainage from the site, Chest x-ray  Nursing Diagnosis What nursing diagnosis do you think are appropriate for a client with an effusion/pneumothorax/hemothorax? Why? What is your priority nursing diagnosis? What psychosocial nursing diagnosis are appropriate? 48 Chronic Obstructive Pulmonary Disease Assessing patients with COPD How do we assess? What could we expect to find?  Ineffective Airway Clearance r/t bronchoconstriction, increase mucous, ineffective cough, infection Impaired Gas Exchange r/t ventilation-perfusion inequality Activity intolerance r/t imbalance between oxygen supply and demand Nursing Anxiety r/t breathlessness, change in health status Death anxiety r/t seriousness of medical Diagnosis for condition, difficulty being able to ‘catch breath’, feeling of suffocation Patients with Ineffective Health Management Imbalanced Nutrition: Less than Body COPD Requirements r/t reduced intake because of dyspnea, increased need of calories from increased work of breathing. Powerlessness r/t progressive nature of the disease Self-care deficit r/t fatigue from increased work of breathing  Smoking cessation Pulmonary rehabilitation Exercise/energy conservation Treatment for Vaccinations for influenza (all COPD patients) and pneumococcus (all COPD COPD patients older than 65 or with other cardiopulmonary disease) Sexual activity Sleep Medications  Bronchodilators Short-acting beta2 agonists Salbutamol and terbutaline Short-acting muscarinic antagonists (also known as anticholingeric) Ipratroprim (Atrovent) Drugs to Treat Long-acting beta2 agonists Selmeterol and formoterol COPD Long-acting muscarinic antagonists Tiotropium Combination therapy Corticosteroids Inhaler technique should be demonstrated for all patients and technique confirmed before concluding a medication is not working.  Atrium Medical (2013). Chest tube management. Retrieved February 6,, 2017, from https://lms.rn.com/getpdf.php/1933.pdf Frace, M.(2010).Tracheostomy care on the medical-surgical unit. MedSurg Nursing, References 19(1), 58-61. Kaufman, G. (2013). The role of inhaled bronchodilators and inhaler devices in COPD management. Primary Health Care,23(8), 33-41. Rushing, J. (2007). Clinical do’s and don’ts: Managing a water-seal chest drainage unit. Nursing 2007, 12