NCM 112 - Medical Surgical (Oxy, Fluids) PDF

NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) From a relatively high level in inspired air to ALTERATIONS IN THE RESPIRATORY progressively lower levels in the respi...

NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) From a relatively high level in inspired air to ALTERATIONS IN THE RESPIRATORY progressively lower levels in the respiratory FUNCTION (ASSESSMENT OF THE tract RESPIRATORY SYSTEM) The alveolar gas to the arterial blood to the capillaries then finally, the The cells of the body derive they needs by cell/mitochondria, where the lowest pO2 the process of oxidation level (reflects the amount of oxygen gas During aerobic respiration, the oxygen a cell dissolved in the blood) combines with glucose to produce energy form of Adenosine triphosphate (ATP), and Effects of pressure on oxygen transport the carbon dioxide and water This is an oxidation reaction in which glucose Oxygen is carried in the blood in two forms: is oxidized and oxygen is reduced. 1. Physically dissolved oxygen in the plasma Cells need energy 2. Combination with the hemoglobin of the Oxygen Transport red blood cells ▪ Each 100 mL of normal arterial blood Oxygen is supplied to and carries 0.3 mL of oxygen physically carbon dioxide is removed dissolved in the plasma and 20 mL of from, cells by the way of the oxygen in combination with circulating blood Movement of carbon hemoglobin. dioxide occurs by diffusion in the opposite direction – Partial Pressure from cell The volume of oxygen transport because Oxygen diffuses from the the solubility of oxygen is so low capillary through the capillary blood A normal arterial blood with a Pa02, the wall to the interstitial fluid greater the amount of oxygen dissolved Partial Pressure Abbreviations Respiration Diffuses through the membrane of tissue cells, where it is used by mitochondria for cellular respiration Respiratory (Pulmonary) Lung Volumes Pa02, is a measurement of oxygen pressure in arterial blood. It reflects how well oxygen is able to move from the lungs to the blood, and it is often altered by severe illnesses. PC02 – is the measure of carbon dioxide within arterial or venous blood. It often serves as a marker of sufficient alveolar ventilation within the lungs. (Ranges Oxygen diffuses down a pressure gradient between 35 to 45 Hg) Airway resistance pg. 1 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) Airway resistance in the bronchi and 3. The whole blood oxygen content (content bronchioles allow more laminar airflow, in 02; units = ml’s of oxygen per 100 ml’s whole which air smoothly flows to the distal blood) segments of the lungs. Assessment Compliance Health history focuses on the physical and A measure of the elasticity, expandability, functional (ADL and quality of life) and distensibility of the lungs and thoracic structures The reason for seeking Health Care Factors that determine lung compliance 1. Dyspnea (shortness of breath) 2. Pain 1. Surface tension of the alveoli (normally low 3. Accumulation of mucus with the presence of surfactant) 4. Wheezing 2. Connective tissue collagen and elastin of 5. Hemoptysis (blood spit up from the the lungs respiratory tract) 6. Edema of the ankles and feet Causes of Increased Airway Resistance 7. Cough 8. General fatigue and weakness Common phenomena that may alter bronchial diameter, which affects airway resistance Collects information 1. Contraction of bronchi smooth muscle – Precipitating factors (asthma) 2. Thickening of bronchi mucosa – (chronic - Duration bronchitis) - Severity, and 3. Obstruction of the airway – by mucus, a - Associated factors or symptoms tumor, or a foreign body 4. Loss of lung elasticity – (emphysema), which Assess for risk factors is characterized by connective tissue Genetic factors that may contribute to the patient’s encircling the airways, thereby keeping lung condition them open during both inspiration and expiration. System affected ❖ Bronchospasm, mucus plugging, and edema in the peripheral airways result in The right ventricle of the heart will be increased airway resistance and affected ultimately by lung disease because obstruction. it must pump blood through the lungs ❖ Air trapping results in lung hyperventilation, against greater resistance ventilation/perfusion (V/Q) mismatch, and It may also be associated with neurologic or increased dead space ventilation neuromuscular disorders such as myasthenia gravis, Guillain-Barre syndrome, or muscular Assessing blood oxygenation dystrophy Blood can be expressed in three different ways: Common symptoms: 1. The partial pressure of oxygen dissolved in 1. Dyspnea the plasma (P02; units = mm Hg) Subjective feeling of difficult or 2. The percent saturation of the hemoglobin labored breathing, shortness of (S02; units = %) breath, breathlessness pg. 2 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) Common to many pulmonary and Chronic Obstructive Pulmonary Disease cardiac disorders, particularly when (COPD) there is decreased lung compliance Orthopnea occasionally in patients or increased airway resistance and with dyspnea with an expiratory Associated with wheeze o Allergic reactions o Anemia Dyspnea (Stridor) o Neurological or The high pitch sound heard (on inspiration) neuromuscular disorders when there is a partial blockage o Trauma o Advanced disease Important to ask the patient the following questions: Common: o End of life How much exertion triggers shortness o Exercise of breath? Is there an associated cough? ▪ Sudden dyspnea Is dyspnea related to other Healthy person symptoms? - Pneumothorax Was the onset of shortness of breath o Air in the pleural cavity sudden or gradual? - Acute Respiratory obstruction At what time of day or night does - Allergic Reaction the dyspnea occur? - Myocardial Infarction Is the shortness of breath worse when Immobilized patient the client is flat in bed? - Pulmonary Embolism Does the shortness of breath occur at rest? With exercise? Running? Dyspnea Climbing stairs? Is the shortness of breath worse while Dyspnea and Tachypnea walking? If so, when walking how (abnormally rapid respiration far? How fast? accompanied by progressive Relief measures: hypoxemia (low blood oxygen level) o The management of In a person who recently dyspnea is aimed at experienced identifying and correcting its o Lung trauma cause. o Shock Relief of the symptom by: o Cardiopulmonary bypass o Placing the patient at rest o Multiple blood transfusion with the head elevated (high Dyspnea (Orthopnea) Fowler’s position) Inability to breathe easily except in an 2. Cough upright position Is a reflex that protects the