Medical Surgical Nursing PDF

I  Republic of the Philippines Bulacan State University City of Malolos Care of Clients with Problems in Oxygenation, Fluid, Electrolyte and Acid – Base Balance, Infectious, Inflammatory and Immunologic and Cellular...

I  Republic of the Philippines Bulacan State University City of Malolos Care of Clients with Problems in Oxygenation, Fluid, Electrolyte and Acid – Base Balance, Infectious, Inflammatory and Immunologic and Cellular Aberrations (Acute and Chronic) (NCM 112 – A/Lecture Course) Unit 1 Title Nursing Care of At Risk and Sick Adult Clients with Alterations/ Problems in Oxygenation (The Upper Respiratory System and its Disorders) Prepared by John Paul E. Mendoza, M.A.N., R.N. Course Instructor A.Y. 2024-2025- 1st Semester Page | 1 Introduction BulSU CON’s NCM 112-A gives additional venue for nursing students to continue developing their knowledge, skills, values and attitudes from their previously finished courses. It further highlights learning outcomes they incurred from courses such as NCM 100 (Theoretical Foundations of Nursing), NCM 101 (Health Assessment), NCM 102 (Health Education), NCM 103 (Fundamentals of Nursing Practice) and NCM 106 (Pharmacology) respectively. This course accounts to 8 units (or 8 hours per week) of the total third level unit requirements during the first semester of the academic year. As the first unit title implies, this course begins with a short review of your respiratory system and ends with medical – surgical managements for every common respiratory disease worldwide. It will cover the upper respiratory system initially succeeding with three other units discussing oxygenation-related concepts as well. Aside from textbooks – derived oxygenation concepts that can be achieved from this module, there will be some exercises or tasks to accomplish which are designed and intended for the aforementioned intent of this course. The evolution of educational system through the outcome-based education (OBE) is reflected from these self- directed activities which not only help the teachers but nursing students themselves monitor their progress in the profession. This particular module is divided into 4 lessons: Lesson 1 Overview of the Respiratory System Lesson 2 Assessment of the Respiratory Functions Lesson 3 Common Respiratory Interventions Lesson 4 Management of the Patients with Upper Respiratory Tract Disorders Objectives/Competencies Upon completion of this module, you are expected to: 1. Examine the extent of your knowledge in respiratory system 2. Apply previously incurred basics of health history-taking and physical examination to respiratory disorders 3. Gather and infer information regarding common respiratory interventions 4. Analyze pathophysiologic responses to oxygenation alterations 5. Formulate a plan of care to address the respiration- related health needs Page | 2 Pre-test 1 Multiple Choice. Shade the letter of your answer in the numbered boxes. Note: It is recommended that a No. 2 pencil be used as it practices consistent and careful test-taking in the future Nursing Licensure Examination (NLE). 1. Which of the following is NOT one of the four main events of respiration? a. pulmonary ventilation b. respiratory gas transport c. residual volume d. external respiration 2. Air from the nasal cavity enters the superior portion of the pharynx called the: a. nasopharynx b. oropharynx c. palatopharynx d. laryngopharynx 3. Which one of the following is NOT true of the lungs? a. the bases rest on the diaphragm b. the left lung has two lobes c. the right lung has three lobes d. both lungs have two lobes 4. The lipid molecule critical to lung function that coats the gas-exposed alveolar surfaces is called: a. surfactant c. kinin b. interferon d. renin 5. Where the respiratory centers are housed which control involuntary breathing rates? a. hypothalamus and thalamus b. cerebellum and occipital lobe c. midbrain and medulla d. medulla and pons 6. Oxygen is carried by which of these tissues of the body? a. Platelets c. Lymphocytes b. WBCs d. None of these 7. The nurse would identify that the client at highest risk for development of upper respiratory disorders is: a. A 30-year old man who smokes one pack of cigarettes per day b. A 60-year old woman who smokes occasionally and is easily fatigued c. A 70-year old man with a 40-year history of alcohol use and heavy smoking d. An 80-year old man who has a very high