OXYGENATION_ Ventilation.pdf

OXYGENATION: VENTILATION Sir Leo Lumalang → Medical-Surgical Nursing RESPIRATORY SYSTEM MECHANISM OF BREATHING PURPOSE: maintain an adequate oxygen level in the b...

OXYGENATION: VENTILATION Sir Leo Lumalang → Medical-Surgical Nursing RESPIRATORY SYSTEM MECHANISM OF BREATHING PURPOSE: maintain an adequate oxygen level in the blood PRIMARY FUNCTION to support cellular life 1. Provide oxygen for metabolism in the tissues Regulated by the brain (medulla oblongata, pons, 2. Remove carbon dioxide → waste product of metabolism hypothalamus and sympathetic nervous system) SECONDARY FUNCTION ANATOMIC AND PHYSIOLOGIC CHANGES DURING RESPIRATION 1. Facilitate sense of smell 2. Produces speech NEGATIVE PRESSURE - the lungs creates a vacuum for 3. Maintains acid-base balance environmental air to enter 4. Maintains body water levels POSITIVE PRESSURE - caused by an external factor such as 5. Maintains heat balance an external wound that causes air to enter the lungs PHYSIOLOGIC CHANGES DURING INSPIRATION ABG → Arterial Blood Gas Oxygen-rich air flows from the environment into the trachea, bronchi, bronchioles and alveoli PaO2 : 96 -100% PCO2 : 35 - 45 DIAPHRAGM: presses the abdominal organs downward and pH : 7.35 - 7.45 → 7.45 - alkalinic forward HCO2 : 22 - 26 Enlargement of the chest cavity through expansion PHYSIOLOGIC CHANGES DURING EXPULSION RESPIRATORY ACIDOSIS: ↓ pH , ↑ CO2 RESPIRATORY ALKALOSIS: ↑ pH , ↓ CO2 Carbon dioxide flows out of the respiratory system and into the environment UPPER RESPIRATORY TRACT INTERCOSTAL MUSCLES and DIAPHRAGM: rises and recoils into resting position From nose to the epiglottis RIB CAGE: assumes dome-shape configuration ○ Nose ○ Sinuses UPPER AIRWAY DISORDERS ○ Pharynx ○ Larynx - voice box EPISTAXIS (NOSE BLEEDS) ○ Epiglottis - prevents aspiration Hemorrhage/bleeding from the nose PURPOSE ANTERIOR BLEEDING: visualized blood coming out the nose Transport gasses to and from the lower airways ○ More common Filter and humidify inspired gasses POSTERIOR BLEEDING: suspected if client is always Protect lower airways from entry of foreign bodies and swallowing microorganisms CAUSES LOWER RESPIRATORY TRACT LOCAL From base of neck to diaphragm ○ TRAUMA - direct blow or injury ; common cause ○ Trachea ○ DRYNESS - causes crust formation (removed by nose ○ Bronchi picking, rubbing or blowing) ○ Bronchioles Humidifier ○ Alveoli Nasal irrigations ○ Lungs Nasal lubricants ○ Thoracic cage SYSTEMIC ○ Hypertension PURPOSE ○ Rheumatic Heart Disease Transport gasses in and out of lugs ○ Cancer (polyps, cancer of nose and sinuses) Promote mucociliary function ○ Bleeding disorders (eg. thrombocytopenia, Dengue) → most common systemic cause RIGHT LUNG LEFT LUNG PATHOPHYSIOLOGY 3 lobes 2 lobes Shorter, broader ○ Because of the More vertical location of heart More commonly affected Longer, narrower by infection and More Horizontal aspiration PLEURA Allows for the expansion of the lungs Serous membrane that lines the lungs and the wall of the thorax VISCERAL PLEURA - lining that covers the lungs ASSESSMENT PARIETAL PLEURA - outer layer of the thorax PLEURAL FLUID - lubricates thorax and lungs during Bleeding from nasal cavity expansion with breaths (approx. 10 cc) Frequent swallowing → not definitive; can be considered if PLEURAL CAVITY/SPACE - space that is filled during lung w/ history of epistaxis expansion BSN 3A - Marjorie D. Solayao  DIAGNOSTIC CLASSIFICATION OF ALLERGIC RHINITIS Direct visual inspection with nasal speculum INTERMITTENT: symptoms present 4 weeks/year NURSING MANAGEMENT PRECIPITATING FACTORS Depends on severity and source of nasal bleeding POSITION: Upright posture, leaning forward (head tipped) Exposure to allergens → to prevent aspiration Breathe gently through mouth A. FOOD: Peanuts, walnuts, brazil nuts, wheat, shellfish, soy, Apply cold compress or ice pack cow’s milk, eggs (Dairy, nuts, shellfish) MONITOR: Vital signs, further bleeding, hypoxia, B. MEDICATIONS: Penicillin, aspirin, sulfa medications and respiratory difficulty/obstruction others. C. INDOOR ALLERGENS: Dust mite feces, dog/cat dander, Assist with control of bleeding molds, cockroach droppings Prevention of recurrence D. OUTDOOR ALLERGENS: trees, weeds, grasses, molds ○ LOCAL: Prevent traumma E. DRUG-INDUCED: ○ SYSTEMIC: control BP/addressing the underlying cause Anti-hypertensives (ACE Inhibitors “-pril”) Care of NASAL PACKING Beta-blockers (-lol) ○ Maintained in place for 3-5 days → to prevent the Antilipidemic agents (-statins) crust from being removed thus triggering another Aspirins episode of bleeding Anti-anxiety ○ Instruct the client on mouth breathing Antidepressants and antipsychotics ○ Acknowledge that the packing is uncomfortable and painful PATHOPHYSIOLOGY MEDICAL MANAGEMENT ANTERIOR BLEEDING ○ Compress soft part of nose with index finger and thumb for 5-10 minutes ○ COTTON PLEDGET: Moist with vasoconstricting agent [Phenylephrine (Neosynephrine)] POSTERIOR BLEEDING ○ Nasal packing layered in nasal cavity ○ May require nasopharynx or balloon tamponade SURGICAL INTERVENTION Cauterization of vessel Surgical ligation of blood vessel COMPLICATIONS IgG → Immunity response ; retained longest (for inflammation) Rhinitis IgA → Passed on through mother’s milk Maxillary/frontal sinusitis IgM → immunity response ; produced first (for inflammation) Otitis media IgE → allergy/parasitic infection IgD → Unknown function; part of bloodstrea EUSTACHIAN TUBE → tube that connects the mouth, nose and ears CLINICAL SIGNS AND SYMPTOMS CLIENT EDUCATION NASAL: Congestion, edema, itching, rhinorrhea w/ clear secretions, sneezing PREVENT NOSE BLEEDS EYES: Edema, itching, burning, tearing, redness, dark circles ○ Avoid blowing/picking nose after nose bleed under eyes (allergic shiners) ○ Apply lubricant to nasal septum 2x/day EARS: itching, fullness ○ Use humidifier for dry environmental air OTHERS: palatal (roof of mouth) itching, throat itching, ○ Address underlying causes of nosebleeds non-productive cough (post-nasal drip), headache COMPLICATIONS RHINOPATHIES Allergic asthma Collective term for the disorders of the nose that interrupts its Chronic otitis media, hearing loss normal functions of olfaction, and warming, filtering and humidifying moist air. Chronic nasal obstruction, sinusitis characterized by inflammation and irritation of the mucous DIAGNOSTICS membrane of the nose SKIN TESTING: to confirm hypersensitivity to certain Can be classified based on: allergens 1. DURATION NASAL SMEAR: increased number of eosinophils → a. Acute suggestive of allergy b. Chronic RAST: Radioallergo Sorbent Test 2. CAUSES ○ Positive test result for offending agent a. Allergic b. Non-allergic BSN 3A - Marjorie D. Solayao  ○ Blood test wherein allergens is introduced and there 2. FACILITATING NORMAL BREATHING PATTERN will be an inflammatory response that will be Mouth breathing observed under the microscope Intranasal saline (NSS) ○ Done under laboratory setting Increase oral fluid intake RHINOSCOPY: to visualize nasal structures Self-administration of medication regimen NURSING ASSESSMENT CLIENT EDUCATION History of severity and seasonality of symptoms Avoid irritating inhalants (smokes, fumes, aerosols) Characteristic tearing, conjunctival erythema, pale nasal Do not overuse nasal sprays/drops mucous membranes w/ clear discharge, allergic shiners and Do not blow nose too frequent or too hard mouth breathing Blow through both nostrils at the same time Wheezing or prolonged respiration Report use of OTC medications and herbal products PHARMACOLOGIC SINUSITIS ➔ ACUTE Inflammation of the mucous membrane of one or more ANTIHISTAMINES: blocks effects of histamines, relieving paranasal sinuses symptoms of allergic rhinitis Pansinusitis - all sinuses ○ Eg: diphenhydramine, loratadine, cetirizine Acute sinusitis ANTICHOLINERGIC AGENTS: inhibit mucous secretions, Chronic sinusitis act as drying agent ○ Eg: Hydrozine (Iterax, Atarax) CAUSES DECONGESTANTS: topical/systemic Cigarette smoking ○ Advised to take only 2-3 days as prescribed to Allergic rhinitis prevent rebound congestion Viral upper respiratory tract infection (URTI) ○ ADVERSE EFFECTS: Nasal congestion Stimulates SNS (insomnia, palpitations, Obstruction of sinuses nervousness) TOPICAL EYE PREPARATIONS: for affectation of eyes PATHOPHYSIOLOGY ➔ PREVENTIVE INTRANASAL CORTICOSTEROIDS: reduce nasal mucosa inflammation ○ Eg: Fluticasone, Mometasone, Beclometasonne ○ ADVERSE EFFECTS: May cause pharyngeal fungal infections MAST CELL STABILIZERS (Cromolyn Sodium): hinders release of chemical mediators LEUKOTRIENE MODIFIERS: hinders release of chemical mediators ○ Eg: Montelukast (singulair), Zarfilykast (Accolate), Zileuton (Zyflo) MEDICAL MANAGEMENT Depends on CAUSE: ○ VIRAL RHINITIS: symptomatic treatment COMPLICATIONS ○ BACTERIAL INFECTION: antimicrobial agent Extension of infection to orbital contents and eyelids ○ ALLERGIC RHINITIS: allergy test, desensitization, and Bone infection (osteomyelitis) corticosteroids may be required CNS