lungs from the May be found in clients with heart disease accumulation of secretions or inhalation of Noisy breathing result from a narrowing of foreign bodies the airway Cough reflex may be impaired: Localized obstruct of a major bronchus by a o Weakness paralysis of the o Tumor respiratory muscle o Foreign body o Prolonged inactivity o Presence of NGT pg. 3 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) o Depressed function of the 3. Sputum Production brain’s medullary center Is the reaction of the lungs to any constantly (Anesthesia, brain disorders) recurring irritant and often result from Cough may result from irritation and persistent coughing, also with nasal inflammation of the mucous membrane discharge o Multiple respiratory disorders Bacterial infection – profuse amount of o Mucus, pus, blood purulent sputum with thick and yellow, o Airborne irritant (smoke or gas) green, or rust in color Common causes of cough: Viral infection – thin, mucoid sputum 1. Asthma Chronic bronchitis or bronchiectasis – 2. GIT reflux disease gradual increase of sputum overtime 3. Infection Lung tumor – pink-tinged mucoid sputum 4. Aspiration Pulmonary edema – profuse, frothy, pink 5. Side effects of medication Angiotensin- material often welling up into the throat converting Enzyme (ACE) inhibitors Lung abscess – foul smelling sputum and bad breath Inquire about the onset and time Sputum color causes and meaning Night cough – left sided heart failure (Bronchial Asthma) Sputum Morning cough – bronchitis The discharge is a combination of mucus produced in the respiratory tract and saliva It worsens in supine position – postnasal drip (rhino from the mouth sinusitis) Contains microorganisms, immune cells, cellular debris, dust and possibly even blood Cough after food intake – aspiration components or whole blood (plasma and Recent cough – acute infection blood cells) ▪ Clear Assess character ▪ White ▪ Gray Dry, irritative cough ▪ Yellow o URTI of viral origin ▪ Green o Side effects of ACE inhibitor ▪ Brown therapy ▪ Pink Irrelative High-Pitched cough ▪ Red o Laryngotracheitis ▪ Rust-colored Brassy cough – tracheal lesion ▪ Black Severe or changing cough – bronchogenic carcinoma Meaning of sputum color Pleuritic chest pain with cough – pleural or chest wall involvement Clear sputum (musculoskeletal) Is considered as normal, however, there are Syncope (fainting) many conditions that may cause excessive sputum production Can be a result from by violent coughing, A profuse amount of clear sputum should bronchial spasm, obstruction and further therefore be considered as abnormal irritation of the bronchi pg. 4 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) o Pulmonary edema (fluid in Organic and non-organic dusts may cause the lungs) – clear, white or a brown to black discoloration of the pink frothy sputum sputum o Viral respiratory tract o Chronic bronchitis – green, yellow, infections – clear to white brown (infection) (acute) o Chronic pneumonia – white, yellow, o Chronic bronchitis (COPD) – green to brown clear to gray o Coal worker’s pneumoconiosis – o Asthma – white to yellow brown to black (thick) o Tuberculosis – red to brown or black o Lung cancer – red to brown to black Yellow colored sputum Red, pink and rust-colored sputum Is due to the presence of white blood cells (neutrophils and eosinophils) Red sputum – an indication of WB that is more These cells are often present in chronic profuse than bleeding in pink colored sputum. It inflammation, allergic, and infectious causes may completely discolor the mucus or appear as In infections, evident due to the presence of streaks or spots. live neutrophils In allergic conditions, particularly airway Pink sputum – is also a sign of bleeding but usually of hypersensitivity, due to the presence of smaller quantities that may stain or streak the eosinophils sputum. o Acute bronchitis – white to yellow Rust-colored sputum – also due to the bleeding o Acute pneumonia – white to yellow although the clotting process may have o Asthma – white to yellow (thick) commenced, and the RBC may have broken down Green sputum o Pneumococcal pneumonia – rusty-red Is indicative of a long-standing, possibly o Lung cancer – pink to red (frothy) chronic, infection. Sputum will be more progressing to brown or black purulent (large amounts of pus) o Tuberculosis – bright red streaks progressing Long standing non-infectious inflammatory to fully red sputum (hemoptysis) conditions. It will be more mucoid (large o Pulmonary embolism – bright red blood amounts of mucus) (acute) o Pneumonia – white, yellow, or green o Lung abscess – green, sudden 4. Chest pain accumulation of large amount of May be associated with pulmonary sputum if the abscess ruptures or cardiac disease o Chronic bronchitis – clear, grey to Chest pain associated with green (infection) pulmonary conditions: o Bronchiectasis, cystic fibrosis – green o Sharp, stabbing, and intermittent, or if it may be Brown or black sputum dull, aching, and persistent o Usually is felt on the side Is an indication of old blood and the color where the pathologic or at may be due to the breakdown of red blood the to the neck, back, or cells thereby releasing hemosiderin (from abdomen hemoglobin) Chest pain may occur o Pneumonia pg. 5 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) o Pulmonary embolism o Pulmonary emboli and infarction o Lung infarction o Pleurisy Blood from the lung o Late symptom of bronchogenic Is usually bright red, frothy, and mixed with carcinoma sputum Initial symptoms include: Assess: o Thickening sensation o In the throat, a salty taste, a burning - the quality, intensity and radiation of pain or bubbling sensation - identifies and explores precipitating factors, along with their relationship to the patient’s Note: the term “hemoptysis” is reserved for the position coughing up of blood arising from a pulmonary - the relationship of pain to the inspiratory hemorrhage. This blood has an alkaline pH (greater and expiratory phases of respiration than 7) Note: lung disease does not always produce 7. Clubbing of the fingers thoracic pain because the lungs and the visceral Is a change in the normal nail bed. It pleura lack sensory nerves and are insensitive to appears a sponginess of the nail bed pain stimuli and loss of nailbed angle A sign of lung disease found in 5. Wheezing patients Is a high-pitched, musical sound heard o Chronic hypoxic conditions mainly on expiration (asthma) and o Chronic lung infections inspiration (bronchitis) o Malignancies of the lung Major finding in patient with 8. Cyanosis bronchoconstriction or airway narrowing Bluish coloring