Care of Clients with Respiratory Disorders PDF

**CARE OF CLIENTS WITH RESPIRATORY DISORDERS** **Respiration-** a process of gas exchange between individual and the environment **3 process of respiration** **Ventilation**- movement of gas in and out of the lungs *2 phases of ventilation* - Inhalation- voluntary - Exhalation- involuntary...

**CARE OF CLIENTS WITH RESPIRATORY DISORDERS** **Respiration-** a process of gas exchange between individual and the environment **3 process of respiration** **Ventilation**- movement of gas in and out of the lungs *2 phases of ventilation* - Inhalation- voluntary - Exhalation- involuntary **Diffusion**- exchange of gas in are where there is high pressure to low pressure **Perfusion**- availability of movement of blood for transport of gas **Structure of respiratory:** 1. **Upper Airways:** ***function***: transport gas to lower airways **Pharynx**- funnel-shaped tubed that extends nose to larynx Way of air of food Common opening of respiratory and digestive *3 sections of pharynx* **Nasopharynx** **Oropharynx** **Laryngopharynx** **Larynx**- it covers the epiglottis Acts as a humidifier of inspiring way It also protects the lower airway **Trachea**- 12 cm long or 4-5 inches long **Carina**- an area where splitting begins for right and left bronchi **Vibrissae**- filters foreign object **Cilia**- hair-like projection **Sinus**- an open area within the skull, also called paranasal sinuses (ex. of sinuses: frontal, maxillary, ethmoid, and sphenoid sinus) **Right bronchus**- shorter, broader, and more vertical than left bronchus 2. **Lower airway** 3. **Lungs** 4. **Thorax and diaphragm** 5. **Respiratory centers** - part of body that is responsible for breathing ***the medulla oblongata and pons are the respiratory centers*** **The medulla oblongata** - is the primary respiratory central it contains chemoreceptors stimulates if patient has high level of carbon dioxide in blood **pons**- **pheumotaxic center**- rhythmic quality of breathing responsible for the **apneutics center** - deep and prolong inspiration **peripheral chemoreceptor**- takes place the work of breathing when central chemoreceptors is damaged IF **CARBON DIOXIDE GETS HIGH,** THE **CENTRAL CHEMORECEPTOR WILL BE ACTIVATED**, BUT **ONCE IT IS DAMAGED** **PERIPHERAL CHEMORECEPTOR TAKES PLACE.** IF **PT IS HYPERTENSIVE**, IT MIGHT HAVE A **RESPIRATORY ALKALOSIS**, BECAUSE OF LOW IN RR. (vice versa if hypotensive) **BIBLIOGRAPHICAL DATA:** secondary to cigarette smoking, exposed to patient with respiratory disorders and genetics **CHIEF COMPLAIN**: dyspnea , cough , chest pain, hx. Of patient past medical hx. BGC vaccine, family hx. Psychosocial hx. (life style , geographical location and personal habits can be.) **Computation: number of years X pack/day =** **Example : 5yrs X 3 pak/day = 15yrs** **DIAGNOSTIC TEST AND STUDIES**: 1. **MANTOUX TEST**- is used to determine if a person is infected with Mycobacterium tuberculosis. It is primarily used to diagnose latent TB infection, where the TB bacteria is in the body but the person is not experiencing any symptoms suggestive of TB disease - Route: intradermal skin test - Use PPD upon injection ( purified protein derivatives ) - 10mm or more means (+) in mantoux test - (+) means exposure to mycobacterium tubercle bacilli - However 5mm for HIV patients considered as Mantoux (+) **NURSING INTERVENTION**: - Bawal basain for 24hrs , bawal likutin, - Arrange a follow-up schedule for return **within 72hrs or 2-3 days**. Ready to be read 2. **CHEST X-RAY-** Before x-ray practice, the patient should hold his breath and deep breathing exercises, remove metal jewelry, etc. 3. **FLUOROSCOPY --** a test that studies the chest and lungs