Complications (ie. meningitis, subdural and epidural purulent drainage, brain abscess (pus)) IMMUNOTHERAPY DESENSITIZATION: SubQ (SQ) injection of increasing NURSING ASSESSMENT amounts of an allergen to decrease sensitivity and reduce ACUTE SINUSITIS severity of symptoms ○ PAIN - stabbing/aching; over infected sinus and ○ ADVERSE EFFECTS: referred to face/head SYSTEMIC: Anaphylaxis ○ Nasal congestion and discharge - maybe present or not LOCAL: Erythema ○ ANOSMIA - lack of smell ○ Only done in a controlled environment where an ○ Red, edematous nasal mucosa emergency drug such as epinephrine can be ○ May present with fever immediately administered. NURSING DIAGNOSIS SINUSITIS FACIAL PAIN 1. MAXILLARY → cheek, upper teeth Ineffective breathing pattern Lowest sinus, more prone to infection ○ GOAL: to decrease symptoms and the client will not Upper sinuses might drain to maxillary manifest symptoms of mouth breathing 2. ETHMOID → In and around the eyes 3. SPHENOID → behind eye, occiput, top of head NURSING MANAGEMENT 1. AVOIDANCE CHRONIC SINUSITIS Minimize contact with offending allergens ○ Persistent nasal obstruction; chronic nasal discharge; Reduce environmental exposure to allergens especially clear or purulent if infected at home (indoors) ○ Cough worse in supine BSN 3A - Marjorie D. Solayao  ○ Feeling of facial fullness/pressure Follow up for recurrence of sinusitis ○ HEADACHE: vague sign; more noticeable in the Sinusitis may cause asthma attacks; be alert for morning, fatigue exacerbations of conditions FOR RECURRENT SINUSITIS: Instruct on nasal irrigation w/ DIAGNOSTICS saline SINUS X-RAYS (Paranasal (PNS) Sinus X-ray, Water’s view)/ Avoid ASA/Aspirin which increases risk of nasal polyps CT SCAN: Air-fluid level (acute); opacification of sinuses; thickened sinus mucous membrane; anatomic obstruction PHARYNGITIS patterns (chronic) GABHS - Group A Beta-hemolytic streptococcus ANTRAL PUNCTURE AND LAVAGE: provide culture sample Inflammation of the pharynx, including palate and tonsils to identify infection BACTERIAL PHARYNGITIS – GABHS, Strep throat ○ Therapeutic modality to clear sinus VIRAL PHARYNGITIS ○ Nasal and sinus endoscopy CHRONIC PHARYNGITIS – secondary to disease MEDICAL MANAGEMENT CAUSES Treat infection Infection: Shrink nasal mucosa ○ BACTERIAL – GABHS Relieve pain caused by increasing pressure secondary to ○ VIRAL – Rhinovirus (common colds) congested nose Irritation from post-nasal drip due to allergic rhinitis and PHARMACOLOGIC chronic sinusitis Chemical irritation ANTIBIOTICS: Based on nasal discharge GS/CS (Gram stain Systemic disease and culture and sensitivity) Other bacterial causes: ○ CO-TRIMOXAZOLE (10-14 days) ○ H. influenzae ○ MACROLIDES: Azithromycin (3-5 days) ○ Moraxella catarrhalis ○ PENICILLIN ○ Corynebacterium diphtheria ○ CEPHALOSPORINS (Cefuroxime) ○ Neisseria gonorrhoeae DECONGESTANTS: (topical/systemic) – for mucosal ○ Other groups of streptococcus origin shrinkage and to encourage drainage Other viral causes: ○ Limit topical use up to 3 consecutive days ○ Adenovirus TOPICAL NASAL CORTICOSTEROIDS – for chronic sinusitis ○ Parainfluenza virus ○ Eg. fluticasone ○ Coxsackievirus ANALGESICS: to relieve pain ○ Coronavirus ○ Drug of choice: codeine ○ Other groups of viral origin ○ Can be used in adjunct to warm compresses; warm vapor humidity for comfort and promote drainage PATHOPHYSIOLOGY SURGERY For CHRONIC SINUSITIS, if unsuccessful therapeutic management FUNCTIONAL ENDOSCOPIC SINUS SURGERY (FESS) – endoscopic removal of diseased sinus tissues Ethmoidectomy Sphenoidectomy Osteoplastic flap surgery for frontal sinusitis CALDWELL - LUC (Radical antrum) surger Do not chew on affected side Caution on oral hygiene No dentures for 10 days COMPLICATIONS Avoid sneezing/blowing nose for 2 weeks Acute rheumatic fever Rheumatic heart disease (RHD) NURSING MANAGEMENT Peritonsillar abscess/cellulitis Acute pain r/t increase pressure/inflammation in the sinuses Acute glomerulonephritis (AGN) Scarlet fever GOAL: Verbalization of relief from pain Sinusitis, otitis media, mastoiditis SIGNS AND SYMPTOMS INTERVENTIONS: 1. Enough rest Varying degrees of: 2. Encourage fluid intake Sore throat 3. Hot wet packs or warm vapors Nasal congestion 4. Irrigation of maxillary sinuses w/ warm NSS Fatigue 5. Administer analgesic, antibiotic Fever CLIENT EDUCATION Swollen, palpable and tender cervical lymph nodes in most cases Promptly seek medical attention for s/sx of acute sinus infection DIAGNOSTICS Discourage swimming and diving if w/ URTI