of the skin Ronchi – low pitched continuous sounds A very late indicator of hypoxia heard over the lungs in partial airway Cyanosis appears when there is 5 construction. Depending on their g/dL of unoxygenated hemoglobin location, severity (maybe heard w/ or A client reducing the effective w/o stethoscope) circulating hemoglobin to 2/3 of the normal level 6. Hemoptysis o An anemic patient rarely Expectoration of blood from the respiratory manifests cyanosis tract o Polycythemia client may Can be small to moderate blood-stained appear cyanotic even if sputum to large hemorrhage adequately oxygenated A symptom of both pulmonary and cardiac disorders Note: therefore, cyanosis is NOT a reliable sign of Onset is usually sudden; it may be hypoxia intermittent or continuous Assessment of cyanosis Causes: o Pulmonary infection Affected by: o Carcinoma of the lung o Abnormalities of the heart or blood o Room lighting vessels o The client’s skin color, and the distance of o Pulmonary artery or vein the blood vessels from the surface of the skin abnormalities pg. 6 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) Central cyanosis inflammatory responses while enhancing innate defense mechanism against Is assessed by observing the color of the respiratory pathogens tongue and lips (this indicates a decrease in ▪ Obesity oxygen tension in the blood) ▪ Excessive exposure to acetaminophen prenatally and in 1st 2 years of life (acetaminophen decreased intracellular Peripheral cyanosis GSH in human pulmonary macrophages Results from decreased blood flow to a and type II pneumocytes and the secretion certain area of the body, seen in of TNF-alpha and possibly IL-6 by human vasoconstriction of the nailbeds or earlobes pulmonary macrophages; suggested that from exposure to cold, (does not necessarily paracetamol was associated with reduced indicate a central systemic problem) antioxidant status and erythrocyte glutathione concentrations) Social and Family History Chest configuration Patient health history Normally, the ratio of anteroposterior o Childhood illness diameter to the lateral diameter is 1:2 o Immunization (influenza, pneumonia) o Medical conditions 4 main deformities of the chest associated with o Injuries respiratory o Hospitalization 1. Barrel Chest o Surgeries 2. Funnel Chest (pectus excavatum) o Allergies 3. Pigeon Chest (pectus carinatum) o Current medical conditions 4. Kyphoscoliosis o Current medical/OTC medications Barrel Chest Personal and Social History Occurs because of overinflation of the lungs o Diet There is an increase in the anteroposterior o Exercise diameter of the thorax o Sleep In a client with emphysema, the ribs are o Recreational habits more widely spaced, and the intercostal o Religion spaces tend to bulge on expiration Risk Factors for respiratory Disease Its presence easily seen, even from a distance ▪ Smoking – the single most important contributor to lung disease Funnel Chest ▪ Exposure to secondhand smoke Occurs when there is a depression in the ▪ Genetic make up lower portion of the sternum ▪ Personal or family history of lung disease This may compress the heart and great ▪ Occupation vessels, resulting in murmurs ▪ Exposure certain allergens and Funnel chest may occur with rickets or environmental pollutants Marfan’s syndrome ▪ Exposure to certain recreational exposure and occupational hazards Pigeon Chest ▪ Vitamin D deficiency (vitamin D appears capable of inhibiting pulmonary pg. 7 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) Occurs as a result of displacement of the o Associate with exertion, anxiety and sternum metabolic acidosis There is an increase in the antero-posterior o Called KUSSMAULS respirations if diameter caused by diabetic ketoacidosis or This may occur with rickets, Marfan’s renal origin syndrome, or severe kyphoscoliosis ▪ Apnea o Period of cessation of breathing o Time duration varies; apnea may Kyphoscoliosis occur briefly during other breathing disorders, such as with Characterized by elevation of the scapula o Sleep apnea and corresponding S-shaped spine o Life threatening if sustained This deformity limits lung expansion within the ▪ Cheyne-Stokes respirations thorax o Varying depth, apnea It may occur with osteoporosis and other o Death rattles skeletal disorders that affect the thorax o Death rales Breathing patterns and Respiratory rates o Regular cycle where the rate and depth of breathing increase, then ▪ Eupnea decrease until apnea (usually about o Normal, breathing at 14-20 20 seconds) occurs o Breaths/minute o Duration of apnea varies and ▪ Bradypnea progressive and lengthen o Decreases rate o Associated with heart failure and o Slower than normal rate (24 o Periods of normal breathing (3-4 breaths/minute breathes) followed by a varying o Associated with pneumonia, period of apnea (usually 10 seconds pulmonary edema, metabolic to 1 minute) acidosis, septicemia, severe pain, or o Also called Ataxic breathing; rib fracture associated with respiratory ▪ Hypoventilation depression resulting from drug o Depth and rate overdose and brain injury, normally o Shallow, irregular breathing at the level of medulla ▪ Hyperpnea o High depth Kussmaul breathing is characterized by a deep, o Increase depth of respiration rapid breathing pattern ▪ Hyperventilation An indication that the body or organs have o High depth and rate become too acidic. In an attempt to expel o Increased rate and depth of CO2, which is an acidic compound in breathing those results in decreased blood, the body starts to breathe faster and PaC02 level deeper o Inspiration and expiration nearly o Caused by a diabetic ketoacidosis equal duration pg. 8 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) o It can also be caused by kidney or Patients usually perform 10 to 20 sustained liver failure deep breath exercises an hour until they o Some cancers, or the ingestion of can achieve their predicted inspiratory toxins reserve volume It is the sum of the expiratory reserve volume, tidal volume, and inspiratory reserve volume PULMONARY DIAGNOSTIC EVALUATION AND The inspiratory capacity (IC) is the amount LABORATORY EXAMINATIONS of air that can be inhaled after the end of a normal expiration. (3,100 male and 1,900 ❖ The test measures lung volume, capacity, female) rates of flow, and gas exchange ❖ Detect disorders like lesions infections and Incentive spirometers (IS) encourage clients to others sustain deep voluntary breathing and maximum inspiration to: Pulmonary Function Tests (PFTs) 1. Open airways, (alveolar sacs) Incentive Spirometer or Spirometry 2. Encourage coughing and prevent or Test that measures how well the