in motion 4. **BRONCHOGRAPHY or BRONCHOGRAM --** a radiopaque medium instilled directly into the trachea - **BRONCHOSCOPE -** is the instrument used in this procedure **NURSING RESPONSIBILITIES** **PRE OP PROCEDURE** - **INVASIVE** must be with consent - **"dye" check for seafood allergies** - **NPO for 6-8hours to prevent aspiration** - **ANTISPASMODIC AGENTS and OXYGEN -- incased patient developed DOB** - **Vitals monitoring** - **PRE OP MEDS:** anticholinergic meds**( ATROPIN SO4)-** Keep airway clean of mucus and saliva **(DIAZEPAM ) --** anxiolytic for anxiety and patient relaxation **, ( TOPICAL ANESTHESIA )-** Spray then followed by **( LOCAL ANESTHESIA )-** directly injected into larynx to **DEPRESS GAG RELFEX** - **NPO** until gag reflex and cough reflex return - **TEACH** patient deep breathing and coughing exercises - Can develop **LOW GRADE FEVER** after the procedure 5. **BRONCHOSCOPY --** direct **inspection** and **observation** of the larynx, trachea and bronchi through a flexible and rigid **bronchoscope** (instrument used in bronchoscopy) **Function:** to collect secretion, for diagnostic tests, to determine the location of pathological process, collection of specimens for biopsy, **Therapeutics -** also can remove an aspirated foreign object and excise small lesions **NURSING INTERVENTION** - **INVASIVE** must be with consent - **PRE-OP MEDS** -- ATROPHIN SO4 , DIAZEPAM , TOPICAL ANESTHESIA (SPRAY) , LOCAL ANESTHESIA - REMOVE DENTURES AND NPO - **SIDE LYING POSITION** -- prevent aspiration and promote drainage - **NPO** until gag reflex return **WATCH OUT FOR DANGERS SIGNS OF PERFORATED BRONCHIAL TREE: CYANOSIS, TACHYCARDIA, HYPOTENSION, ARRHYTHMIAS, HEMOPTYSIS -- coughing of blood and DYSPNEA.** 6. **LUNG SCAN -** following **injection of radioisotopes**, scans are taken with an instillation camera**, it MEASURES BLOOD PERFUSION through the LUNGS** - Also to confirm patient have **PULMONARY EMBOLISM** and other **BLOOD FLOW** abnormalities **NURSING INTERVENTION:** - **Consent** because its **COSY** - Instruct patient to **remain still during** the procedure **7. Sputum examination**- assess gross appearance **Rusty sputum**- pt has pneumococcal pneumonia  **Greenish sputum**- pt has pseudomonas infection  **Bloody sputum**- pt has PTB **Sputum culture and sensitivity-** test under a microscope, it is done to detect the actual microorganisms causing the respiratory infection  **Acid-fast bacillus (AFB)** - **staining** is the specific test Used to detect PTB  **Cytologic examination**- use to detect presence of cancer cell **NURSING RESPONSIBILITIES** Proper collection of sputum: Early morning sputum specimen (easy to expectorate) Can advise to clean or rinse the mouth using plain water, do not use mouthwash. Put sputum in a sterile container (to ensure that the specimen is not contaminated) **If testing for AFB**- we need to collect 3 consecutive mornings usually early in the morning around 5:00 to 5:30 am **If collected at home**, it needs to be brought to the lab immediately  If testing for **culture and sensitivity**- collected before the first dose of anti-microbial **Lung Biopsy** is done in 3 forms  **Transbronchoscopic biopsy**- usually done together with bronchoscopy  **Percutaneous needle biopsy- ** **Open lung biopsy**- in this procedure, it can collect sample during operation **Lymph node biopsy**- first to be affected is cervicomediastinal lymph nodes or scalene, done if we want to know if it metastasized already  **PULMONARY FUNCTION STUDIES** **Vital capacity** - maximum value of air that can be exhaled after a maximum inhalation If pt has **COPD,** the Vital Capacity is **reduced.** **Tidal Volume**- volume of air inhaled and exhaled **with normal quiet breathing ** **IRV-** maximum volume that can be **inhaled** following a normal quiet exhalation  **ERV-** maximum volume that can be **exhaled** following a normal quiet inhalation  **FRC-** volume of air **remains in lungs** after normal quiet inhalation **RV-** air remains **after forceful exhalation** **Spirometer-** measure the volume of air inhaled and exhaled by the lungs. **Arterial blood gas (ABG) -** studies used to assess ventilation and acid-base balance  **Radial artery**- Most common site for withdrawal of blood **NURSING RESPONSIBILITY** Assess for **Allen's test**- check if there is the adequacy of collateral circulation of the hand (needed to do if we are going to extract blood from a radial or ulnar artery) **STEPS IN ALLENS TESTING ** - Inform and explain procedures  - Apply pressure on both radial and ulnar arteries  - Ask to close open hands until they blanch or pale - Release ulnar artery if already pale - Assess how long it is to get pinkish again - Normal if it becomes pinkish within 6 secs. - If it is longer than 6 secs there is poor collateral circulation  **How many are we going to get in ABG testing- 10ml pre-heparinized syringe** **Why does it need to have heparin? to prevent clotting of the specimen** **Place the specimen in a container with ICE so that hemolysis does not occur** **Hemolysis**- destruction of blood **Always check the O2sat. Before the ABG ** **8. Thoracentesis**- aspiration of fluid or air from pleural space, is the procedure done if the patient has this kind of disease - **Pleural effusion-** if too much accumulation of **fluid i**n the pleural cavity - **Pneumothorax**- if too much accumulation of **air** in the pleural cavity - **Hemothorax**- if too much accumulation of **blood i**n the pleural cavity **NURSING RESPONSIBILTY** **BEFORE procedure:** consent  Monitor VS to have a baseline Position in semi fowler or sitting upright leaning on over bed table or orthopneic position Instruct to remain still  Instruct to avoid coughing during insertion Tell the patient that they could feel a pressure sensation during the insertion of the needle Topical anesthetic agents are used **AFTER procedure:** Position the patient on the **unaffected side** to prevent **leakage of fluid** in the **thoracic cavity** Instruct for **bed rest** until vs are stable (common is **postural hypotension**) Instruct to **report expectoration of blood** (indicates lung **trauma** if expectoration of blood occurs) Monitor VS (asses if a patient is experiencing hemorrhage HYPO TAC TAC) Shock may occur after hypotactac (hypovolemic) **Pulse oximetry**- to determine oxygen saturation of blood and it is placed in the **index finger**, **earlobe,** or over the nose pulse ox can affect the result in **sunlight or Nail polish** **COMMON RESPIRATORY INTERVENTIONS** **1. OXYGEN THERAPY** **Mask oxygen** provides more good oxygen Instruct relative that **no smoking** is Oxygen can explode Regulate oxygen therapy **3-5L**  **2. TRACHEOBROCHIAL SUCTIONING** Position: **semi fowler** Hyperventilate pt **100% oxygen** Enter the suction tube **3-5 inch** Check for breath sound  Evaluate the breath sound of the patient and document the findings **3. Bronchial hygiene measures --** steam or suob in Tagalog, steam using aerosol **4. Incentive spirometry --** enhances deep inhalation of a person **5. Chest physiotherapy** - promote postural drainage through performing percussion and vibration to promote drainage **NURSING RESPONSIBILITY** Verify dr order  Assess accumulation of mucous secretion  Place patient on desired positions to allow expectoration of mucous secretion by gravity (10-15mns on each position) Do percussion and vibration