THROAT SWAB (GS/CS) Stress importance of complying w/ antibiotic therapy for ○ Throat culture or rapid streptococcal antigen detection complete duration test BSN 3A - Marjorie D. Solayao  ○ Throat culture on thayer-martin medium or gonococcal CLINICAL SIGNS AND SYMPTOMS antigen detection test Sore throat ○ Solid-phase enzyme immunoassays (ELISA) Fever ○ Streptolysin titers Snoring (obstruction) PHARMACOLOGIC Dysphagia (difficulty swallowing) ANTIBIOTICS: based on throat GS/CS IF ADENOIDS ALSO AFFECTED: ○ Drug of choice: Penicillin (PO, IM) Mouth breathing ○ Erythromycin (if allergic to penicillin) Earache ○ Macrolides (Azithromycin) Draining ears ○ Cephalosporins (Cefuroxime) Frequent colds ANALGESICS: For pain Bronchitis ○ Eg: acetaminophen Foul-smelling breath ANTITUSSIVES: Suppress cough especially at night Voice impairment ○ Eg: codeine, dextromethorphan Noisy respirations VIRAL PHARYNGITIS: Supportive measures Nasal obstructions NUTRITIONAL THERAPY DIAGNOSTICS Liquid/soft diet during acute stage Throat swab (GS/CS) Cool beverages, warm liquid are often shooting Physical assessment and history IV Fluids given in severe condition Encourage to drink at least 2-3L/day of liquids TONSIL GRADING NURSING MANAGEMENT GRADE 0 - Surgically removed Lukewarm saline gargles and medications given GRADE 1 - Tonsils hidden within tonsil pillars Encourage bed rest w/ increase in fluid intake as tolerated GRADE 2 - Tonsils extending to the pillars during fever GRADE 3 - Tonsils are beyond the pillars Ice collars GRADE 4 - Tonsils extend to midline Infection control, proper disposal of secretions When to call a physician: DOB, drooling, dysphagia, etc. EXUDATES - White patches on the tonsils CLIENT EDUCATION MEDICAL MANAGEMENT Have sore throat w/ fever evaluated especially if without Supportive measures cold symptoms ○ Increase fluid intake Compliance to full course of antibiotic therapy ○ Warm saline gargle PREVENTIVE MEASURES: ANTIBIOTIC THERAPY ○ No sharing of utensils, glasses, napkins, food or towels ○ Drug of choice: Penicillin ○ Clean telephones after use ○ Erythromycin/amoxicillin (alternative) ○ Use tissue to sneeze/cough; dispose properly ANALGESICS as ordered ○ Avoid exposure to tobacco and second-hand smoke SURGERY TONSILLITIS Tonsillectomy/Adenoidectommy Inflammation/infection of the tonsils TONSILS: composed of lymphatic tissues and are situated on each side of the oropharynx INDICATIONS COMMON SITES AFFECTED: Facial/palatine tonsils and Repeated recurrence/bouts of tonsillitis (5-6x/year) lingual tonsils Hypertrophy of tonsils and adenoids causing obstructive COMMON CAUSE: GABHS sleep apnea (OSA) Repeated attacks of purulent otitis media PATHOPHYSIOLOGY Exacerbation of asthma or rheumatic fever NURSING MANAGEMENT POST-OP CARE: ○ POSITION: Lateral/side-lying position (ALTERNATIVE: Prone w/pillow under chest) → for the secretions to drain outside and prevent aspiration ○ Maintain oral airway till gag reflex returns ○ Ice collar on the neck ○ Ice-cold fluids/ice chips as prescribed ○ Avoid ice cream/milk → thickens secretions and mucus ○ Avoid ASA/Aspirin → prevents clotting ○ Expect normally dark or black stool for few days ○ MONITOR COMPLICATIONS: Frequent swallowing → might be having an active episodes of bleeding ○ Report frank bleeding to physician (hemorrhage) COMPLICATIONS ○ Sore throat, stiff neck, vomiting may occur 24 hours after surgery Same as pharyngitis BSN 3A - Marjorie D. Solayao  ○ No red or dark colored food and beverages (eg. PATHOPHYSIOLOGY chocolates, prune juice, cranberry juice, tomato juice etc.) ○ No irritating foods and beverages (eg. citrus fruits/fruit juices, spicy foods, pineapple, cola etc.) ○ No milk, milk products ○ No hard or scratchy food (eg. popcorn, pretzels, nuts etc.) ○ No drinking straw ○ CAUTION ON ORAL HYGIENE: Avoid rigorous toothbrush or gargling VENTILATION DISORDERS BRONCHIAL ASTHMA Chronic inflammatory disorder of airways in which many cells and cellular elements play a role A REVERSIBLE process 3 CLASSIC CHARACTERISTICS OF ASTHMA 1. Bronchoconstriction → r/t hyperresponsiveness of airways 2. Hypersecretion of mucus in bronchial tree CLINICAL SIGNS AND SYMPTOMS 3. Mucosal edema Episodes of coughing (At night, early morning) Wheezing CLASSIFICATIONS Dyspnea 1. EXTRINSIC ASTHMA: Hypersensitivity to inhalant allergen; Chest tightness mediated by IgE Breathlessness (DOB/SOB) 2. INTRINSIC ASTHMA: No inciting allergen; environmental stimuli/infection (viral) SEVERE CASES: 3. MIXED ASTHMA Diaphoresis Tachycardia