lungs work reduce atelectasis Assessment methods allow for detailed 3. Enhance deep voluntary breathing and evaluation of expiratory flow limitations and sustained inspiration. (Encourages slow-long airway inflammation breath) Interpretation Indication Basis of the degree of deviation from normal Used for: o Clients with respiratory symptoms Postoperative clients (dyspnea, wheezing, cough, sputum Chest trauma victims production) usually undergoes a Clients with respiratory disorders complete diagnostic evaluation, Clients who have had abdominal or even though the results of PFTs are thoracic surgery “normal” Elderly clients are especially at risk for Consideration: atelectasis and consolidation o Height o Occurs when the air that usually fills o Weight the small airways in the lungs is o Age replaced-depending on the cause, o Gender the air may be replaced with: ❖ The inspiratory capacity (IC) is the amount - A fluid, such as pus, blood, or of air that can be inhaled after the end of a water normal expiration - A solid, such as stomach Assisting a client with an incentive spirometer contents or cells Overview Indication Incentive spirometry is a goal-oriented Used as adjunct treatment in other high-risk inhalation maneuver in which the patient is clients such as those: encouraged by visual feedback from a Clients on long-term bed rest spirometer to execute sustained maximal Clients with chronic and restrictive inhalation lung diseases pg. 9 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) Clients on medications that depress respiration ❖ The main benefits of spirometer exercises are: The patients get rid of the excess Pulse oximetry fluid and the micro-organisms Is a non-invasive method of continuously forming inside the lungs that can monitoring the oxygen saturation of cause diseases hemoglobin (SpO2 or SaO2) Strengthen the lung muscles and thereby the patient will be less prone Purpose to infections. An effective tool to monitor for subtle or Arterial Blood Gas Studies (ABG) sudden change in oxygen saturation Maybe incorporated into a multi monitor Obtained through an arterial puncture at Pulse oximetry does not replace arterial the radial, brachial, or femoral artery or blood gas measurement through an indwelling arterial catheter. Normal SpO2 value (95% to 100%) Purpose: Values less than 85% indicate that the tissues Assessing the ability of the lungs to provide are not receiving enough oxygen, and the adequate 02 and remove client needs further evaluation Ability of the kidneys to reabsorb or excrete HC03 – ions to maintain normal body pH, Unreliable PO2 values obtained which reflects metabolic states. In cardiac arrest Bicarbonate is a by product of the body’s Shock metabolism Dyes (i.e., methylene blue) Vasoconstriction medication The blood brings bicarbonate to the lungs, and then it is exhaled as carbon dioxide. Inaccurate: The kidneys also help regulate bicarbonate Bicarbonate is excreted and reabsorbed by Severe anemia or the kidneys. This regulates the body’s pH, or A high carbon monoxide level acid balance. Dark skin patient or wearing nail polish Bright light (sunlight) Indication Client’s movement (shivering) The arterial oxygen tension (PaO2) – Cultures indicates the degree of oxygenation of the blood Throat, nasal and nasopharyngeal cultures The arterial carbon dioxide tension (PaCO2) can identify organisms (pathogens) indicates the adequacy of alveolar responsible for infection ventilation Throat culture Complication Performed in adults with severe sore throats Pain accompanied by fever and lymph nodes Infection enlargement Hemorrhage More useful detecting streptococcal infection (infection in the LRT) pg. 10 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) Other infection such as staphylococcus - Extent of infection aureus or influenza - To tumor growth in cancer Sputum Studies Chest X-ray Identify pathogenic organisms Usually taken after full inspiration (a deep To determine whether malignant cells are breath) present in sputum Lungs are best visualized when they are well aerated Purpose Diaphragm is at its lowest level and the largest expanse of lung is visible ▪ In general If taken on expiration, x-ray film may o Sputum cultures are used in accentuate an unnoticed pneumothorax or diagnosis, for drug sensitivity testing obstruction of a major artery o And to guide treatment Normal pulmonary tissue is radiolucent; ❖ Assess for hypersensitivity states (in which therefore, densities produced by: fluid, there is an increase in eosinophils) tumors, foreign bodies, and other ❖ Periodic sputum examination may be pathologic conditions can be detected by necessary for client’s receiving antibiotics, x-ray examination corticosteroids, and immunosuppressive medications for prolonged periods Computed Tomography (because these agents are associated with opportunistic infections.) CT is an imaging method in which the lungs are scanned in successive layers by a Collecting Specimen narrow-beam x-ray The images produced provide a cross- Expectorant is the usual method for sectional view of the chest collecting a sputum specimen May be used to define pulmonary nodules Obtained in the morning before the client and small tumors adjacent to pleural has had anything to eat or drink surfaces that are not visible on routine chest The client is instructed to clear the nose and x-ray throat and rinse the mouth to decrease demonstrate mediastinal abnormalities and contamination of the sputum hilar adenopathy, which are difficult to After taking a few deep breaths, the client visualize with other techniques coughs (rather than spits), using the ▪ lymphadenopathy and tumors diaphragm ▪ pulmonary venous hypertension Note: all cultures should be obtained prior to ▪ pulmonary arterial hypertension initiation of antibiotic therapy Potential Complications Imaging Studies Acute Renal Failure – contrast agents ▪ Chest x-rays reduce renal blood flow in the medulla, ▪ Computed tomography (CT) scan induce free oxygen radicals, and induce ▪ Magnetic resonance imaging (MRI) apoptosis of renal tubular cells ▪ Radioisotope or nuclear scan diagnostic Acidosis secondary to contrast scans Contraindications Part of any diagnostic workup determination Allergy to dye pg. 11 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) Pregnancy Fluoroscopy Claustrophobia Morbid obesity An imaging technique that uses X-rays to obtain real time moving images of the Magnetic Resonance Imaging interior of an object., allows a physician to see the internal structure and function of the Similar to CT scans except that magnetic body fields and radiofrequency signals are used