intake of caffeinated beverages Page | 3  8. Ideally, airway suctioning must only happen in a span of 5 minutes since applying suction for too long may decrease client’s oxygen supply. How long shall a nurse consider as intervals between each suction? a. 5 to 10 seconds c. 30 to 60 seconds b. 20 to 30 seconds d. No limits 9. The priority nursing diagnosis for a client with nasal fracture is: a. Body image disturbance c. Ineffective airway clearance b. Pain d. Impaired tissue integrity 10. If a patient undergo a surgical removal of the larynx, he or she would be unable to: a. speak c. eat b. sneeze d. hear Page | 4 Lesson 1: Overview of the Respiratory System Duration: 1 hour Lesson Proper THE RESPIRATORY SYSTEM Along with the cardiovascular system, the respiratory system share responsibility for supplying the body with oxygen and disposing of carbon dioxide. The organs of the respiratory system include the nose, pharynx, larynx, trachea, bronchi, and their smaller branches, and the lungs, which contain the alveoli, or terminal air sacs. (Marieb, 2018) Figure 1.1 Parts of the Respiratory System I. Functional Anatomy of the Upper Respiratory System A. Nose B. Paranasal sinuses They lighten the skull, and they act as resonance chambers for speech Classifications: 1. Frontal 2. Sphenoid 3. Ethmoid 4. Maxillary bones C. Pharynx It serves as a passageway for food and air Subdivided into three portion: nasopharynx, oropharynx and laryngopharynx Page | 5  Auditory tubes, which drain the middle ear, open into the nasopharynx Tonsils – found also in the pharynx; the pharyngeal tonsils (adenoid), palatine tonsils, and lingual tonsils D. Larynx “Voicebox”; routes air and food into the proper channels and plays a role in speech Thyroid cartilage – common called the “adam’s apple” is the largest hyaline cartilage which protrudes anteriorly Epiglottis – “guardian of the airways”; protects superior opening of the larynx Vocal folds or true vocal cords – it vibrates with expelled air which allows us to speak Glottis – slitlike passageway between the vocal folds E. Trachea Also called “windpipe”, has a length of 10-12 cm or about 4in, is lined with a ciliated mucosa. Cilia of the trachea function to propel mucus. Loaded with dust particles and other debris, away from the lungs to the throat, where it can be swallowed or spat out. II. Functional Anatomy of the Lower Respiratory System A. Primary Bronchi The right and left primary bronchi are formed by the division of the trachea The right primary bronchus is wider, shorter and straighter than the left; also more to some lodging of foreign object It warm, cleanse and humidify air that enters the lungs B. Lungs They occupy the entire thoracic cavity except for the most central area – mediastinum Apex – the narrow superior portion of each lung, located just deep to the clavicle Base – broad lung area resting on the diaphragm Each lung is divided into lobes by fissures; the left lung has 2 lobes and the right lung has 3 lobes Pleura – visceral serosa that covers the surface of each lung; it has 2 forms: the parietal pleura and the visceral pleura Bronchioles – subdivisions of the primary bronchi inside the lungs before it terminate in alveoli Alveoli – air sacs; the only site of gas exchange III. Respiratory Physiology A. 4 Distinct Events during Respiration: 1. Pulmonary ventilation 2. External respiration 3. Respiratory gas transport 4. Internal respiration B. Mechanics of Breathing Page | 6  1. Inspiration 2. Expiration 3. Nonrespiratory Air Movements C. Respiratory Volumes and Capacities Tidal volume – the volume of air inhaled and exhaled with normal quiet breathing (500ml) Inspiratory reserve volume – the maximum volume that can be inhaled following a normal quiet inhalation (2100-3200ml) Expiratory reserve volume - the maximum volume that can be exhaled following a normal quiet exhalation (1200ml) Residual volume – the volume of air that remains in the lungs after forceful exhalation Vital capacity – the maximum volume of air that can be exhaled after a maximum inhalation; the sum of the TV, IRV, and ERV (4800ml) Inspiratory Capacity – total amount of air that can be inhaled following normal quiet exhalation; the sum of TV and IRV (3,600ml) Total Lung Capacity – the total volume of the lungs at maximum inflation; sum of TV, IRV, ERV and RV (6,000ml) D. Respiratory Sounds 1. Bronchial sounds 2. Vesicular breathing sounds E. Factors Influencing