for us to loosen the mucous secretion  Then change position gradually to **prevent postural hypotension**, it would last **60mns or 1 hour ** Best time to do chest physio **1 hour before meals or early morning upon waking up or at bedtime (2hours after dinner)** Provide oral hygiene **Close chest drainage (CCD** **Close chest drainage (CCD)** also called **thoracostomy** because we use a thoracostomy tube this procedure is used to remove air and fluid from pleural spaces used to establish **negative pressure on the lungs** and expand the lungs **PRINCIPLE OF CCD** **Drainage by gravity**- bottle should be **2-3 ft** below level of chest never place bottle at **level or above chest** **Displacement principle**- extra tube as air vent used to expel the air from bottle as drainage occupy air in the bottle **Suction or negative pressure**- aid in removing air or fluid from pleural spaces **3 TYPES OF CCD** **one bottle system**- serves as drainage or collection bottle at the same time it also act as water seal bottle **IMPORTANT THINGS TO REMEMBER IN 1B SYSTEM** We need to emerse the tip of the tube in **2-3cm at sterile nss/water** **Never** raise the water **level or above the chest** because it might cause reflux **Always check for patency**- check for bubbles upon breathing but **should be intermittent**, if bubbles **continue** there might be an **air leakage**. If no bubbles meaning it is **not patent** and **obstruction** (Possible cause of obstruction- baka may nag buhol) or Or the lungs started to re-expand (validated thru x-ray) To **remove the obstruction**- milk the tube going to the bottle **Two-bottle system**- could be connected or not to the suction machine **If not connected** - first bottle is drainage bottle (collects what we get @ plueral space) and the second is water seal Observe for **bubbles** or **fluctuation at the water seal** If connected- b1 serves as a **drainage bottle** and **water seal bottle**, and b2 use as a **suction control bottle** **IMPORTANT THINGS TO REMEMBER AT 2B SYSTEM** Check **bubbles at b1** Expect the 2b to continue bubbling **Three bottle system-** always connected to apparatus, b1 drainage b2 water seal (intermittent bubling) b3 serves as suction control (continuous bubbling) Connected to a suction machine and check intermittent bubbling at b2 **NR** Encourage **deep breathing and coughing exercises** to promote drainage Turn side to **side at regular basis every 2hours** Encourage to do **ADL** (ambulate, ROM) Mark the **amount of drainage** at regular interval **qshift** Avoid frequent **milking and clamping** (could result in **tension pneumothorax**) **REMOVAL OF CCD** Shift to **1b system for 24 hours** before removal (Materials to prepare) - Suture - Sterile gauze - Adhesive tape - Petrolatum gauze Place pt in **semi fowlers position** Exhale deeply and do the **Valsalva maneuver** Assess for complications (**subcutaneous emphysema or respiratory distress**) **ASSESSMENT OF LUNGS** IPPA **(Inspection)** Always check for inhalation and exhalation of pt Check breathing pattern or there is DOB (color, breathing pattern, chest wall pattern) **(Palpation)** Vibration when talking **(Percussion)** Normal lung field area sound- **resonance sound** **(Auscultation)** Checking breath sound @ diaphragm of a stet Check for voice sound **Egophony**- an increase resonance of voice sound, usually it increases if pt is talking while auscultating **HOW TO CHECK FOR EGOPHONY** make pt say \"E\" if we hear muffled sound which is clear A it is an abnormal sign, **lung consolidation** occurs when normal airfield space of lungs are filled with the product of diseases **Whispered Pectoriloquy**- increased **loudness of whispering** noted during auscultation of the lungs (state 3 consecutive numbers usually we should hear faint sound and muffled) **Bronchophony**- an abnormal increase of amplitude in clarity of vocal sound (state 99 should be soft and muffled but if clear and loud it could be **lung consolidation**) **DISEASES** **1. Deviated septum**- deflection of nasal septum septum is bent on one side **ETIOLOGY** - Trauma - Congenital disproportion (size of septum is proportional) **SIGNS & SYMPTOMS** - Obvious bend on nasal septum - Obstruction to nasal breathing - Nasal edema - Epistaxis **MANAGEMENT** - Could use nasal allergy control (antihistamine) - Nasal Septoplasty- realignment deviated septum **2. Nasal fracture-** could be unilateral, bilateral (mas mag fflat ang nose) or complex (subsequent damage to the sub **ETIOLOGY** - Trauma- a substantial blow to the middle of the face **COMPLICATIONS** - Airway obstruction - Epistaxis - Septal deviation - Hematoma - Could have a Racoons eye **MANIFESTATION** - Obvious facial deformity - Epistaxis - Hematoma - Ecchymosis in the eye **NR** Inspect **nose** and **check secretion** Check for **clear** secretion maybe pt has **cerebrospinal fluid** pt will undergo **a glucose test** if **positive** its **csf** Keep pt **in an upright position** **Apply ice pack** to face and nose Provide **emotional support** **SURGERY** - Open reduction (**rhinoplasty**) - **Septoplasty** (realignment of nose) **COMPLICATION** - Infection (continues medication and must be cleaned) - Bleeding **Epistaxis-** nosebleed **ETIOLOGY** - Trauma - Hypertension - Rheumatic heart disease - Nose cancer **MANAGEMENT** - Site down Lean forward tuck your head - Put pressure over soft tissue for at least **4-15 minutes** - Put a **cold compress** over nose or head area to **promote vasoconstriction** - Put nasal pack with medication (**neo synephrine**) - **Liquid to soft diet** to facilitate swallowing - Avoid oral temperature - Avoid blowing of nose for nose - Tell to notify the physician if epistaxis is recurrent **3. Sinusitis**- inflammation of the lining of sinuses C:\\Users\\zoldy\\AppData\\Local\\Microsoft\\Windows\\INetCache\\Content.MSO\\CF8646CC.tmp **ETIOLOGY** - upper respiratory tract infection - Smokers **PATHOPHYSIO** Allergic rhinitis ⏩ inflammation to edema ⏩ mucous membrane ⏩ hypersecretion of mucous ⏩ infection **SIGN & SYMPTOMS** - facial pain at maxillary area, upper teeth area, frontal area - Plugged nose - Nasal mucous - Persistent cough - Headache and fever **NR** - provide **rest** and **sleep** - Increase fluid intake - **Warm wet packs** - Given **codeine** (pain reliever) except aspirin it increases the possibility of **nasal polyps** - Anti-infectives or anti-biotics (**amoxicillin**) - Nasal decongestants (decolgen, neozep or dimetap is use for 3 days) - Sinus irrigation (PNNS) - **Do not chew** on the affected side - Be cautious - Do not wear dentures for 10 days - Instruct not to blow nose for 2wks - Avoid sneezing 2wks (open the mouth if di mapigilan ang atching) **SURGERY** **Ethmoidotomy** first before **ethmoidectomy** or **flap surgery** at frontal sinus or functional endoscopic sinus surgery or caldwell lut surgery/radical antrum surgery **Hydrothorax**- water is at pleural space **Pyothorax**- puss is at pleural space also called empyema **4. Atelectasis**- lung collapse **CAUSES** secondary to trauma, compression, tumor, bronchospasm(lumiliit ang airways) Could lead to **airway obstruction PATHOPHYSIOLOGY** Artery obstruction to surfactan progressive regional hyperventilation **SIGN AND SYMPTOMS** - Restlessness - Pain - Tachypnea/shallow breathing - Tachycardia - Dullbess of percussion - Absent bronchial breathing - Crackles upon