instead of a narrow-beam x-ray Fluoroscopic Studies MRIs yield a much more detailed diagnostic image than CT scans Is used to assist with invasive procedures, such as a chest needle biopsy or Purpose transbronchial biopsy Performed to identify lesions Use to characterize pulmonary nodules It also may be used to study the movement To help stage bronchogenic carcinoma of the chest wall, mediastinum, heart, and (assessment of chest wall invasion) diaphragm Evaluate inflammatory activity in interstitial To detect diaphragm paralysis, and to lung disease locate lung masses Detect acute pulmonary embolism Chronic thrombolytic pulmonary Pulmonary Angiography hypertension Is most commonly used to investigate Contraindication: thromboembolic disease of the lungs Morbid obesity To visualize Claustrophobia Confusion and agitation It involves the rapid injection of a Having implanted metal or metal support radiopaque agent into the vasculature of devices that are consider unsafe – metal the lungs for radiographic study of the implant can be dangerous in an MRI pulmonary tree environment due to the powerful magnetic Performed by injecting the radiopaque field. The magnet can cause the metal agent into a vein with a needle or catheter implant to move and damage surrounding in one or both arms (simultaneously) tissue. In some cases, it can even cause the o the femoral vein, jugular, brachial, implant to dislodge from the body subclavian with the main pulmonary artery branches Contraindicated implant in MRI o great veins proximal to the pulmonary artery Cochlear (ear) implant or hearing aides Brain aneurysm clips Contraindication Metal coils/stents placed inside blood vessels Allergy to dye/radio opaque Neurostimulators or implanted Pregnancy programmable devices Claustrophobia Cardiac defibrillators and pacemakers Bleeding abnormalities Recent improvements (medical devices such as Potential complications infusion pumps and ventilations are all safe) Renal failure Acidosis pg. 12 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) Cardiac dysrhythmias Bronchoscopy Nursing intervention The direct inspection and examination of the larynx, trachea, and bronchi ▪ Verify informed consent has been obtained Through either a flexible fiberoptic ▪ Assess for known allergies bronchoscope (small size, its flexibility, and ▪ Assess anticoagulants status (APTT activated its excellent optical system, it allows partial thromboplastin time) and renal failure increased visualization of the peripheral ▪ Ensure that the client has not eaten airways anything to drink procedurally as prescribed. A rigid bronchoscope (metal tube wit a light (NPO 6 to 8 hours) at it performs in the O.R removing foreign ▪ Administer pre procedure medication that substances, investigating the source of may include anti-anxiety, medication, massive hemoptysis, or performing secretion reducing agents and endobronchial surgical procedures) antihistamines ▪ Nurse should instruct the patient that they Purpose: may experience a warm flushing sensation or chest pain during the injection of dye ▪ To examine tissues or collect secretions ▪ To determine the location and extent of the After the procedure pathologic process and to obtain a tissue sample for diagnosis – by biting or cutting ▪ Closely monitor the vital signs forceps, curettage, or brush biopsy ▪ Level of consciousness ▪ To determine if a tumor can be resected ▪ Oxygen saturation surgically ▪ Vascular site for bleeding and hematoma ▪ To diagnose bleeding sites (source of hemoptysis) Radioisotope diagnostic procedures – lung scans Therapeutic Bronchoscopy is used to: Are used to detect normal lung functioning, pulmonary vascular supply, and gas ▪ Remove foreign bodies from the exchange tracheobronchial tree ▪ Remove secretions obstructing the Types of lung scans tracheobronchial tree when the patient ▪ Ventilation – perfusion scan cannot clear them ▪ Gallium scan ▪ Treat postoperative atelectasis ▪ Positron emission tomography ▪ Destroy and excise lesions Performed by injecting a radioactive agent into a Nursing interventions peripheral vein and then obtaining a scan called Administers preoperative medication usually tracer sends out gamma rays. These rays are picked atropine sulfate and a sedative or opioid up by the scanner to take a picture of the lungs o As prescribed to inhibit vagal Endoscopic procedures stimulation (thereby guarding against – bradycardia, dysrhythmias, ▪ Bronchoscopy and hypotension) ▪ Thoracoscopy o Suppress the cough reflex, sedate ▪ Thoracentesis the patient and relieve anxiety o Also reduce salivation and bronchial secretions before surgery pg. 13 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) o Or as an antidote for overdose of endoscope and fluid tissues can be cholinergic drugs or mushroom obtained for analysis poisoning Performed in the O.R under anesthesia Small incisions are made into the pleural Nursing alert! Sedation given to patients with cavity in an ICS. Any fluid present in the respiratory insufficiency may be precipitate pleural cavity is aspirated, after the respiratory arrest procedure Remove dentures and other oral prosthesis Primarily indication: of the patient Usually performed under local anesthesia In the diagnostic evaluation of pleural but general anesthesia may be needed for effusions, and disease tumor staging rigid bronchoscopy Biopsies of the lesions can be performed Anesthetic such as lidocaine (xylocaine) under visualization for diagnosis may be sprayed on the pharynx or dropped on the epiglottis and vocal cords and into A chest tube may be inserted and the pleural the traches (to suppress the cough reflex cavity is drained by negative-pressure water-seal and minimize discomfort) drainage Sedatives or opioids are administered Nursing interventions intravenously as prescribed to provide moderate sedation ▪ Monitor the patient for SOB which might be indicate a pneumothorax Nursing responsibility ▪ Minor activity restrictions, which vary ▪ After the procedure, it is important – NPO depending on the intensity of the procedure until the cough reflex returns ▪ If a chest tube is in place, monitoring the ▪ Once the client demonstrates a cough chest drainage system and chest tube reflex, offer ice chips and eventually fluids insertion site is essential ▪ Assess for confusion and lethargy in the Thoracentesis elderly, which may be due to the large doses of lidocaine given during the Is the aspiration of fluid and air from the procedure pleural space ▪ Monitors the patient’s respiratory status and observes for hypoxia, hypotension, Purpose tachycardia, dysrhythmias, hemoptysis, and Removal of fluid