OTHER CLASSIFICATIONS: Hypoxemia Aspirin-induces Central cyanosis Exercise-induced COMPLICATIONS Occupational asthma STATUS ASTHMATICUS - severe life-threatening persistent CLASSIFICATIONS (SEVERITY) asthma that does not respond to conventional therapy; 1. MILD INTERMITTENT attacks last longer than 24 hours ≤2 days/week ○ Fibrosis (rigidity) of the airways ≤2 nights/month ○ Death 2. MILD PERSISTENT DIAGNOSTICS ≥ 2 day/week, but 2 nights/month PULMONARY FUNCTION TEST (PFT): increase in FEV, PF 3. MODERATE PERSISTENT variability Daily Increased serum IgE > 1 night/week SKIN TESTING: Identify causative allergens 4. SEVERE PERSISTENT CHEST X-RAY: Exclude other lung diseases Continual ABG: Respiratory acidosis (increased PCO2, decreased pH) Frequent NURSING ASSESSMENT CAUSES Presence of coughing, DOB, Chest tightness, wheezing, Allergy (allergens) exertional changes, increased mucus production Environmental stimuli Rate, depth, character of respirations: assess peak flow Infection (viral) BREATH SOUNDS: Wheeze Medications (aspirin) Inhalation techniques Exercise Pulse oximetry; V/S Occupational hazards (industrial fumes, dust, allergens, (+) family, environmental and occupational history gasses) Secondary to disease (eg. sinusitis, GERD) CLASSIC SIGNS OF ASTHMA Restlessness Wheezing or crackles Prolonged exhalation Tachypnea Decreased O2 Saturation Hyperresonance Use of accessory muscles; chest retractions BSN 3A - Marjorie D. Solayao PHARMACOLOGIC Should not be given QUICK RELIEF w/out inhaled steroids Administered first before MEDICATION NURSING CONSIDERATION inhaled steroids SHORT-ACTING Rapid onset of BRONCHODILATORS/ LEUKOTRIENES MODIFIERS Add-on therapy in those bronchodilation BETA-AGONIST BY not controlled w/ low BEST USE: symptom relief Eg: Montelukast INHALATION (SABA) dose of inhaled steroids No effect in chronic Zafirlukast Indicated for aspirin or inflammation Zileuton Eg: Salbutamol exercise-induced asthma May cause tremors, Procaterol palpitations (in elderly), Terbutaline and mild hypokalemia MEDICAL MANAGEMENT Albuterol Bronchodilators before Smoking cessation inhaled steroids Regular physical activity Occupational aspects ANTICHOLINERGIC AGENTS Provides additional Breathing technique benefit when used in Immunization (Influenza, Pneumococcal) Eg: ipratropium (atrovent) combination w/ SABA inn Environmental control those w/ severe Immunotherapy symptoms Avoid foods that contain food dyes (Yellow dye no. 5) ANTIBIOTICS: if asthma has s/sx of bacterial infection ADVERSE EFFECTS: Dry mouth (most common) NURSING DIAGNOSIS Urinary retention Ineffective breathing pattern glaucoma Anxiety METHYLXANTHINES (PO, IV) Nausea, vomiting and GOALS: Symptoms (wheezing, coughing, chest tightness) reduces; headache (most common) peak flow improves Ex: Theophylline Arrhythmias, seizures and Aminophylline deaths @ high NURSING MANAGEMENT Doxofylline concentrations ATTAIN RELIEF OF DYSPNEIC BREATHING Need to monitor w/ Monitor V/S, skin color, retraction, degree of restlessness blood tests to ascertain (hypoxia) therapeutic levels Medication and O2 as prescribed QUICK RELIEF/LONG TERM Monitor airway functioning with a peak flow meter or a pulmonary function test STEROIDS Useful for treatment of Encourage intake of fluids acute exacerbations POSITION: Sit upright and lean forward on table (Tripod Eg: Prednisone (O) position) Methylprednisolone (IV) ADVERSE EFFECTS IN LONG Breathing techniques (pursed-lip breathing) Hydrocortisone (IV) TERM USE: Chest physiotherapy/postural drainage → after giving Weight gain, easy bronchodilators CAUTION: bruisability, osteoporosis, Auscultate lung sounds before, during and after treatments Taper meds before DM, ulcers, hypertension discontinuing RELIEVE ANXIETY LONG TERM Explain rationale for interventions Provide care in prompt, confident manner INHALED STEROIDS Most effective Help clarify sources of anxiety; measures to reduce anxiety anti-inflammatory agent and control breathing Eg: Beclomethasone Drug of choice for asthma Active participation and support efforts Budesonide control CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Fluticasone Best route to provide Mometasone targeted drug delivery, Characterized by airflow limitation that is progressive and acts faster and a small not fully reversible dose required Normally due to inflammatory response of lungs due to irritants ADVERSE EFFECTS: Chronic bronchitis Hoarseness of voice, oral Emphysema candidiasis (fungal infection) CHRONIC BRONCHITIS Chronic inflammation of the lower respiratory tract LONG-ACTING BETA-2 Improves asthma control Characterized by excessive mucus secretion, cough and AGONISTS (LABA) Reduce inflammation dyspnea when added to inhaled Associated w/ recurring infections of the lower resp. Tract Eg: Formoterol steroids, allowing lower Salmeterol doses of steroids to be given BSN 3A - Marjorie D. Solayao PATHOPHYSIOLOGY ○ Mild sputum expectoration ○ Increased AP Diameter of chest (Barrel chest) COMPLICATIONS Atelectasis - lungs collapsed Respiratory failure Pneumonia, overwhelming respiratory infection Right sided HF, dysrhythmias Depression Skeletal muscle dysfunction DIAGNOSTICS PFT: Demonstrated airflow obstruction ABG: Respiratory acidosis CHEST X-RAY: Hyperinflation flattened diaphragm, increased retrosternal space, decreased vascular markings, possible bullae (late stage) EMPHYSEMA Alpha antitrypsin acid Complex lung disease MEDICAL MANAGEMENT Characterized by destruction of alveoli, enlargement of distal airspaces and breakdown of alveolar walls GOALS: Slowly progressive deterioration of lung function for many Reverse airflow obstruction years before development of illness Prevent progression of disease process BARREL CHEST: Classic manifestation ○ 1:1 ratio → AP Diameter = Transverse Diameter Smoking cessation ○ NORMAL: 1:2 Ratio → Transverse Diameter > AP Chest physiotherapy Diameter SUPPLEMENTAL OXYGEN → 1-2 L/min via NC PATHOPHYSIOLOGY PHARMACOLOGIC INHALED BRONCHODILATORS - to reduce DOB and bronchospasm ANTICHOLINERGICS SABA LABA METHYLXANTHINES (theophylline) – for chronic maintenance therapy INHALED CORTICOSTEROIDS – for symptomatic COPD ORAL CORTICOSTEROIDS – for acute exacerbations ANTIBIOTICS – for bacterial infections NURSING DIAGNOSIS 1. Ineffective airway clearance 2. Ineffective breathing pattern 3. Risk for infection 4. Impaired gas exchange 5. Imbalanced nutrition: less than body requirements 6. Activity intolerance NURSING MANAGEMENT COPD ETIOLOGY IMPROVE AIRWAY CLEARANCE Cigarette smoking Eliminate pulmonary irritants: Air pollution ○ Smoking cessation Occupational exposure ○ Room dust-free Allergy ○ Add moisture to indoor environment (vaporizer, Autoimmunity humidifier) Infection Postural drainage positions Genetic predisposition Controlled coughing Aging Keep secretions liquid: ○ Encourage fluid intake (2-2.5 L/day), if not CLINICAL SIGNS AND SYMPTOMS contraindicated CHRONIC BRONCHITIS ○ NSS Nebulizations ○ Presence of productive cough lasting at least 2 ○ Avoid dairy product months/year for 2 successive years ○ Production of yellowish/greenish, gelatinous sputum; CONTROLLING INFECTION greater amount during superimposed infection. Early s/sx of infection: ○ Wheezing and dyspnea as disease progress ○ Increased DOB EMPHYSEMA ○ Fatigue ○ Dyspnea, decreased exercise tolerance ○ Changes in character, amount and color of sputum ○ Minimal cough, except if w/ respiratory infections ○ Low-grade fever BSN 3A - Marjorie D. Solayao  ○ Irritability ○ Tuberculosis (TB) pleuritis Sputum sample for GS/CS ○ Hemothorax Administer antimicrobials as prescribed for infections EMPYEMA - accumulation of pus in the lungs IMPROVING GAS EXCHANGE CLINICAL SIGNS AND SYMPTOMS Monitor O2 saturation – maintain O2 support Standby ventilation/intubation if acute respiratory Dyspnea, pleuritic chest pain, cough failure/rapid CO2 retention occurs Dullness or flatness to percussion (over areas of fluid); decreased/absent breath sound IMPROVING NUTRITION Decreased/absent tactile fremitus upon palpation Nutritional history, right anthropometric measure (baseline) Frequent small meals (esp. If dyspneic) DIAGNOSTICS Nutritional supplement CHEST X-RAY, UTZ, CT SCAN: detects presence of fluid Avoid gas forming food THORACENTESIS: biochemical, bacteriologic, and cytologic High calorie, high protein diet/snacks analysis of pleural fluid indicates cause ○ Provide sources of energy for body MEDICAL MANAGEMENT HIGH PROTEIN: Enhances absorption of bronchodilators LOW CARB: Prevents excessive formation of CO2 Treat underlying cause ○ Retention, slow down excretion of bronchodilators → Thoracentesis increase risk for toxicity FOR MALIGNANT EFFUSIONS: INCREASE ACTIVITY TOLERANCE ○ CTT Drainage, radiation, chemotherapy, surgical Importance of graded exercise and physical conditioning pleurectomy, shunt, pleurodesis programs NURSING DIAGNOSIS ○ Consistent walking, stationary biking ○ Portable O2 for walking Ineffective breathing pattern Refer to PT/OT Energy conservation techniques GOAL: Reports