Respiratory Rate and Depth: 1. Physical factors 2. Volition (Conscious Control) 3. Emotional factors 4. Chemical factors F. Neurologic Control of the Respiratory System 1. Medulla oblongata – center for respiration 2. Pons – control rate and depth of respiration 3. Phrenic Nerve – controls diaphragmatic movement 4. Pneumotaxic center – controls pattern of respiration (E.g. Kussmaul’s) 5. Apneustic center – stimulate medulla o create prolonged and deep respiration This outline or summary of respiratory parts and physiologies were chiefly patterned after the textbook of Marieb’s Anatomy and Physiology particularly the chapter of Respiratory System. This mentioned textbook has been the leading recommended textbook of the college over the years and full discussion of many anatomical terminologies noted can be browsed in there. Though the sequencing of chapter numbers may vary to all textbook editions, the topics or contents for respiratory system would be almost similar hence every nursing student is encouraged to keep a hard copy or e-book of it for future usage and uniformity of their medical knowledge. Page | 7 Self-Check 1.1 Let’s Label and Identify Your Respiratory Parts 1) The nasal cavity is indicated by the letter _, which function is _. 2) The trachea is indicated by letter __ , which function is _ _ _ _. 3) The diaphragm muscle is indicated by letter _, which function is ____ _. 4) The larynx is indicated by letter __, which function is _ _ _. 5) The pharynx is indicated by letter _ , which function is _ _ _. Page | 8 Lesson 2: Assessment of the Respiratory Functions Duration: 1.5 hour Lesson Proper As stated in the beginning of the course, it is advisable that nursing students fully recall their understanding of establishing their knowledge with Anatomy and Physiology and all other nursing courses that enable them to compose a complete nursing care particularly Fundamentals of Nursing Practice, Health Assessment and Health Education. Lesson 2 outlines key points to a complete respiratory function assessment as follows:  Risk / Causative Factors  Physical Examination  Diagnostic Procedures / Evaluation This section of the course unit best guide nursing students as they read their Medical – Surgical Nursing textbooks since majority of the information vital to their learning process were simplified here based also on the contents of most common references which this course utilized such as Brunner & Suddarth’s Textbook of Medical-Surgical Nursing and Udan’s Medical-Surgical Nursing: Concepts and Clinical Application. Similarly, nursing students for practical reasons are not encouraged to become very particular with the latest editions they should secure for studying since previous editions may still suffice as agreed throughout the course. Chapters for respiratory system and its disorders among all Medical – Surgical Nursing textbooks will provide full discussion of outlined topics. A. Risk Factors for Respiratory Diseases 1. Smoking (the single most important contributor to lung disease) 2. Exposure to secondhand smoke 3. Personal or family history of lung disease 4. Genetic makeup 5. Allergens and environmental pollutants 6. Recreational and occupational exposure B. Physical Examination 1. Dyspnea - Most common manifestations of all respiratory problems - Also referred to as difficulty of breathing (DOB) or shortness of breathing (SOB) - Ask the time it started and how it started 2. Cough - A reflex that protects the lungs from accumulation of secretions or inhalation of foreign bodies - It results from irritation of the mucous membranes anywhere in the respiratory tract Page | 9  - Described as dry, hacking/barking, brassy, wheezing, loose or severe - Ask the time it started, how it started, the frequency and characteristics 3. Sputum production - The reaction of the lungs to any constantly recurring irritant and may also be associated with nasal discharge - Assess for color, odor, quality and quantity of sputum - Common characteristics of sputum with its associated condition: i. Purulent sputum (thick and yellow, green or rust-colored): bacterial infection ii. Thin, mucoid sputum: chronic bronchitis or bronchiectasis iii. Pink-tinged mucoid sputum: lung tumor iv. Profuse, frothy, pink-tinged: pulmonary edema v. Foul smelling sputum: lung abscess, bronchiectasis or any associated infection 4. Chest Pain - May be associated with pulmonary or cardiac disease - May be described