and air from the pleural dyspnea cavity ▪ Any abnormality is reported promptly Aspiration of pleural fluid for analysis ▪ The client is not discharged from the Pleural biopsy recovery area until adequate cough reflex Instillation of medication into the pleural and respiratory status are present space ▪ The nurse instructs the patient and family caregivers to report any SOB or bleeding Studies of pleural fluid include gram’s stain culture immediately and sensitivity, acid-fast staining and culture, differential cell count, cytology, pH, specific gravity, Thoracoscopy total protein, and lactic dehydrogenase Is a diagnostic procedure in which the pleural cavity is examined with an pg. 14 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) Biopsy histologic study under fluoroscopic or CT guidance. ▪ The excision of a small amount of tissue, may Analgesia may be given before the be performed procedure. The skin over the biopsy site is ▪ To permit examination of cells from the cleansed and anesthetized and a small pharynx, larynx and nasal passages incision is made. ▪ Local, topical, or general anesthesia may The biopsy needle is inserted through the be administered, depending on the site and incision into the pleura with the patient the procedure holding their breath in mid expiration. The surgeon guides the needle into the Lung biopsy procedures periphery of the lesion and obtains a tissue Performed to obtain lung tissue for sample from the mass. examination to identify Nursing interventions The nature of the lesion Potential interstitial lung disease For bronchoscopy and thoracoscopy (cancer) Infection ▪ Monitoring the client for shortness of breath, bleeding, and infection 3 Nonsurgical lung biopsy techniques ▪ The client and/or family is instructed to report pain, SOB, visible bleeding, or redness 1. Transcatheter bronchial brushing of the biopsy site or pus to the health care 2. Transbronchial lung biopsy provider immediately 3. Percutaneous needle biopsy (through-the- skin) needle biopsy Caring for biopsy site Transcatheter Bronchial brushing ▪ keep the bandage on the biopsy until the day after the biopsy Procedure is useful for cytologic evaluations ▪ leave the Steri-Strips (thin strips of paper of lung lesions tape) on your biopsy site For the identification of pathogenic ▪ shower 24 hours (1 day) after the biopsy organisms (nocardia, aspergillus, ▪ observe if client have swelling and bruising pneumocystis carinii, and other pathogens) after biopsy Transbronchial Lung Biopsy Lymph Node Biopsy Uses biting or cutting forceps introduced by performed to detect lymph node spread of a fiberoptic bronchoscope pulmonary disease and to establish a Indication: diagnosis or prognosis in such diseases: ▪ Hodgkin’s disease When a lung lesion is suspected and the ▪ Sarcoidosis results of routine sputum ▪ Fungal disease o Samples and bronchoscopic ▪ Tuberculosis washings are negative ▪ Carcinoma Percutaneous Needle Biopsy Mediastinoscopy a cutting needle or a spinal-type needle is Is the endoscopic examination of the used to obtain a tissue specimen for mediastinum pg. 15 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) For exploration and biopsy of mediastinal ▪ Female: 7.4 – 9.9 mmol/L (SI units) lymph nodes that drain the lungs An incision is made in the area of the 2 nd or Signs and symptoms of Hypoxemia 3rd costal cartilage Shortness of breath Chest tube drainage is required after the Rapid breathing procedure Coughing Valuable to determine whether a Sweating pulmonary lesion is dissectible Wheezing Nursing interventions Indication of oxygen therapy Post procedure care focuses on: ❖ Hypoxemia ▪ Providing adequate oxygenation Decrease in the arterial tension in the ▪ Monitoring for bleeding, and providing pain blood relief Sign and symptoms The nurse should instruct the client and family to: ▪ Changes in the mental status progresses ▪ Monitoring for changes in respiratory status ▪ Impaired judgement ▪ Consider the impact of anxiety about the ▪ Agitation potential findings of the biopsy on their ▪ Confusion ability to remember those instructions (when ▪ Lethargic discharge after few hours) ▪ Disorientation ▪ Coma The client may be discharged a few hours after the chest drainage system is removed Dyspnea Invasive/Non-Invasive Respiratory Therapies ▪ Increase blood pressure ▪ Changes in heart rate 1. Oxygen therapy ▪ Central cyanosis Is the administration of oxygen at ▪ Diaphoresis concentration greater that found in ▪ Cool extremities the environmental atmosphere Goal: provide adequate transport of ❖ Hypoxia oxygen in the blood while Decrease in the oxygen supply to decreasing the work of breathing tissues and cells cause by problems and reducing stress in the outside the respiratory system (life myocardium threatening if severe) Factors that effect O2 transport Signs and symptoms 1. Cardiac output ▪ Lack of coordination ▪ the volume of blood being pumped ▪ Impaired judgement by the heart ▪ Fatigue 2. Arterial oxygen content ▪ Drowsiness ▪ depends on hgb concentration (or ▪ Apathy packed cell volume) PVC and ▪ Inattentiveness and lately delayed reaction saturation with oxygen time 3. Concentration of hemoglobin ▪ Male: 8.7 – 11.2 mmol/L (SI units) pg. 16 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) Types of Hypoxia Postural drainage Anemic hypoxia Method for cleaning the lungs by Result in the decreased effective changing position hemoglobin concentration Allows the force of gravity to assist in the removal of bronchial secretions, Cause its removed by coughing or suctioning ▪ Decrease in the oxygen carrying capacity of the blood Chest percussion and vibration ▪ Carbon monoxide poisoning (the oxygen capacity of the hgb) Clapping and vibration may be added to the postural drainage routine. This will help Histotoxic Hypoxia the thick secretions that are difficult to Occurs when toxic substance, cough out may be loosened (cyanide) interferes with the ability of It helps the mucous from the small air sacs to the tissues to use available oxygen the larger airways where it can be coughed or suctioned out Complication Clapping and vibration are done when the person is placed in certain postural ▪ Produce toxic effects on the lungs and CNS drainage positions ▪ Depress ventilation Never clap over the spine, kidneys or lower Remember: part of the back on each side, or on the breasts or stomach. Always stop clapping ▪ Higher fraction of inspired oxygen (Fi02) while the person is coughing values adds no significance amounts of Clap gently with the cupped hand for 3 – 5 oxygen to the RBC, produced toxicity minutes over the congested area Suppression