absence of SOB CLIENT EDUCATION NURSING INTERVENTIONS GENERAL EDUCATION Institute treatment to address underlying cause as ordered ○ Explanation of disease process; informational resources Assist in thoracentesis, if indicated ○ Work w/patient to set SMART goals Maintain CTT drainage ○ Encourage pt and SO involvement NURSING MANAGEMENTS Avoid exposure to respiratory irritants ○ Smoking cessation Post-pleurodesis care: ○ Provide a clean environment ○ Monitor for excessive pain; may cause hypoventilation ○ Avoid alcohol drinking ○ Administer: prescribed analgesics; oxygen as indicated Prevent and treat respiratory infections ○ Observe V/S, O2 Sat, and breathing pattern ○ Avoid exposure to people w/ pulmonary infections ○ Avoid crowds and areas w/ poor ventilation ** PLEURODESIS → procedure that sticks your lung to your chest wall. ○ Stress importance of annual vaccination (influenza, pneumococcal, flu) This procedure removes the space between your lung and your chest wall (pleural space) so that fluid or air no longer builds PLEURAL EFFUSION up between the layers. a collection of fluid in pleural space PNEUMOTHORAX almost always secondary to other diseases Air in the pleural space occurring spontaneously or from Normal pleural fluid: 10 CC trauma TRANSUDATIVE: Non-inflammatory related, low-protein fluid TYPES EXUDATIVE: inflammatory-related, high-protein fluid 1. PYOTHORAX/EMPYEMA - pus in the pleural space 2. HEMOTHORAX - blood in the pleural space r/t stab THORACENTESIS → removal of pleural fluid from pleural space wound/open wound CAUSES 3. HYDROTHORAX - water in the pleural space TRANSUDATIVE CLASSIFICATIONS ○ Effusion due to a heart failure (most common cause) 1. SPONTANEOUS - sudden onset in the absence of trauma ○ Liver cirrhosis (right lung usually affected) 2. OPEN (sucking wound of chest): opening in chest wall large ○ Nephrotic syndrome enough to allow air to pass ○ Myxedema 3. TENSION: Build-up of air under pressure in pleural space ○ Atelectasis (eg. mechanical vent) RISK FACTORS EXUDATIVE ○ Parapneumonic infection - most common cause of Thin, white males exudative (bacterial pneumonia, lung abscess, Family hx of pneumothorax bronchioectasis, empyema) ○ Malignancy (lung CA, breast CA, lymphoma) —> common cancers causing pleural effusion ○ Pulmonary embolism BSN 3A - Marjorie D. Solayao  CAUSES Ineffective Emergency care: Idiopathic (unknown) breathing ○ Apply petroleum gauze to open Rupture of sub pleural bleb due to chronic respiratory disease pattern wound (emphysema, cancer, infection) ○ Assist w/ emergency Direct trauma GOAL: Breath thoracentesis/thoracostomy Thoracic surgery, (+) pressure ventilation, CVP line insertion, sounds equal ○ CPR/ACLS for cardiovascular thoracentesis bilaterally; less collapse dyspneic Maintain patent airway PATHOPHYSIOLOGY POSITION: upright if condition permits → promotes lung expansion Maintain patent CTT Splint chest while turning/coughing → hug a pillow while turning/coughing Administer: prescribed analgesics Impaired Monitor pulse oximetry, ABG levels as gas indicated exchange Incentive spirometer → for lung expansion GOAL: Oxygen support PRN (HIGH FLOW: 10 ABG levels - 15 LPM) improved MONITOR: hypovolemic shock (Blood transfusion as ordered) → shock related to increased blood/fluid loss CLINICAL SIGNS AND SYMPTOMS Possible recurrence of spontaneous Air hunger, agitation, hypotension, cyanosis pneumothorax; report DOB STAT → Anxiety, restlessness Early s/sx of recurrent spontaneous Mild to moderate DOB and chest discomfort in spontaneous pneumothorax pneumothorax Tachycardia PULMONARY EMBOLISM Tachypnea obstruction of one/more pulmonary arteries by a thrombus (or Hyperresonance; diminished/absent breath sounds —> bc of thrombi) originating usually in the deep veins of the legs, lung collapse/ presence of fluids right side of the heart, or upper extremity, which is dislodged Reduced mobility of affected half of thorax (asymmetrical and is carried to the pulmonary vasculature chest expansion) PREDISPOSING FACTORS TENSION PNEUMOTHORAX: Tracheal deviation AWAY from affected side Stasis, prolonged immobilization Concurrent phlebitis → inflammation of blood vessel COMPLICATIONS Previous lung/heart disease (HF, MI) Acute respiratory failure Injury to vessel wall (trauma) Cardiovascular collapse with tension pneumothorax Coagulation disorders Infection (Sepsis) DIAGNOSTICS CHEST X-RAY: to confirm presence of air in pleural space; Metabolic, endocrine, vascular, or collagen disorders tracheal deviation