as sharp, stabbing or intermittent, or it may be dull, aching and persistent - Assess for scale of pain, location and intensity 5. Adventitious Breath Sounds a. Crackles - Soft, high-pitched, popping sounds may indicate fluids in the lungs b. Wheezing - High – pitched; continuous; hoarse; whistling - Indicates obstruction or narrowing common among asthma and COPD patients c. Stridor - Strong gush of air; a turbulent gas flow from the upper respiratory airway - E.g. obstruction of epiglottis, laryngeal tumor Knowledge Bonus 1.1 Hear your Breath Sounds If given an opportunity for online browsing, hearing these different abnormal breath sounds can also level up your interest with the topic. Your course instructor provides you an NCLEX Review link entitled “Lung sounds - Breath sounds Types & Causes” as a bonus. In the link, it clearly differentiates the breath types especially their distinct actual sounds. You may copy the link here - https://www.youtube.com/watch?v=0fEy-EDHP5Q Page | 10 6. Clubbing of Fingers - Hypertrophy of tissues in nail beds caused by prolonged hypoxia due to a lung disease 7. Cyanosis - Bluish coloring of the skin indicative of hypoxia or due to deoxygenation of hemoglobin o Central cyanosis – mouth, tongue and lips o Peripheral / acrocyanosis – extremities 8. Chest Inspection / Configuration a. Barrel chest - Observed as a rounded, over-inflated lungs common among emphysema patients b. Pigeon chest (Bowed chest or Pectus carinatum) - It results from sternal displacement and observed as protrusion over the sternum c. Funnel chest (Pectus excavatum) - Sunken appearance of the sternum which may be congenital d. Thoracic Kyphoscoliosis - Combination of kyphosis and scoliosis 9. Chest Palpation - Palpation of masses - Palpation of tactile fremitus - Palpation of thoracic excursion 10. Chest Percussion o Resonance – low pitched hollow sound heard over the lung tissue o Hypperesonance – very loud lower-pitched sound; normally not present; presence may indicate emphysema 11. Rates and Depth of Respiration o Eupnea o Bradypnea o Tachypnea o Hypoventilation o Hyperventilation o Apnea o Cheyne’s Stokes respiration o Biot’s respiration Page | 11 Exercise 1.1 Reflection Paper Now you’ve gathered most necessary information in regards to comprehensive assessment a nurse takes through a thorough interview and physical examination, you will be given a video-recorded nurse- patient interview and physical assessment. The choices for video clip will come from repository of remarkable course outputs of selected former nursing students in BulSU College of Nursing. Right after watching the video presentation, you will be required to compose a reflection paper following a paper format that will be given separately by your course instructor. Please refer to rubric for reflection paper in your course syllabus for further guidance. C. Diagnostic Evaluation 1. Chest X-ray - It can reveal an extensive pathologic process in the lungs in the absence of symptoms - Normal pulmonary tissue is radiolucent; therefore, densities produced by fluid, tumors, foreign bodies and other pathologic conditions can be detected - Nursing Responsibility: i. Instruct the client on how to hold his breath and to do deep breathing ii. Instruct the client to remove metals from the chest 2. Bronchoscopy - The direct inspection and Figure 1.2 Bronchoscopy examination of the larynx, trachea, and bronchi through a flexible or rigid bronchoscope - Diagnostic use: (a) to collect secretions and (b) to determine location of pathologic process and collect specimen for biopsy - Therapeutic use: (a) to remove foreign object and secretions, (b) treat postoperative atelectasis, and (c) to destroy and excise lesions - Nursing interventions(Before the Procedure): i. Secure consent before the procedure ii. Atropine and valium pre-procedure; topical anesthesia is sprayed followed by local anesthesia injected into larynx iii. NPO for 6 to 8 hours Page | 12  iv. Remove dentures, prostheses, contact lenses - Nursing interventions (After the procedure): i. Side – lying position ii. Check for the return of cough and gag reflexes before giving fluid per orem iii. Watch for cyanosis, hypotension, tachycardia, arrhythmias, hemoptysis, dyspnea. These signs and symptoms indicate perforation of bronchial tree 3. Thoracoscopy - A procedure in which the pleural cavity is examined with an endoscope wherein a small incisions are made