of Ventilation Breathing Retraining Exercise The stimulus of respiration is decrease Consist of exercise and breathing practices in blood oxygen rather than for COPD client elevation in the carbon dioxide Slow, relaxed, rhythmic breathing The administration of H- diaphragmatic breathing and pursed lip concentration of O2 removes the breathing (improves oxygen transport, and respiratory drive that created by the prevent airway collapses secondary to loss chronic low O2 tension – decrease of lung elasticity in emphysema) alveolar ventilation – progressive inc. in arterial carbon dioxide pressure Airway Management (PaCO2) – respiratory failure Used when the airway become narrowed or Recommended flow of O2 is 1-2 LPM blocked 2. Small volume nebulizer therapy Causes: Is handled apparatus that disperses a moisturizing agent or medication ▪ Disease such as bronchodilator or mucolytic ▪ Bronchoconstriction agent into microscopic particles and ▪ A foreign body or secretions delivers it to the lungs as the patient inhales 1. Endotracheal Intubation pg. 17 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) Involves passing an endotracheal tube through the mouth or nose into the trachea It provides patent airway when patient is having a respiratory distress that cannot be treated with a simple method – choice of emergency care Providing an airway for patient who cannot maintain an adequate airway on their own ▪ Comatose ▪ Those who needs mechanical ventilator ▪ Cardiac arrest ▪ For suctioning secretions from the pulmonary tree 2. Tracheostomy ▪ Tracheotomy – surgical procedure in which an opening is made into the trachea ▪ Tracheostomy tube – the indwelling tube inserted into the trachea (the stoma that is the product of the tracheostomy) - Maybe temporary or permanent Mechanical Ventilation A positive or negative pressure breathing device that can maintain ventilation and oxygen delivery for a prolonged period Indications: ▪ Respiratory failure ▪ Compromised airway ▪ Endotracheal intubation ▪ Mechanical ventilator is indicated pg. 18 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) NURSING MANAGEMENT OF CLIENT (ADULT) Obstructive sleep apnea occurs when the muscles in the back of the throat relax too WITH UPPER RESPIRATORY TRACT INFECTION much to allow normal breathing Parts of the upper respiratory tract These muscles support structures including the soft palate, uvula, the tonsils and the tongue Sleep apnea is classified into three types: 1. Obstructive – lack of air flow due to pharyngeal occlusion 2. Central – simultaneously cessation of both air flow and respiratory movements 3. Mixed – a combination of central and obstructive apnea within one apneic episode The most common type – obstructive sleep apnea Upper airway muscles have both tonic and phasic activity to maintain the patency of the airway during breathing Obstruction and Trauma of the Upper Respiratory Airway Continuous tonic contraction occurs in most pharyngeal muscles, supplemented by Sleep Apnea Syndrome stronger, phasic contraction during inspiration, particularly when ventilation Defined as cessation of breathing (apnea) rates are high (e: during exercise) during sleep severe problem – CO2 retention Apnea (hypercapnia) the most common cause of obstructive ▪ Describe slowed or stopped breathing sleep apnea (OSA) is mechanical ▪ Can affect people of all ages, and the obstructive due to obesity cause depends on the type of apnea ▪ Usually occurs during sleep, for this - Obesity reason, it’s often called sleep apnea - A condition Mechanical factors (sleep The obstructive sleep apnea cycle that reduces related disorders) pharyngeal ▪ Quiet breathing – open airway, air moves - Reduced diameter of muscle tone in/out easily the upper airway (e.g., ▪ Snoring – partly collapsed airway, air moves - Dynamic changes in neuromuscular less easily the upper airway disease, ▪ Silence-apnea – fully collapsed airway, no during sleep sedative/hypn air movement - The activity of the otic tonic dilator muscles medications, The cycle is repeated over and over, robbing you of acute of the upper airway is restful sleep ingestion of reduced during sleep alcohol pg. 19 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) Complaints by the partner that the patient Apneic snores loudly or is unusually restless during Increased upper airway episodes/hour sleep collapse with the small to several amounts of negative hundred/night Obstruction cause: pressure generated during inspiration 1. Mechanical factors Repetitive apneic Reduced diameter of the upper events airway or dynamic changes in the upper airway during sleep Triggers a Effects in the heart and The activity of the tonic dilator sympathetic the lungs (hypoxia and muscles of the upper airways is response hypercapnia) reduced during sleep These sleep-related changes may predispose the patient to increased upper airway collapse with the small amounts of negative pressure hypertension stroke Cardiovascular Risk of generated during inspiration disease, the myocardial dysrhythmias nocturnal The genioglossus is a large upper airway infarction hypoxemia dilator muscle that is responsible for moving the tongue forward and Clinical Manifestations widening the oropharyngeal airway More prevalent: during inspiration men those who are older and overweight During wakefulness, pharyngeal muscle cigarette smoking is a risk factor activity is maintained by reflex-driven augmented pharyngeal dilator muscle Obstructive Sleep Apnea activity Defined as a frequent and loud snoring and During sleep, the upper airways muscles breathing cessation for 10 seconds or more are relaxed compared to awake, so the for 5 episodes/hr or more, followed by upper airways can e critically awakening abruptly with a l oud snort as the compromised at sleep onset because of blood oxygen level drops the general fall in muscle tone and May experience anywhere from 5 apneic reflex functions which occurs episodes per hour to several hundred/night 2. Obesity Other symptoms: When a person gain weight, there is an increase in fat deposits in the soft Excessive daytime sleepiness tissues of the throat Morning headache Fat deposits in the upper respiratory Sore throat tract narrow the airway; there is a Intellectual deterioration decrease in muscle activity in this Personality changes region, leading to hypoxic and Behavioral disorders apneic episodes, ultimately resulting Enuresis in sleep apnea Impotence Being overweight, extra pounds can Obesity mean more than a tight waistband pg. 20 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) 3. Conditions that reduce pharyngeal muscle - An increased risk of tone myocardial infarction - Stroke Neuromuscular disease o In patients with underlying cardiovascular disease, the nocturnal hypoxemia (sleep Central alveolar hypoventilation (CAH), apnea and mild lung disease can cause polio and myotonic dystrophy, may nocturnal hypoxemia – when the blood have involvement of the central oxygen levels drop during sleep – may controllers of respiration, leading to predispose to dysrhythmias central apneic events during REM and non-REM sleep Medical management Use of some medication ▪ In mild cases, the client is advised to: - Avoid alcohol and ▪ Sedative/hypnotic medications: medications that depress the Some prescription medication upper airways A sedative drug decreases - To lose weight activity, moderates’ ▪ The gold-standard treatment for excitement, and calmness sleep apnea A hypnotic drug produces - If the client can wear it as drowsiness and facilitates the prescribed, it’s 100% effective onset and maintenance of a - If the client can sleep with a state of sleep CPAP (continuous positive ▪ Acute ingestion of alcohol (drinking airway pressure), it can alcohol) provide a 100% correction It can relax the airway to the ▪ Severe cases involving hypoxemia point that it gets blocked with severe CO2 retention ▪ Sleeping position (hypercapnia), the treatment Conditions that reduce includes: pharyngeal muscle tone o Continuous positive airway pressure (CPAP) Diagnosis or Bilevel positive airways pressure (BiPAP) therapy via nasal cannula 1. Clinical features - CPAP provides air at a 2. Polysomnographic findings (sleep test), in pressure just high enough to which the cardiopulmonary status of the prevent the collapse of patient is monitored during an episode of airway sleep - The pressurized air is provided is provided through a mask Effects of obstructive sleep apnea that seals with the mouth or o Can seriously affect the heart and nose lungs Medical management (surgical procedures) o Repetitive apneic events result in hypoxia and hypercapnia, which 1. Uvulopalatopharyngoplasty triggers a sympathetic response - May be performed to correct o Consequently, patients have a high the obstruction prevalence: 2. Tracheostomy - Hypertension - As a last resort – is performed to bypass the obstruction if pg. 21 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) the potential for respiratory The nurse also instructs the patient and failure or life-threatening family about: dysrhythmias exists ▪ Treatments, including the correct - The tracheostomy is and safe use of oxygen, if unplugged only during sleep prescribed - Although this is an effective treatment, it is used in a Epistaxis limited number of patients because of its associated physical disfigurement Pharmacologic therapy Treatment of Central Sleep Apnea 1. Medication ▪ Protriptyline (triptil) given at bedtime is thought to increase the respiratory drive and improve upper airways muscle tone ▪ Medroxyprogesterone acetate A hemorrhage from the nose caused by: (provera) The rupture of tiny, distended ▪ Acetazolamide (Diamox) vessels in the mucous membrane of any area of Recommended for sleep apnea associated with the nose chronic alveolar hypoventilation (the body’s CO2 level rises. This causes a buildup of acid and too Three major blood vessels enter the little oxygen in the blood) but their benefits have nasal cavity: not been well established 1. Anterior ethmoidal artery on the 2. Oxygen therapy (Nasal cannula) forward part of the roof ▪ Administration of low-flow nasal (kesselbach’s plexus) oxygen at night can help relieve 2. The sphenopalatine artery in the hypoxemia in some patients but has posterosuperior region little effect on the frequency or 3. The internal maxillary branches (the severity of apnea plexus of veins located at the back ▪ Only deliver a nasal cannula flow of the lateral wall under the inferior rate of 4 to 6 liters of oxygen per turbinate minute Causes associated with epistaxis: Nursing management o Trauma, infection, inhalation of illicit drugs, The client with obstructive sleep apnea cardiovascular diseases, blood dyscrasias, may not recognize the potential nasal tumors, low humidity, a foreign body in consequences of the disorder the nose, and a deviated nasal septum ▪ The nurse explains the disorder in o Vigorous nose blowing and nose picking language that is understandable have been associated with epistaxis to the patient and related symptoms (daytime sleepiness) to the underlying disorder pg. 22 – MARALIT, HERSEL JOY N.  NCM 112 – MEDICAL SURGICAL (OXY, FLUIDS) Medical management o Provide emesis basin to allow the patient to expectorate any excess blood o Initial treatment o It is not uncommon for patients to be - Applying direct pressure anxious in response to a nosebleed. Blood o The patient sits upright with the head tilted loss on clothing and handkerchiefs can be forward to prevent swallowing and frightening, and the nasal examinations and aspiration of blood treatment are uncomfortable o Directed to pinch the soft outer portion of o Assuring the patient in a calm, efficient the nose against the midline septum for 5 to manner that bleeding can be controlled 10 minutes continuously can help reduce anxiety In anterior nosebleeds, the area may be treated Teaching patients’ self-care with a: Discharge teaching includes reviewing ways to 1. Silver nitrate applicator and gelfoam, by prevent epistaxis: electrocautery 2. Topical vasoconstrictors, adrenaline (1 - Avoiding forceful nose 1,000), cocaine (0.5%), and phenylephrine blowing may be prescribed - Straining - High altitudes If bleeding is occurring from posterior regions - Nasal trauma (including nose picking) o Cotton pledges soaked in - Adequate humidification vasoconstricting solution may be may prevent drying of the inserted into the nose to reduce the nasal passages blood flow and improve the examiners’ view of the bleeding site The nurse instructs the patient how to apply direct o Alternatively, a cotton tampon may be pressure to the nose with the thumb and the index used to try to stop the bleeding finger for 15 minutes in the case of a recurrent o Suction may be used to remove excess nosebleed blood and clots from the field of inspection If recurrent bleeding cannot be stopped, the o The nose may be packed with gauze patient is instructed to seek additional medical impregnated with petroleum jelly or attention antibiotic ointment o A topical anesthesia spray and Rhinitis decongestant agent may be used prior Mean inflammation of the nose to inserting the gauze packing, or a A group of disorders characterized by balloon-inflated catheter may be used inflammation and irritati