Malignancy ABG Advancing age MEDICAL MANAGEMENT WHAT COULD BECOME AN EMBOLI? SPONTANEOUS Pregnancy (amniotic) ○ Non-operative Fracture of long bones, obesity, trauma (fat) ○ Spontaneous resolution Invasive procedures (air) ○ Needle aspiration or chest tube drainage PATHOPHYSIOLOGY ○ Pleurodesis ○ Thoracotomy w/ resection of apical bleb OPEN ○ Close chest wound immediately (pressure dressing applied) ○ CTT inserted w/ water-sealed drainage setup ○ Surgical intervention to repair trauma TENSION ○ Immediate decompression by thoracentesis or CTT insertion ○ CTT Drainage w/ underwater-seal suction CTT - Chest Thoracotomy Tube NURSING NURSING INTERVENTION DIAGNOSIS BSN 3A - Marjorie D. Solayao  CLINICAL SIGNS AND SYMPTOMS GOAL: Monitor urine output hourly Dyspnea, pleuritic chest pain, tachypnea Vital signs stable; Chest pain with apprehension & a sense of impending doom adequate urinary Cyanosis, syncope, tachyarrhythmias, circulatory collapse output Pleural friction rub Diaphoresis Acute Pain MONITOR: signs of pain/discomfort; Dilated pupils (Pleuritic) if pain worsens with deep breathing & Subtle deterioration in patient's conditions with no coughing; auscultate friction rub explainable cause GOAL: Reports ADMINISTER: prescribed morphine; Death in massive pulmonary embolism relief from pain monitor for relief of pain & anxiety POSITION: head of bed slightly COMPLICATIONS elevated (if not contraindicated) Bleeding as a result of treatment SPLINTING of chest for deep Respiratory failure breathing & coughing Sudden death Evaluate for signs of hypoxia during anxiety, restlessness, agitation (might DIAGNOSTICS be indication of new onset) ABG LEVELS: decreased Pa02 CHEST X-RAY: normal or possible wedge-shaped infiltrate Anxiety Correct DOB & relieve physical V/Q LUNG SCANS: perfusion scan investigate regional blood discomfort flow GOAL: Appears Explain diagnostic procedures & tests PULMONARY ANGIOGRAM: emboli seen as "filling defect” more relaxed Attentive listening sleeping at long Speak calmly & slowly intervals Enhance patient's sense of control MEDICAL MANAGEMENT EMERGENCY MANAGEMENT Risk for Injury Alert for shock due to low cardiac GOAL: establish cardio-pulmonary status (Bleeding) output (HF) Administer: O2 support Skin color changes (nail beds, lips, IV infusion for drugs & fluids GOAL: Progressive earlobes, mucous membrane) Emergency drugs (inotropics, vasopressors, anti-dysrhythmics) improvement w/out BP, urine output Continuous cardiac monitoring complication IV infusion of vasopressor Small doses of IV morphine (relieve pain) Pulmonary angiography NURSING MANAGEMENT ABG analysis BLEEDING DUE TO ANTI-COAGULANTS/THROMBOLYTICS FURTHER MANAGEMENT FOBT or Gulac test IV HEPARIN - anticoagulant & antithrombotic (2 weeks) Monitor platelet count ○ Monitor PT with INR, PTT Bleeding precaution during venipuncture/invasive procedure After heparin therapy, ORAL ANTICOAGULANT WITH STRICT BED REST avoid unnecessary handling WARFARIN (COUMADIN): prevent new clots from forming Discontinue infusion in case of bleeding (3-6 months) Notify PCP for changes in LOC, sensation, ability to move limbs and follow commands, respond to questions with clear PHARMACOLOGIC articulation THROMBOLYTIC AGENTS (STREPTOKINASE) → used to CLIENT EDUCATION dissolve clots (for MASSIVE pulmonary embolism affectation) REDUCE RECURRENCE RISKS Need for continuous anticoagulant therapy SURGICAL INTERVENTIONS Elastic stockings to prevent venous stasis Insertion of filter in IVC Smoking Cessation Embolectomy Abstain from hormonal contraceptives Avoid wearing restrictive clothing esp. on extremities NURSING NURSING INTERVENTION Avoid prolonged periods of standing & sitting (crossing legs) DIAGNOSIS Warn against sports/activities, constipation (may cause injury) Ineffective ASSESS: hypoxia, headache, Wear MedicAlert bracelet (warning bracelet) breathing restlessness, apprehension, Weight reduction as applicable pattern pallor/cyanosis, behavioral changes V/S, ECG, oximetry, ABG levels PREVENT COMPLICATIONS GOAL: Verbalize Response to IV fluids/ vasopressors Signs of bleeding esp. In gums, nose, bruising, blood in urine less SOB (inotropic) or stools O2 therapy Bleeding precautions Standby for assisted ventilation Avoid ASA, NSAIDs (intubation Inform prior any dental or invasive procedures Ineffective ICU care; close monitoring for shock Tissue (hypotension, tachycardia, Perfusion tachypnea), cool, clammy skin (Pulmonary) Administer: prescribed medications Bed rest BSN 3A - Marjorie D. Solayao