Respiratory N172- Monitor/Manage/Teach

Central Chemoreceptors

Peripheral Chemoreceptors

Increase in respiratory rate

the respiratory center

it identifies if a person has an obstructive or restrictive defect with their lungs

• Obstructive defect
• COPD-hypersecretions, mucous

• Restrictive Defect
• Asthma-narrowing of airway

Don't smoke 6-8 hrs before, and don't use your inhaler 4-6 hours before

• Forced vital capacity
• +80%

• Forced Expiratory volume in first second of expiration
• (FEV1)

it grades the severity of a persons airway obstruction

FEV1/FVC ratio

• PEFR
• Peak Expiratory Flow Rate

Maximum airflow rate during forced expiration

• Respiratory rate, rhythm, quality, IE Ratio
• Skin color
• Shape of chest

Start at the apex....side to side and moving down.

Start at bases....or divide it up and have breaks in between

Barrel chest from an in crease AP diameter related to chronic air trapping

1 : 3

Asthma....1:3 or 1:4....prolonged expiration

COPD.....1 : 5

Resonance....low pitched

Hyperresonance.....Loud, low pitched

Tympany.....loud drum

Dull

• Bronchovesicular 1:1
• Bronchial 2:3
• Vesicular 3:1

Heard over most lung fields...they are soft, low pitched and rustling sound

Heard over the main bronchi...and they are loud and high pitched.  Sound like air blowing through a hollow pipe.

Over the trachea....and they are loud and high pitched.  Sound like air blowing through a pipe.

• Pneumonia and Pleural Effusion
• While listening over the thorax, have the patient repeat the letter "e".  If it is heard as an "a", then they are positive for one of the above.

• Lung consolidation....Cancer (solid) and Pneumonia (fluid)
• Have the patient whisper "1,2,3"...if it is heard through the stethoscope clearly/distinctly....then they have one of the two.

High pitched sound heard before the end of inspiration (collapsed alveoli snap open).

• Pneumonia
• Early Pulmonary Edema
• Atelectasis
• Early CHF

(Roll finger in hair by ears)

Series of long-duration, discontinuous low pitched sounds caused by air passing thru occluded mucous.

• Pneumonia
• Severe Congestion
• COPD
• Heart Failure
• Pulmonary Edema

Continuous rumbling, snoring or rattling from obstruction of large airways with secretions.  Most prominent during expiration.

• Pneumonia
• COPD
• Cystic Fibrosis

High pitched squeak....first evident on expiration, but then evident on inspiration as obstruction increases.  Possibly audible without stethoscope.

• Asthma (Bronchospasm)
• COPD
• Airway Obstruction

Continuous musical sound as a result of a partial obstruction of the larynx or trachea.

• Croup
• Vocal Cord edema after extubation
• Foreign body

• Lobectomy
• Pleural Effusion
• Large atelectasis

Creaking or grating sound

• Pneumonia
• Pleurisy
• Pulmonary Infarct

• pH 7.35-7.45
• PaO2 80-100 mmHg
• SaO2 >95%
• PaCO2 48-32 mmHg
• HCO3 22-26

Acid-low pH but high CO2 (hydrogen ions) (acidosis)

Base-high pH low CO2 (hydrogen ions) (alkalosis)

(hydrogen = acid)

hypoxemia

• Respiratory
• Metabolic Alkalosis

• Respiratory
• Metabolic Acidosis

• Metabolic
• Respiratory Alkalosis

• Metabolic
• Respiratory Acidosis

Increase their ventilation

Decrease their ventilation

Treat the problem and/or administer Sodium Bicarbonate (NaHCO3)

Treat the problem, administer acid and/or dialysis

• Hypoventilation
• Obstruction
• COPD
• Pulmonary Edema
• Overdose (respiratory ctr depression)

• Decreased mental status
• Drowsiness
• Tachy
• Headache, weak, tremors

• TCDB
• Aerosol Therapy/Suctioning
• IPPB
• IS
• Pain Meds

Artificial Airways/Mechanical Ventilation

Hyperventilation due to anxiety, pain, fever or Pulmonary Embolism

• Exercise
• Mechanical Hyperventilation

• Reassurance
• Sedation/Pain Meds
• Rebreathe CO2 (paper bag)
• Reduce ventilator settings to decrease RR

• Low Base
• Diarrhea, Renal Failure, Fistula, Pancreatic Drainage

• Increased Acid
• Alicylate OD
• Sepsis
• Shock
• Starvation

• TREAT THE UNDERLYING CAUSE!!!
• Monitor I&O and electrolytes
• Correlate I&O with weight, VS, skin color, turgor and temp
• Prevent Infection
• Monitor arrhythmias
• Protect from injury (seizures)
• Monitor ABG's
• In sever cases NaHCO3 may be ordered

• Increased Base
• NaHCO3 administration
• Ingestion of Antacids (alkaloids)

• Decreased Acids
• Vomiting
• N/G tube suctioning
• Electrolyte Imbalance

• Increased Respiratory Rate
• Cramps
• Tetany
• Paresthesias (tingly)
• Seizures

• Decreased Mental Status
• Seizures
• Fatigue
• Hypotension
• Anorexia/vomiting/Nausea

• Confusion
• Hand Tremor
• Light headedness
• muscle twitch

• TREAT THE UNDERLYING CAUSE
• Monitor VS and electrolytes
• Monitor I&O
• Protect pt from injury
• Admin Acid (Ammonium chloride)
• Increase HCO3 excretion with Diamox
• In sever cases dialysis may be ordered

Diamox

• Low pH <7.35
• High PaCO2 > 48
• High HCO3 >26

• Compensated Respiratory Acidosis
• Kidneys have kicked in to hold in or conserve HCO3 to help increase the pH back to a normal range

Assesses perfusion of the lung...or lack there of when a person has a pulmonary embolism

minimal nursing intervention cuz it's like an x-ray

It is used for diagnosis or treatment by a lighted scope being passed in to the bronchial tree.

• NPO 6-12 hrs prior to test, and swallow eval done after test prior to food/fluids
• HOB 30 degrees
• Teach pt. may have a little blood, and a scratchy throat after

Increases plasma volume.

Since this solution doesn't cause a fluid shift in to other compartments, watch for HEMODILUTION (decrease in Hgb, Hct and Electrolytes)

They hydrate cells interstitial compartment...CELLS SWELL AND VESSELS Shrink

It pulls fluid from the intravascular space to intracellular space.  Watch for HYPOTENSION, CEll and BRAIN EDEMA and DEATH

They hydrate and replace electrolytes.  Pulls ECF from interstitial space to intravascular space

CELLS SHRINK and VESSELS SWELL.  Watch for Circulatory overload, irritation of vein walls and CELL DEHYDRATION

Removal of specimen for diagnosis, removal of pleural fluid or to instill medication

Monitor pulse, color O2 saturation during procedure

Apply dressing over the puncture site and position pt on unaffected side for 1 hr after.

Recheck vital signs regularly after.

Respiratory Alkalosis initially....then Respiratory Acidosis.

Inflammation of the bronchials resulting in airflow obstruction caused by the inflammatory cascade.

They are susceptible to another one for the next 4-10 hours that can be more severe and last longer

• Dyspnea
• Wheezing and Coughing...but not a good predictor of severity of their attack
• Tight Chest
• Prolonged Expiration
• Use of Accessory Muscles
• Increased RR
• Severe Anxiety
• Silent chest
• Hypoxemia

• Restlesness
• Inappropriate Behavior
• Increased pulse and BP

Hyper-Resonance

Acidosis

Metabolic Alkalosis

When a person has a chronic productive cough for 3 months in each of 2 consecutive hears.

It is an inflammation of the Bronchi and Bronchioles due to chronic exposure to irritants

Chronic Bronchitis and Emphysema

When a person has a loss of lung elasticity and hyperinflation of lung tissue.  It causes destruction of the alveoli leading to decreased surface are for gas exchange, carbon dioxide retention.

Continued exposure to noxious particles causing an inflammation of the airways, hyperplasia of cells and increased production of mucous.

It reduces the diameter of their airway and increases the difficulty in clearing secretions.

• Dyspnea upon exertion
• Productive cough....mostly in the AM
• Crackles/Wheezes
• Rapid/Shallow Respirations
• Barrel Chest
• Thing Extremities
• Clubbing
• Pallor and Cyanosis
• Decreased O2 Saturations

Hyper-Resonance due to trapped air

People with COPD get this....right sided heart failure

Super thin with enlarged neck muscles

• QUIT SMOKING!!!
• Drug Therapy
• O2 Therapy
• Airway Clearance Techniques
• Breathing Retraining
• Weight Management
• Good Fluid Intake

• Teach Huff Coughing (Forced Expiratory Cough)
• Chest Physiotherapy

• Pursed Lip Breathing...prolongs exhalation and slows RR
• Diaphragmatic Breathing....use of diaphragm and not accessory muscles

They are underweight and this correlates to a poor prognosis.  Teach how to make eating less exhausting.

Cuz of the mucous accumulation...but not good if they have CHF or Renal failure too!!

3L/Day

• Respiratory Rate, rhythm, quality and IE Ratio
• Skin Color
• Shape of Chest
• Use of Accessory Muscles?

90%

If the patient tires easily start at the bases...or separate your listening with breaks in between

A positioning technique that drains secretions from specific segments of the lung and bronchi into the trachea.

• Put in different positions for 5 min each.
• Do 1 hr before meals or 3 hours after
• Side lying position if pt cant tolerate a head down position
• Use aerosolized bronchidilators and hydration therapy prior to procedure
• Do 2-4 times a day

• Loss of weight
• Muscle Atrophy
• Fatigue/Weak
• Loss of appetite

between meals

• Is the client able to.....
• maintain adequate gas exchange
• prevent acute attacks
• have relief of symptoms
• adhere to the medication regime

• Is the client able to.....
• maintain adequate gas exchange
• be able to keep a patent airway
• remain free from infection
• maintain a healthy weight

• Prevention of disease progression
• Relieve symptoms and improve exercise tolerance
• Prevent and treat complications
• Promote patient participation in care
• Prevent and treat exacerbations
• Improve quality of life and reduce mortality risk

Venous return and lympathics bring tumor cells from distant sites in the body to the heart and pulmonary circulation which provides a hospitable environment for the tumor cell

• Smoker
• Non smokers, but former smokers
• True non smokers

30-50%

The carcinogens inhaled are a lower airway irritant that changes bronchial epithelium

• Higher incidence in men
• More men die

BUT....women smokers have a higher risk of developing LC than male smokers

upper

Metabolic changes....

• Hypercalcemia
• Anemia
• SIADH
• Leukocytosis

are smokers or have been exposed to environmental carcinogens.

Paraneoplastic Syndromes

Less than 2 years to live.  Metastasizes early and grows FAST

Limited...tumor is confined to the chest and regional lymph nodes

Extensive....cancer has extended to the chest wall or to other parts of the body.

7-10 months

NSCLC....most common in women

something else starts to bother them....cuz there are no clinical manifestations till it is widespread/metastasized

OR

Get a chest x ray for something else and see masses

• Persistent cough with sputum
• Blood tinged Sputum
• Chest pain
• Dyspnea
• Wheezes

• anorexia/weight loss
• NVD
• Hoarseness
• Dysphagia
• SVC Syndrome
• Palpable Lymph nodes in the neck

• Cardiac Tamponade
• Dysrhythmias

Pericardial Effusion

• long bones
• vertebrae
• liver
• adrenals
• BRAIN

• ID risk factors and appropriate referrals for screening
• Promote smoking cessation and healthy living
• Nursing care related to chemo, targeted therapy, radiation and surgery

• Provide support and reassurance
• Care of the patient
• Management of disease symptoms and side effects of treatments
• Assess smoking cessation readiness
• Patient teaching on pain management
• Coping strategies

Surgical Resection

the size of the primary tumor and co morbidities

removal of entire lung

removal of one or more lobes of the lung

Removal of large portion of a lobe

removal of a small portion of a lobe

removal of entire lobe and part of the bronchus

when a patient has a solitary pulmonary nodule without metastases or regional lymph node involvement

• What to expect post op ....
• TCDB
• IS
• Pain meds

TNM staging system

• T=tumor size, location and degree of invasion
• N=regional lymph NODE involvement
• M=presence or absence of distant metastases

estimating disease progression and appropriate treatment

• XRAY to confirm placement
• Note drainage
• Palpate for Crepitus
• Pain Management

• VTE (Venous Thrombeo Embolism)
• Pulmonary Edema
• Cardiac Dysrhythmias
• Hemorrhage
• Hemothorax
• Hypovolemic shock

Accumulation of blood in the pleural space

Blood tinged sputum

If they have a PCA you can look at how many times they push the button in an hour, if it is excessive ask them how this approach is working.  May need to change it.

Color and circle around the drainage stain so you can tell if it is getting larger

to check for placement....and to make sure they are progressing

Chemo

as adjuvant therapy when a person has a non resectable tumor

blocks the growth of molecules involved in tumor growth

• Treats both NSCLC and SCLC
• Curative, palliative and adjuvant therapy
• Used in combo with chemo
• Used for patients that cant tolerate surgery
• Pre-op to reduce the size of the tumor before surgery

• esophagitis
• skin irritation
• radiation pneumonitis

• treatment of dyspnea and pain
• radiation therapy
• laser therapy
• Thoracentesis
• Pleurodesis

• mucosa
• muscle
• bone
• METS to lung and liver

• Poor diet in fruits and vegetables
• HPV
• 50+
• Tobacco and alcohol

• Dentist.....
• They should assess area under the tongue using a flashlight to visualize the area.  Also palpate for lumps

• Leukoplakia (white)
• Erythroplakia (red)

• painless growth in the mouth
• ulcer that doesn't heal
• change in the fit of dentures
• pain in the late stages cuz aggrevated by acidic foods

• C/o persistent unilateral sore throat
• otalgia (ear pain)
• hoarseness....that lasts longer than 2 weeks
• lump in throat

• Pain
• dysphagia
• decreased motility of the tongue
• airway obstruction
• cranial nerve neuropathies

placement of a radioactive source into or near the tumor.  The goal is to deliver high doses of radiation to the target area while limiting exposure of surrounding tissues

• Assess skin, mouth; area being radiated.
• Check patients ability to swallow and communicate
• Is there redness, skin irritation, swelling, dry mouth??
• Bone pain?
• Nausea
• Fatigue

if you have a moist skin reaction

No sun exposure for 1 YEAR after treatment is done!!!

• Frequent rest periods during the day
• light exercise

dry mouth

• increase fluid intake
• chew sugarless gum and candy
• use nonalcoholic mouth rinses (baking soda too)
• Brush teeth with soft tooth brush
• Mouth rinses with 1/2 water and 1/2 NS

Salagen

Inflammation of the mucous membrane in the mouth

partial removal of one vocal cord when there is a superficial tumor

removal of one vocal cord or part of a cord...requires a TEMPORARY Trach

removing structures above the true cords, the false vocal cords and epiglottis...requires a temporary tracheostomy

Hemilaryngectomy and Supraglottic Laryngectomy

high risk for aspiration  cuz it removes the epiglottis

hemilaryngectomy and Supraglottic Laryngectomy

used for treatment of advanced lesions...removal of the entire larynx and pre-epiglottic region

Total Laryngectomy

With a total laryngectomy

Decreases the risk of lymphatic spread

Other structures may be removed as well....thyroid, IJV, mandible....

Surgery that spares as many structures as possible

a dentist specializing in oncology

Medical Oncologist Consultant

• plan to prevent airway obstruction
• hemorrhage
• wound problems

• Risks of surgery
• If trach is needed and for how long
• complications?
• Disfigurement?
• Wound Problems

• plan for voice restoration
• swallow exercises
• prevention of long problems with eating

• deep breathing
• pain management
• communication
• special breathing with Trach
• Nutrition
• ambulation

• Airway maintenance
• Ventilation
• Gas Exchange
• Reconstructive tissue care
• pain control
• Nutrition
• PT
• Psych adjustment

• NG Tube
• G Tube
• PEG
• TPN

Incision sites, dressings.....

Color, amount, and drainage

with a humidifier to prevent drying of secretions

• auscultation of breath sounds
• SPO2
• communication
• pain
• ambulation

providing patient with exercises to maintain strength and movement in the affected should and neck....to prevent development of frozen shoulder

NOT if they have a hole in their throat

Rejection of new tissues...any flaps/grafts

• Patient/Family Education on care
• Body image/emotional support
• Trach Care
• Caution when showering, shaving, applying makeup (Shield opening)
• Bedside humidifier
• Medic Alert Bracelet

Use a....

• manufacturers cover
• dry cloth
• childs bib with the plastic faced outward

voice rehab....

it is a soft plastic device inserted in to the fistula made btwn the esophagus and trachea

Allows for air from the lungs to enter the esophagus by way of the stoma

Speak manually by blocking stoma....words are formed by moving tongue and lips

voice rehab....

it is a hand held batter powered device that speech is made by sound waves

Voice Therapy....

Special plastic tube placed in the corner of the mouth to create vibrations

voice therapy

placed against the neck rather than in the mouth

speech therapy....

method of swallowing, trap the air in the esophagus and release air to creat sound

• highest mortality rates
• highest incidence of lung cancer
• most likely to die from lung cancer

you will have more complications due to your older immune system and comorbidities

• Pneumothorax (collapsed lung)
• Hemothorax (blood in lungs)
• Post op drainage
• lung abscess
• Pleural Effusion (fluid in lungs)

• Any signs of resp. distress? (deviated trach?)
• Is the dressing in tact? Crepitus?
• Are there any kinks in the tubing?
• Clots in tubing?
• Is there the expected amount of drainage in the collection chamber?  type/color?
• Does the water seal chamber have the correct water level?  Bubbling
• Is the suction chamber suctioning at the prescribed amount?

there is an air leak somewhere....

You will see bubbles flowing from right to left in the chamber

Rated by 0-5 (low to high)

leakage of air in to the subcutaneous tissues

*monitor for discomfort and respiratory distress

air leak.....cuz air is being removed from the chest

• IS q1-2
• TCDB
• OOB
• Report pain and PQRST

• *Report sudden pain or SOB
• *report tube disconnection or dislodgement
• * Report change in color of the drainage

• Get help from coworkers...bring supplies to you
• Put patient in comfy position
• Place end of tubing in to sterile water
• Notify MD
• Use standard precautions for body fluids

• Get help from co workers....bring supplies to you
• Put patient in comfy position
• Call MD
• If necessary call Rapid Response
• Assess exit site for drainage pain and bleeding
• VS
• Lungs sounds
• Respirations

Give MD SBAR when he calls  you back.  May need to put a sterile dressing over exit site

• Teach
• Emotional support about body image
• Care