auscultation **NURSING DIAGNOSIS** - Impaired gas exchange (shallow breathing) - Pain (collapse lung) - Fear **NURSING INTERVENTION** To Relieve hypoxia: - Respiration assessment - Respiratory hygiene measure - (do deep breathing exercises, coughing exercise, every 1hour use spirometer) - O2 inhalation **Position**: unaffected side **TO PREVENT COMPLICATIONS** - Meds (antibiotics) - Ambulation (decrease possiblity of pneumonia) **HEALTH TEACHING** - DBE and CE - Increase fluid intake **5. Pulmonary embolism**- undissolve mass that travels in bloodstream and occludes a blood vessel (may foreign material na bumara (blood clot) **CAUSES** - Obstructed bloodflow to lungs (thromboplebitis/surgery/obesity) - Increase pressure on pulmonary artery and reflex constriction of the pulmonary blood vessel - Decrease pulmonary circulation **SIGN AND SYMPTOMS** - Chestpain (substernal chest pain) - Levine signs (rubbing of sternal part of body) - Stabbing pain - Crashing pain - Sudden onset of dyspnea - Common to see: - Restlessness - Irritable and anxious - Friction rub upon auscultation or crackles - Sign of shock (hypotactac) **NURSING DIAGNOSIS** - Ineffective breathing pattern - Impaired gas exhange - Pain - Altered tissue perfusion - Fear/anxiety **NURSING INTERVENTIONS** - Monitoring s/s of respiratory distress - Auscultation (frequent respi assessment) - If may PE pwede marinig is decress to absence breathsound Elevate head of the bed - Monitor pulse oximetry- 02 Inhalation - Monitor blood coagulation (PT/PTT) - Anticoagulant therapy (heparin or aspirin kaya bawal sya sa may bleeding) - Ambulate **SURGERY** Embolectomy **HEALTH TEACHINGS** - Prevent further occurrence - Instruct and let them know the use pf anti embolic stockings - Tell them to avoid birth control pills - Impotance of compliance of drugs - Importance of follow up care **6. Pulmonary Edema-** Sudden transulation of fluid from pulmonary capillaries in alveoli **PINK FROTHY SPUTUM PATHOPHYSIOLOGY** Increase capillary permeability increase hydrostatic pressure decrease blood colloidal osmotic pressure Fluid accumulation in alveoli decrease Diffusion of gas hypoxia **SIGNS AND SYMPTOMS** - Anxiety - Restlessness - Fear - Dyspnea, orthopnea, fatigue - Increase HR - Increase RR - Pale cool skin - RVHF- right ventricular heart failure - 2 set of s/s - If left HF- Lungs (rr) - If right HR- systemic (buong katawan affected like edema on peripheral areas) Distended veins (neck vein, jugular vein) **NURSING INTERVENTION** - Relieve anxiety (morphine sulfate) - Stay with clienr - Deep breathing exercises - Frequent rest period - Improve cardiax function (02 inhalation) - Aminophylline- decrease venous pressure and increase cardiac output - D5W- common ivt - High fowlers position - Digitalis - Diuretics - Diet: LS decreased fluid intake - 1L of water for 24hours **HEALTH TEACHINGS** - Meds - Rest - Diet **COMPLICATIONS** - edema - Wt gain - Dyspnea **7. Tonsillitis/ adenositis SIGNS AND SYMPTOMS** - Sore throat - Fever - Dysphagia - Mouth breathing - Voice impaired (husky and crackles) - Noisy respiratory - Draining ears **NURSING DIAGNOSIS** - Pain - Aspiration **MANAGEMENT** - Promote rest - Increase fluid intake - Warm gargle - Analgesic - Anti microbial **SURGERY** - Tonsillectomy - adenoidectomy **PRE OP CARE** - Assess if may URTI - Check PTT - Post op care - Lareral pain/ prone with pillow under the chest - Semifowlers-if awake - Ngt until gag reflex - Monitor s/s hemorrhage (frequent swallowing maybe blood or frequent clearing of throat may also be blood or if patient vomits (color red)) - Promote comfort (ice collars, pain reliever, cold foods) - Diet: blunt diet - Tell them not to drink or give red or dark beverages