into the pleural cavity in an intercostals space - Indicated in the diagnosis of pleural effusion, pleural disease and tumour staging. - Nursing Responsibility: i. Assess for shortness of breath after the procedure which might indicate pneumothorax 4. Computed Tomography (CT) Scan and Fluoroscopy - Studies the lungs and chest via series of x-ray in different dimensions or in motion like in fluoroscopy - Used to assist with invasive procedures, such as a chest needle biopsy or transbronchial biopsy - Nursing Responsibility: i. Check for iodine-allergy if with contrast ii. Instruct the client to remain still iii. Assess for claustrophobia 5. Magnetic Resonance Imaging (MRI) - A non-invasive diagnostic tool that uses a powerful magnetic field and computer-generated pictures to image the lungs and its associated diseases - Nursing intervention: i. The patient is instructed to remove any jewelries, watches or any metal items ii. Interview if the patient has pacemakers, metal plates, prosthetic joints or any metallic implants iii. The patient is instructed to be motionless during the procedure iv. Know if the patient has claustrophobia 6. Lung Scan - Following injection of a radioisotope, scans are taken with a scintillation camera. Measure blood perfusion through the lungs. Confirm pulmonary embolism or other blood-flow abnormalities - Instruct the client to remain still during the procedure 7. Sputum examination - Obtained for analysis to identify pathogenic organisms and to determine whether malignant cells are present Page | 13 - Forms of examination: (a) gross appearance, (b) sputum C&S, (c) AFB staining, (d) Cytologic examination / Papanicolau examination - Nursing Responsibility: i. Early morning sputum specimen is to be collected ii. Rinse mouth with plain water iii. Use sterile container iv. Sputum specimen for C and S is collected before the first dose of antimicrobial 8. Bronchography - A radiopaque medium is instilled directly into the trachea and bronchi and the entire bronchial tree or selected areas may be visualized through x-ray - Nursing Responsibility Before the Procedure: i. Secure written consent ii. Check for allergies to iodine or seafoods iii. NPO for 6 to 8 hours iv. Pre – op meds: atropine S04 and valium, topical anesthesia sprayed, followed by local anesthetic injected into larynx v. Have oxygen and antispasmodic agents ready 9. Pulmonary Function Studies a. Vital Capacity - The maximum volume of air that can be exhaled after a maximum inhalation b. Tidal Volume - The volume of air inhaled and exhaled with normal quiet breathing c. Inspiratory Reserve Volume - The maximum volume that can be inhaled following a normal quiet inhalation d. Expiratory Reserve Volume - The maximum volume that can be exhaled following a normal quiet exhalation e. Functional Residual Capacity - The volume of air that remains in the lungs after normal, quiet exhalation f. Residual volume - The volume of air that remains in the lungs after forceful exhalation 10. Thoracentesis - Aspiration of fluid or air from the pleural space - Nursing Responsibility (Before Procedure): i. Secure consent ii. Take initial VS iii. Orthopneic position iv. Instruct to remain still, avoid coughing during insertion of needle Page | 14  v. Pressure sensation is felt on insertion of needle - Nursing Responsibility (After Procedure) i. Turn on the unaffected side to prevent leakage of fluid in the thoracic cavity ii. Bed rest until VS is stable iii. Check for the expectoration of blood. Notify the physician iv. Monitor VS 11. Lung Biopsy - Performed to obtain lung tissue for examination to identify the nature of the lesion - Different techniques of biopsy: i. Transbronchoscopic biopsy – done during bronchoscopy ii. Percutaneous needle biopsy iii. Open lung biopsy Figure 1.3 Pulse Oximetry 12. Pulse Oximetry - A non-invasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2). - Normal value: 95 to 100% (below 85% indicate hypoxia) 13. Arterial Blood Gas - Performed to assess ventilation and acid-base balance - Radial artery is the common site for withdrawal of blood specimen. - Allen’s test is done to assess for adequacy of collateral circulation of the hand - 10ml pre-heparinized syringe to prevent clotting of specimen - Container with ice to prevent hemolysis of the specimen - Analysis of ABG values: a. Ph level Normal value: 7.35 – 7.45 Acidosis: 7.45 b. PaCO2 Normal value: 35-45 Acidosis: >45 Alkalosis: