Mod 6 Respiratory

  1. Tidal Volume:
    Volume of air  exchanged with each breath from about 500 mL inhaled
    • c
    •  Primary function: gas exchanges of O2 and CO2 between atmosphere and blood.

     Upper Respiratory Tract:

    • • Made of nose/mouth, pharynx, epiglottis, larynx and trachea.
    • Nose: warms air and filters small particles.
    • • Epiglottis: flap that closes over larynx to prevent food entering airway
    •  Lower Respiratory: Bronchi, bronchioles, alveolar ducts and alveoli
    • • Gases are exchanged at the alveolar cpilalar membrane where the alveoli come in contact with pulmonary capillaries.
    • • Surfactant: lipoprotein that lowers the surface tension in alveoli, reducing pressure needed to inflate the alveoli so that they are less likely to collapse. “Atelectasis” when not enough surfactant leads to collapse.
    • • Blood Supply: Pulmonary circulation provides lungs with blood that participates in gas exchange, from pulmonary artery that contains deoxygenated blood. Pulmonary veins: return oxygenated blood back to left atrium-> left ventricle.

    •  Chest Wall: Thoracic cage: 24 ribs and sternum, lined with parietal pleura. Lungs lined with visceral pleura
    • • Parietal pleura irritation causes pain.
    • • Intrapleural space contains 25 mL of fluid that: provide lubrication between pleural layers and increases cohesion between layers to facilitate expansion of pleurae and lungs during inspiration.
    • • Pleural effusion: accumulation of greater amounts of fluids.
    • • Diaphragm: major inspiration contraction muscle which pushes abdominal contents down.
  3. Physiology of Respiration: 
    Elastic Recoil
    • Ventilation: involves inspiration/inhalation and expiration/exhalation due to Intrathoracic pressure

    • Dyspnea: shortness of breath occurs, neck and should muscles can assist the effort

    • Elastic recoil: tendency for the lungs to relax after being stretched or expanded. Intrathoracic pressure causes chair to move OUT lungs

    • Compliance: Dispensability; measure of the ease of expansion of the lungs. Produce of elasticity ad elastic recoil of the chest wall. Compliance increases with COPD
  4. Diffusion:
    partial pressure of oxygen in arterial blood (pa O2)

    arterial oxygen saturation (SaO2)
    • The lungs ability to oxygenate arterial blood adequately is assessed by examination of the partial pressure of oxygen in arterial blood (pa O2) and arterial oxygen saturation (SaO2)

     Pressure of Oxygen in Arterial blood (PaO2):represents the amount of oxygen dissolved in the plasma, expressed in millimetes of mecury mmHg

     Arterial Oxygen Saturation (SaO2): amount of oxygen bound to hemoglobin in comparison with the amount of oxygen the hemoglobin can carry.
  5.  Arterial Blood Gasses:
    • • Two methods used to assess the efficiency of gas transfer in the the lung and tissue oxygenation.
    • 1. Analysis of arterial blood gases: measured to determine odygenation status and acid base balance, includes measurement of the PaO2, paCO2, acidity and biocobante in arterial blood. SaO2 is calculated during analysis.
    • Normal at sea level: 7.35-.45 pH, paO2: 80-100 mmHg, SaO2 >95%, paCO2: 35-45 mmHg, HCO3: 22-26 mEq

    • 2. Pulse oximetry: measures arterial oxygen saturation noninvasilvely through a probe on finger, toe, ear.
    • • Normal Pa O2 decreased with adanced ages and above sea level.

    • • Manifestations of Inadequate Oxygen:
    •  Central NS: unexplained apprehension, restlessness, confusion, eventually coma.
    •  Respiratory: Tachypnea, dyspnea at rest and eventually use of accessory muscles, pauses between words.
    •  Cardiovascular: Tachy, mild hypertension, Dysrhythmias eventually: cyanosis, hypotension, clammy/cool skin
    •  Other: Diaphoresis: decreased urine output and unexplained fatigue.
  6. Mixed Venous Blood Gases:
    • Pulmonary Artery Cath is used for mixed venous sampling, consists of venous blood that has returned to the heart and “mixes in the right ventiricle.”

    • PvO2: 38-42, SvO2: 60-80%, Bicarb is the same.
    • • Decrease in SvO2 provide an early warning of a change in cardia output or tissue oxygen delivery. Normally 60-80%
  7. Carbon Monoxide Monitoring: Transcutaneous CO2 and End Tidal CO2
     • Transcutaneous CO2: non invasive method of estimating arterial pressure of CO2 using an electrodode placed on the skin

    • End-Tidal CO2 (PETCO2): noninvasive measurement of alveolar CO2 at the end of exhalation when CO2 concentration is at its peak. Used to monitor and assess trends in the patient’s ventilator status. '

    • Measurement of oxygen saturation is primarily used to assess for hypoxia. While CO2 is used to monitor hypoventilation.
  8. Control of Respiration:  Chemoreceptors, Peripheral, mechanical Receptors
    Resp Defense Mechanisms
    Alveolar Macrophages
    • Chemoreceptors: responds to change in the chemical composition of fluid in medulla, responds to H+ concentration and increase respirtartory rate and tidal volume. Vice versa. Changes in paCO2 regulate ventilation primarily by theireffect on the pH of the cerebrospinal fluid. When PaCO2 level increased, CO2 is combined with water to form carobonic acid to lower pH and lower resp rate.

    •  Peripheral chemoreceptors: carotid bodies and aortic bodies
    • • Mechanical Receptors: Juxacapillary and irritant, located in the lungs, upper airways, chewt wall and iaphragm. Stimulated by a variety of physiological factors, such as irritants, muscle stretching and alveolar wall distortion. Signaled from stretch receptors. Juxtacapillary Receptors believed to cause rapid respiration seen in pulmonary edema.

    •  Respiratory Defense Mechanisms:
    • • Filtration of Air: Mucous catches most particles
    • • Mucociliary Clearance System:Below larynx, secretion of mucus and the ciliary activity. COPD and cystic fibrosis have destroyed ciliar resulting in impaired secretion cleariance, a chronic productive cough and chronic bacteria-->resp tract infections.

    • • Cough Reflex: high pressure, high veolicit flow of air to remove esecretions about main airways.
    • • Reflex Brochoconstriction prevent entry of irritants.
    • • Alveolar Machrophages: primary defense mechanism at the alveolar level; rapidly phagocytize inhaled foreign particles such as bacteria and move to the bronchioles for removal by the cilia or from lungs to lymph system. Particles that can’t be phagotize remain in lungs and stim inflammatory responses.
    •  Smokers high risk for lung disease b/c alveolar macrophages are impaired .
  9. Gerontologic Considerations:  Effects of Aging on respiratory System
    • • Age related changes:
    •  Costal cartilages get calcified: interfereds with chest expansion.
    •  Barrel shaped chest: outward curvature of the spine.
    •  Lungs harder to inflate.
    •  Loss if subcutaneous tissue and bony prominences
    •  Functional alveoli decrease and less elastic , small airways close earlier in expiration
    •  more inspired air in the lung apex, ventiliation is less well matched to perfusion which lowers paO2. Therefore less tolerance for exertion, dyspnea can occur. (Assessment finding: Decreased cough ability, secretion clearance but higher risk of upper resp aspiration, infection, influenza, pneumonia.

     Respiratory defense mechanisms: less effective b/c of decline in immunity-macrophages are weaker an cough is less forceful, less functional cilia. Retained mucus=> Resp tract infection. Slower swallowing. Reduced sensation of pharynx (aspiration likely).

     Respiratory control altered-can’t change resp rate as fast anymore when blood gases are imbalanced, greater decrease in O2 while decrease in CO2, decrease of acid-base balance, Hypercapnia may happen, Retained secretions.
    • Past health history: allergies & severity, ask about lower resp diseases: asthma, TB, COPD, pneumonia.

    • • Medications:
    • ACE: angiotensin converting enzyme inhibiotor-side effect is cough.
    • If patient uses Oxygen to ease breathing problems, document the fraction of inspired oxygen concentration (FIO2), liter flow, method of administration, number of hors used per day and effectiveness of therapy.
    • • Surgery/Other treatments: ask about response to resp treatments like Nebulizer, humidifier, airway clearance modalities, percussion, postural drainage.
    • • Health Perception Health Management Pattern: Ask about perceived change in health status in past few days/months. Carefully document common signs of problems and describe the course of pt’s illness. Carefully document any changes because they offen sugges cause of illness.
    •  Evaluate cough: Loose sounding: indicates secretions. Dry hacking cough=air way irritation/obstruction. Harsh/Barky cough=upper airway obstruction from inhibited vocal cord movements related to subglottic edema. Cough strength? Pattern? “Do you clear throat a lot?”
    •  Evaluate Sputum:
    • -amount color consistency and ordor. Normal color is clear/slightly whitish. COPD: clear, whitish or slightly yellow sputum.?
    • -Thick, thin, frothy? Dehydration, postanasal drip or sinus drainage or possible edema.
    • -Foul order= infectious process.

     Hemoptysis: coughing up blood vs. Hematemesis: vomiting blood. Differentiate by testing acidic pH which is in blood

    •  Wheezes: musical sounds
    •  Ask about influenza nd pneumovax vaccine. Ask whre patient lived or traveled.

    • • Nutritional-Metabolic pattern: weiht loss is a symptom, mobidly obese may hypoventilate.
    • • Activity Exercise Pattern: limited by dyspnea at rest or during exercise
    • • Sleep rest Pattern: COPD may awaken at night with chest tightness, weezing, coughing. Orthopnea: resp issues while laying flat.
    • • Cognitive Perceptual Pattern: hypoxia can cause apprehension, restlessness, irritability and memory changes.
    •  Pleuritic pain described as a sharp localized stabbing pain associated with movement or deep breathing. Fractured ribs.

    • • Self Perceptual pattern.
    • • Role relationship pattrn: document nature of pt’s work environment and affect work performance.
    • • Coping stress ntolerance pattern: dyspnea causes anxiety which exacerbates dyspnea
    • • Valued belief pattern.
  11. OBJECTIVE DATA: Physical Assessment (INSPECTION)

    Cheyne stokes
    •  Vital signs
    •  Nose: patency, inflammation, discharge, no bogginess (edema) or bleeding. Watery discharge: allergies or cebrospinal fluid. Bloody discharge: trauma or ryness. Thick mucosal discharge: infection.
    •  Mouth/Pharynx: Poor dention, Normal gagging response=cranial nerve 9 (Glossopharyngeal) and 10 (vagus) are intact and airway is protected.
    •  Neck: palpate lymph nodes, shotty-small, mobile non tender (Normal) vs Tender, hard or fixed nodes-> disease.

    •  Thorax/Lungs:
    • Perform assessment IPaPeAu.
    • o Inspection:

    • 1. First observe the patient’s appearance and note any evidence of respiratory distress such as tachypnea or use of accessory mucscles
    • 2. Determine shape/symmetry of chest. 1:2 transverse ratio.
    • 3. Next observe resp rate, deth and rhythm.
    • • Eldery 16-25 is normal. Inspiration half as long as expiration.
    • Kussmaul: Abnormal: rapid, deep breathiing
    • Cheyne Stokes: abnormal; respirations characterized y alternation perods of apnea and deep, rapid breathing.
    • Biot’s: irregular breaithing with apnea ever four to five cycles.

    4. Skin color: cyanosis (means hypoxemia/heart failure, conjunctivae of dark skinned) Clubbing: long standing hypoxemia.

    5. Posterior chest: pt leans forward with arms folded. Spinal curvatures affect breathing!
  12. OBJECTIVE DATA: Physical Assessment (PALPATION)
    • 1. Normal tracheal position is midline.
    • 2. Symmetry of chest expansion (normal is 1 inch). Unequal means aire entry is limited by conditions involving lung. Equal & dimished expansion occurs in conditions that produce hyper inflated or barrel chest .
    • 3. Fremitus: vibration of chest wall vocalization. Most itense adjacent to the sternum and between the scapulae because these areas are closeset to the major bronchi.
    • • Increased fremitus: when lung is filled with fluid/dense.
    • • Decreaed : harther from the lung or hyperinflated lung.
    • • Absent: noted with pneumothorac or atelectasis.
  13. OBJECTIVE DATA: Physical Assessment (PERCUSSION)
    • Percussion: To assess the density or aeration of the lungs.
    • 1. Resonance: low pitched sound heard over normal lungs.
    • 2. Hyperresonance: lousd, lower pitch sound tahan normal, heard over hyperinflated lung (COPD or acute asthma)
    • 3. Tymphany : Drum like, loud, empty quality heard over gas filled stomach or intest or pneumothroal.
    • 4. Dull: sound with medium-intensity pitch ad duration heard over areas of “mixed” soli and lung tissue, such as over top area of lver, partially consolidated lung tissue (pneumonia) or fluid filled pleural space.
    • 5. Flat: soft, high pitched sound of short duration heard over very dense tissue where air is not present, such as posterior chest below level of diaphragm.
  14. OBJECTIVE DATA: Physical Assessment (AUSCULTATE) 
    Normal breath sounds and ratios?

    Abnormal? Egophony, Bronchophony, Pectoriloquy
    • 1. Instruct pt to breath slowly and a little more deeply.
    • 2. While documenting the location, divide the anterior and posterior lung into thirds.
    • 3. Three Normal breath sounds: vesicular, Bronchovesicular, and bronchial.
    • • Vesicular: relatively soft, low pitched, gently rustling sounds, heard over all lung areas except major bronchi. 3:1 ratio.
    • • Bronchovesicular. Medium pitch and intenstiry, heard anteriolory over the mainstem bronchi on either side of the sternum and posteriorly b/w scapulae. 1:1 ratio.
    • • Bronchial: louder, higher pitched and resemble air blowing through a hollow pipe. 2:3 ration with a gap b/w inspiration and expiration-relects the short pauses between respiratory cycles. (head in trachea/neck)

    4. Abnormal breath sounds:

    • • Adventitious: abnormal extra breath sounds-crackles, rhonchi, wheezes, pleural friction rub.
    • • Egophony: Positive=abornoal; E sounds like A.
    • • Bronchophony: positive/Abnormal: when ninety nine is heard clearly.
    • • Pectoriloquy: positive/abnormal: when patient whispers “ one two three” and it is heard! (it shouldn’t normally be heard).
  15. Pursed Lip breathing:
    Exhalation through mouth w/ lips pursed together to slow exhalation

    COPD, asthma. Means Increased breathlessness, aims to slow expiration to decrease dyspnea.
  16. Tripod positon/Inability to lie flat:
    Leaning forwarn with arm/elbows supported on overbed table--> COPD, asthma in excaervation, pulmonary edema. Indicates moderate to severe resp distress.
  17. Use of accessory Muscles: neck and shoulder muscles used to assist breathing, muscles b/w ribs pull in during inspiration COPD, asthma in exacerbation, secretion retention. Indicates severe ressp distress, hypoxemia.
    neck and shoulder muscles used to assist breathing, muscles b/w ribs pull in during inspiration--> COPD, asthma in exacerbation, secretion retention. Indicates severe ressp distress, hypoxemia.
  18. Splinting:
    voluntary decrease in tidal volume to decrease pain on chest expansion--> Thoracic/abdominal incision, chest trauma, pleurisy, COPD, asthma, cystic fibrosis, lung hyperinflation, advanced age.
  19. Increased AP chest diameter:
    slope of ribs more horizontal to spine--> COPD, asthma, cystic fibrosis, lung hyperinflation, advanced age.
  20. Tachypnea:
    Rate > 20 breaths/min or 25 (older)--> Fever, anxiety hypoxemia, restrictive lung disease. Magnitude of increase above noral rate reflects increased work of breathing.
  21. Kussmaul:
    Regular, rapid, deep respirations -->metabolic acidosis. Increases CO2 incretion
  22. Cyanosis:
    bluish skin hue--> reflects 5-6 g hemoglobin no bound with O2, decrease oxygen transfer in lung, and cardiac output. Nonspecific unreliable indicator.
  23. Finger Clubbing:
    Depth, bulk, sponginess of distal portion of finger-->chronic hypoxemia, cycstic fibrosis, lung cancer, bronchiectasis
  24. Abdominal Paradox:
    inward movement of abdomen during inspiration-->inefficient and ineffective breathing pattern. Nonspecific indicataor of severe respiratory distress
  25. Tracheal deviation (Palp):
    leftward or r/ward movment of tachea form normal midline positon--> med emergency if caused by tension pneumothorax.
  26. Altered tactile fremitus (Palp) :
    increased/decreased vibrations--> Increase in pneumonia, pulonary edema, decrease in pleural effusion, lung hyperinflation. Absent in pneumothorac, atelectasis.
  27. Altered Chest movement (Palp):
    unequal or equal&diminished movement of two sides of chest with inspiration--> Unequal movement caused by atelectasis, pneumothorax, pleural effusion, splinting. Equal/diminished caused by barrel chest, restrictive disease, neuromuscular disease.
  28. Hyperresonance:
    loud, lower pitched sound over areas that normally produce a resonant sound--> Lung hyperinflation (COPD), lung collase *pneumothorax), air trapping (asthma)
  29. Dullness:
    Med pitched sound over areas that are norally resonant--> increased denity (pneumonia, large atelectasis), increased fluid in pleural space (pleural effusion)
  30. Fine crackles:  .
    short duration, discontinuous, high pitched sounds heard just before end of inspiration-->idiopaqthich pulmonary fibrosis, interstitial edema, alveolar filling (pneumonia), loss of lung volume (atelectasis), early phase of heart failure
  31. Coarse crackles:
    series of long duration, discount, low pitched sound, increase in bubbling quality with more fluid (straw under water), evidence in inspiration--> heart failure, pulmonary edema, pneumonia iwht sever congestion, COPD
  32. Rhonchi:
    Continues rumbling, snoring, or rattling sounds from obstruction of large airways with secretion, mostly on expiration, change often evident after coughing or suctioning--> COPD, cystic fibrosis, pneumonia, bronchiectasis.
  33. Wheezes:
    first evident on expiration=>Bronchspasm (asthma), airway obstruction (Caused by foreign body, tumor), COPD
  34. Stridor:
    continuous musical or crowing sound of constant pitch, result of partial obstrucytion of larynx or trachea--> croup, epiglottitis, vocal cord edema after extubation, forign body.
  35. Absent breath sounds:
    no sound evident over entire lung-->pleural effusion, minstem bronchi obstruction, large atelectasis, pneumonectomy, lobectomy
  36. Pleural friction rub:
    creaking/grating, inflamed pleural surfaces rubbing togerher --> Pleurisy, pneumonia, pulmonary infarct
  37. Bronchophony/whispered pectriloquy: .
    spoken or whispered syllable more distinct than normal on auscultation--> pneumonia
  38. Egophony:
    E sounds like A--> pneumonia, pleural effusion.
  39. Chest Examinations:  COPD
    Inspection: Barel chest, cyanosis, tripod position, use of accessory muscles. 

    Palpation: Decreased movment

    Percussion: Hyperresonant or dull if consolidated

    Auscultated: crackles, rhonchi, wheezes, distant breath sounds
  40. Chest Examinations: Asthma
    • Inspection: Prlonged expiration, tripod positon, pursed lips (exacberation)
    • Palpation: Decreased movement.
    • Percussion: Hyperressonance
    • Auscultated: Wheezes, decreased breath sounds ominous sign
  41. Chest Examinations: Pneumonia
    • Inspection: Tachypnea, use of accessory muscles, cyanosis
    • Palpation: Increased fremitus over affected area
    • Percussion: Dull over affected area
    • Auscultated: Bronchial sounds (early) but later-crackles, rhonchi, egophony, whispered pectoriloquy
  42. Chest Examinations: Atelectasis
    • Inspection: No change unless involves entire segment or lobe
    • Palpation: decreased movement and fremitus is large.
    • Percussion:  Dull over affected regions
    • Auscultated: crackles that might disappear with deep breaths
  43. Chest Examinations: Pulmonary Edema
    • Inspection: Tachypnea, labored respirations, cyanosis
    • Palpation: Decreased movement or  normal
    • Percussion: Dull or normal depending on amount of fluid
    • Auscultated: Fine or coarse crackles at bases.
  44. Pleural Effusion
    • Inspection: Tachypnea, use of accessory muscles
    • Palpation: Increaed fremitus above effusion
    • Percussion: Dull
    • Auscultated: Diminished or absent over effusion, egophony over effusion.
  45. Hemoglobin:
    • Reflect amt of hemoglobin avaliavle for combination with oxygen. Venous blood used.
    • Male:13.2-17.3 g/dL
  46. Hematocrit:
    • reflects ratio of red blood cells to plasma. Increased hematocrit (polycythemia) found in chronic hypoxemia. Venous blood used.
    • Male: 39-50% and F: 35-47%
  47. Arterial Blood Gases (ABGs):
    Arterial blood is obrained through radial/femoral artery puncture or through arterial cath. Performed to assess acid-base balance, ventilation status, need for oxygen therapy, change in oxygen therapy, or change in ventilator settings. continous ABG monitoring is also possible via a sensor or electrode inserted into arterial cath.

    Nursing Responsibility: Inidicate whether patient uses Oxygen, Avoid change in Oxygen therapy or interventions (suctioning/position change) for 20 min before obtaining sample. Assist with position, collect blood in heparinized syringe. To ensure accurate results, expel all air bubble and place sample in ice, unless it will be analyzed in less than one minute. Apply pressure to artery for at least 5 minutes after specimen is obtained to prevent hematoma at the arterial puncture site.
  48. Oxygen Monitoring:Oximetry:
    Monitors arterial or venous Oxygen saturation. Probe attaches to finger, toe, earlobe, bridge of nose for SpO2 monitoring or is contained in a pulmonary artery catheter for SvO2 monitoring. Oximetry is used for intermittent or continous monitoring and exercise testing.

    • Nursing responsibility: Apply probe. When interpreting spO2 and SvO2 values, first assess patient status and presence of factors than can alter accuracy of pulse oximeter reading.
    • For SpO2 these include motion, low perfusion, cold extremities, bright lights, acrylic nails, dark skin color, carbon monoxide and anemia.
    • For SvO2: these include change in oxygen delivery or oxygen consumption.
  49. End-Tidal CO2 (PETCO2 or Capnography):
    Assesses the level of Carbon dioxide in exhaled air. Graphically displays partial pressure of Carbon dioxide.

    • Capnography: Expired gasses are sampled from patient airway and are analyzed by a CO2 Sensor that uses infrared light to measure exhaled CO2, sensor attached to an adaptor on endotracheal or tracheostomy tube. A nasal cannula with a sidestream capnometer can be used in patients without an artificial airway. Can be used as a diagnostic measure to detect lung disease and for monitoring patients.

    Normal difference between PaCO2 and PETCO2 is 2-5 mmHg (PaCO2:35-45 mmHg while PETCO2: 37-50 mm Hg)

    • Nurse Responsibility:
    Teach patient and caregiver about the purpose of Capnography monitoring, emphasizing the benefit of continuous monitoring. Make sure that sensor is properly attached. Record and document data per intuition policy.
  50. Sputum studies:
    obtained by expectoration, tracheal suction or bronchoscopy or “Sputum induction”: collected by inhalation of an irritating aerosol (hypertonic saline) when patient can't expectorate spontaneously Observe sputum for color, blood, volume and viscosity.

    Includes: Culture/Sensitivity, Gram Stain, Acid-Fast Smear/Culture, Cytology
  51. Culture & Sensitivity:
    Purpose is to diagnose bacterial infection, slect antibiotic and evaluate treatment. Sputum specimen is collected in a sterile container. Takes 48-72 hours for results. Nurse resp: Intruct pt on how to produce a good specimen, if pt cannot produce specimen, bronchoscopy may be used.
  52. Gram Stain:
    Staining of sputum permits classification of bacteria into gram negative and gram positive type. Results guide therapy until culture and sensitivity results are obtained. Nurse resp: Instruct pt. to expectorate sputum into container after coughing deeply. Obtain sputum, not saliva. Obtain specimen in AM after mouth care, try increasing oral fluid intake unless if unsuccessful. Collect sputum in sterile container during suctioning or by aspirating secretions from trachea. Send to lab immediately.
  53. Acid-Fat smear & Culture:
    Assesses sputum for acid-fast bacilli (Mycobacterium Tuberculosis). A series of three early morning speciments is used. Nurse Resp: Instruct patient how to produce a good specimen. Cover specimen and send to lab for analysis.
  54. Cytology:
    Determines presence of abnormal cells that may indicate malignant condition. Single sputum specimen is collected in special container with fixative solution. Nursing Resp: Instruct patient on how to produce a good specimen, use bronchoscopy if they can’t. Send to lab immediately.
  55. Chest x Ray:
    • Used to screen, diagnose and evaluate changes in resp system, most common view: anterioposterior (AP) and lateral.
    • NP: instruct pt. to undress to waist and put on gown and remove any metal b/w neck and waist.
  56. Computed Tomography (CT):
    Performed for diagnosis of lesions difficult to assess (mediastinum, hilum, pleura) by conventional xray studies. Common types are helical or spiral CT (contrast medium use) and high resolution CT scan (contrast medium not used). Spiral CT used to diagnos a pulmonary embolism.

    NP: Contrast medium may b e given through IV. Evaluation of BUN and serum creatinine is done before to assess renal function. Assess if pt. is allergic to shellfish (iodine). Make sure Patient is hydrated. Warn pt. contrast dye gives a feeling of being warm and flushed. Instruct pt. that he will need to lie still on a hard table and the scanner will revolve around the body with clicking noises.
  57. Magnetic Resonance Imaging (MRI):
    Used for diagnosis of lesions difficult to assess by CT scan (lung apex) and for distinguishing vascular from non vascular structures.

    NP: Same as for chest xray and CT scan, except contrast medium is NOT idodine based. Caution of claustrophobia. Pt. must remove all metal before test. Pt. with pacemakers and implantable cardioverter defibrillators CANNOT have an MRI done!!
  58. Ventilation-Perfusion Scan (V/Q):
    Used to assess ventilation and perfusion of lungs. IV radioisotope given to assess perfusion. For the ventilation portion, the patient inhales a radioactive gas (xenon or krypton) which outlines the alveoli. Normal scans show homogenous radioactivity. Diminished or absent radioactivity suggesrts lack of perfusion or airflow. Ventilation w/o perfusion suggest a pulmonary embolus.

    NP: Same as for chest xray. No precautions needed afterward b/c gass and isotope transmit radioactivity for only a brief interval.
  59. Pulmonary Angiogram:
    Used to visualize pulmonary vasculature and locate obstruction or pathologic conditions (pulm embolus).  Contrast medium injected thru cath threaded into pulm artery or right side of the heart. Series of x rays are taken after contrast medium is injected into pulm artery. Chest CT is replacing angiography, since it is less invasive.

    NP: Same as for X ray, same CT scan contrast media precautions, check pressure dressing site after procedure, monitor blood pressure, pulse, and circulation distal to injection site. Report significant changes.
  60. Positron Emission Tomography (PET) scan:
    Used to distinguish benign and malignant pul nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan, which uses IV radioactive glucose prpep can demonstrate increased uptake of glucose in malignant lung cells.

    • NP:
    • Preprocedure: Check blood glucose levels as high levels may interefere with test. Food and fluids other than water may be restricted for 4-6 hrs.
    • Post: Encourage fluids to excrete radioactive substances.
  61. Bronchoscopy:
    Flexible fiber optic scope is used for diagnosis, bipsy, specimen collection or assessment of changes. It may also be done to suction mucous plugs, lavage the lungs or remove foreign objects.

    NP: Tell pt. to be NPO for 6-12 hours BEFORE test, obtain signed prmit. Give sedative if ordered. After procedure, keep pt. NPO until gag reflex returns. Monitor for recovery from sedation. Blood tinged mucus is not abnormal. If biopsy was done, monitor for hemorrhage and pneumothorax.
  62. Mediastinoscopy:
    Scope is inserted through a small incision in the suprasternal notch and advanced into the mediastinum to inspect and biopsy lymph nodes. Used to diagnose lung cancer, non Hodgkin’s, lymphoma, granulomatous infections and sarcoidosis.

    NP: Prep pt. for surgical intervention; obtain signed informed consent, performed in the operating room using a general anesthetic. Afterward, monitor as for bronchoscopy.
  63. Exercise Testing:
    Used to diagnose exercise capacity. Complet test Involves walking on treadmill while expired oxygen and Carb Dioxide, resp rate, HR., and Heart rhytm are monitored. In a modified test (desat test) only SpO2 monitored.

    o 6 Min Walk Test: used to measure functional capacity and response to treatment in pt. with heart  or lung disease. Pulse ox is usually monitored. Distance walked is measured and used to monitor progression.
  64. Lung Biopsy:

     Purpose:

     May be done by:
    1. Transbronchially:
    2. Percutaneously or via transthoracic needle aspiration (TTNS
    3. Video assisted thoracic surgery (VATS):
    4. As an open lung biopsy:
    •  Purpose: obtain tissues, cells or secretions for evaluation.
    • 1. Transbronchially: passing forceps or needle through bronchoscope for specimen-cultured or examined for malignant cells. BAL can be combined to differentiate infection and rejection in lung transplant recipiens.

    • 2. Percutaneously or via transthoracic needle aspiration (TTNS): inserting a needle through the chest wall, usually under computed tomography (CT) guidance. This causes a risk of pneumothorax.
    • NResp: Check breath sounds every 4 hrs for 24 hrs and report any resp distress. Check incision site for bleeding. Chest xray should be done after TTNA or transbronchial biopsy to check for pneumothorax.

    • 3. Video assisted thoracic surgery (VATS): rigid scope with lens is passed through a trocar placed into the pleura via one/two small incisions in the intercostal muscles. The physician views the lesions on a monitor directly via the lens so that biopsy specimens can be taken. Chest tube kept until the lungs Expands. Biopsy any lesions.
    • NResp: chest tube may be in postprocedure until lung reexpands. Monitor breath sounds to follow chest chest reexpansion, Encourage deep breathing for lung reinflation, obtain signed informed consent for all procedures.

    4. As an open lung biopsy: when pulmonary disease cannot be diagnosed by other procedures, the pt is anesthetized. Chest is opened with a thoracotomy incision and a biopsy specimen is obtained
  65. Thoracentesis
     The insertion of a large bore needle though the chest wall into the pleural space to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space.

     Position patient sitting upright with elbows on an overbed table and feet supported. The skin is cleaned and local anesthetic (lidocaine) instilled subcutaneously. Chest tube may be inserted to permit further drainage of fluid. Chest exray always obtained after procedure to check for pneumothorax.

     NResp: Explain procedure to pt. and obtain signed informed consent before procedure, high is usually performed in the patient’s room. Position pt. upright with elbows on an oberbed table and feet supported. Instruct pt. not to talk or cough, assist during procedure. Observe fro signs of hypoxia and pneumothorax, and verify breat sounds in all fields after procedure. Encourage deep breaths to expands lungs. Send spec to lab.
  66. Pulmonary Function Tests:
    used to measure lung function. Involves us of spirometer to assess air movment. measure lung volumes and airflow, results are used to diagnose pulmonary disease, monitor disease progression, evaluate disability and assess response to bronchodilators.

    •  Spirometer: airflow measurmetn, pt insperts a mouthpierce, takes a deep breath as possible and exhales as hard, fast and long as possible. May be ordered before/after administration of bronchodilator to determine patient’s response, oand coument reversibility of airway obstruction. Greater than 200 mL increase or great than 12 % increase b/w pre and post administration values is POSITIVE!!
    •  Home spirometry: monitors lung fn for asthma, cystic fibrosis or COPD. Spirometry changes at home may warn of early lung transplant rejection or infection.
    •  Nurse Resp: Avoid scheduling immediately ater mealtime. Avoid administration of inhaled bronchodilator 6 hours before procedure. Assess for respiratory distress and report. Provide rest post op.
  67. Skin tests:  
    Nursing responsibilities
    Performed to test for allergic reactions or TB Bacilli/fungi exposure. Inovlve intradermal injection. Positive result on TB skin test: patient has ben exposed to antigen NOT THAT TB IS PRESENT! Negative TB result: no exposure or a depression of cell mediated immunity that occurs in HIV infections.

    •  Nursing responsibilities for all skin tests:
    • 1. To prevent false negative reaction make sure inection is intradermal and NOT subcuatenous.
    • 2. After injection, circle site and instruct pt not to remove mark
    • 3. Charting: draw diagram of forearm and label injection sites.
    • 4. Reading: use good light. Use pen to mark peripheral of aninduration if present and measure diameter in mm (don’t measure reddened flat areas)
  68. Endoscopic Examinations Bronchoscopy:
    A bronchoscopy is a procedure in which the bronchi are visualized through a fiber optic scope.

    • 1. Used for:
    •  Can be used to obtain biopsy specimen and assess results of treatment.
    • BAL (Bronchoalveolar Lavage): 30 mL of Saline may be injected and withdrawn to examine cells
    •  Treatments such a s removing mucous plugs/foreign bodies

    2. Procedure: Anesthetize the nasopharynx and oropharynx, coat bronchoscope with lidocaine and insert through nose and into airways. Can be done no mechanically ventilated pts.
  69. RESPIRATORY MANAGEMENT Nursing Diagnoses:
    Impaired gas exchanged r/t alveolar hypoventilation, Ineffective airway clearance r/t excessive secretions, Ineffective breathing pattern r/t neuromuscular impairment of respirations, and bronchospasm
  70. Acute Resp Failure: PLANNING & PREVENTION

    Overall Goals for patient with acute respiratory failure:

    • 1. Normal ABG values/baseline
    • 2. Normal breath sounds
    • 3. No dyspnea or weird breathing patterns
    • 4. Independent maintenance of the airway
    • 5. Effective cough and ability to clear secretions.

    Prevention: Involves thourough history and physical assessment to identify the pt. at risk for resp failure than then initiation of appropraiate nursing interventions: teaching pt. about deep breathing and coughing, use of incentive spirometry, and ambulation. Prevention of atlectatsis, pneumonia and complications of immobility as well as hydration and nutrition.
  71. Respiratory Therapy: The major goals of care include ?
    maintain adequate oxygen and ventilation.  

    Interventions: O2 therapy, mobilization of secretions and positive pressure ventilation (PPV)
  72. Oxygen Therapy:
    • Goal is to correct HYPOxemia.
    • • If oxygen therapy is seconday to V/Q mismatch, supplemental oxygen administered at 1-3 L/min by nasal cannula or 24-32% by venture mask
    • • Hypoxemia secondary to intrapulmonary shunt: requires PPV to provide oxygen therapy and humidiciation, decreases WOB and reduces respiratory muscle fatigue. PPV assists in opening airway and decreasing shunt. PPV is provided via an endotracheal tubee or mask.
    • • The selected O2 Delivery system must also maintain Pa O2 at 55 to 60 mmHg higher and SaO2 at 90% or highter at the lowerst O2 concentration possible.
    • • High O2 concentrations replace the nitrogen gas normally present in the alveoli-->causing instability and atelectasis.
    • • Intubated pts: FIO2 for longer than 48 hrs-> significant risk for oxygen toxicity.
    • • Prolong Oxygen exposure include: increased pulmonary capillary permeability, decreased surfactant production and surfactant inactivationand fibrotic changes in the alveoli. • Hypercapnia pt. risks (COPD): Hypercapnia blunts the response o chemoreceptors in the medulla to elevated CO2 levels as a respiratory stimulant. Hypoxia will stimulate respirations. Therefore use a low flow device such as nasal cannula at 1-2 L per minute or venture mask at 24% and monitor
    • • Closely monitor mental status, respiratory rate, and ABG results until their PaO2 level has reached their baseline normal value.
  73. Mobilizing Secretions:  
    -Effective coughing Types
    • Retained pulmonary secretions may cause acute resp failure b/c movement of oxygen into the alveoli and removal of CO2 are blocked. Secretions can be monilized through effective coughing, adequate hydration, humidication, chest physiotherapy, airway suctioning and ambulation.

    • • Effective Coughing:
    •  Augmented Coughing: place one or both hands on anterlateralbase of lungs, as the patient ends respiration and begins exration, move your hands forcfully upward, increasing abdominal pressure and facilitating the cough. This measure helps increase expiratory flow and thereby facilitates secretion clearance. Helps for neuromuscular weakness from exhaustion/disease and can’t generate enough airwaiy pressures.
    •  Huff Coughing: series of coughs while saying the word “huff” This technique prevents the glottis from closing during the cough. Patient’s with COPD generate higher flow rates with a hugh cough than is possible with normal couch. Effective in clearing only central airways but it may assist in moving secretions upwards.
    •  Staged cough: assist in mobilizing secretions. Pt. assumes sitting position, breathes three or four times and out through mouth and coughs while bending forward and pressing a pillow inward against the diagphragm.

     Position pt. upright or 45 degree angle, maximize thoracic expansion to decrease dyspnea and improve secretion mobilization. Assists in venous pooling in dependent body areas. Upright lungs: ventilation and perfusion are best in the lung bases.

     Lateral position may be used in pt With disease involving only one lung, “ good lung down”: allows for improved V/Q matching in the affected lung. Pulm blood flow and ventilation are optimal in dependent lung areas, slows secretions to drain out of affected lung for suctioning. Side lying also good for pts whose tongue is aspiration risk.
  74. • Hydration/Humidifcation:
     Adequate fluid intake (2-3 L day) keeps secretions thin and easier to remove, IV hydration (if cardiac/renal status is okay) Regularly assess for fluid overload (crackles, dyspnea) and invasive monitoring (increased Central Venous Pressure)

    •  Aerosols of sterile normal saline, using nebulizer, to liquiefy secretions. Therapy may INDUCE bronchospasm and severe couching that decreases PaO2. Mucolytic agents such as benulized acetycysteine (Mucomyst) mixed with a broncho dilator may be used to htin secretios.
    • Side effect of these drugs is bronchospasms.

    • • Chest Physiotherpy: indicated in pts with more than 30 ml of sputum per day or evidence of severe atelectasis.
    • • Airway suctioning: aka blind suctioning without a tracheal tube. Mini tracheostomy is used to suction pts who have difficulty mobilizing secretions and when blind suctioning is ineffective.
  75. Positive Pressure Ventilation:
    PPV may be provided invasively through intubation or noninvasively through a nasal/face mask.

    -NIPPV (Noninvasive positive pressure ventilation) is used for patients with acute or chronic respiratory failure. Possible to decrease WOB without intubation

    -BiPAP (Bilevel posiive airway pressure is a form of NIPPV in which different pressure levels are set for inspiration and expiration.

    -CPAP: continuous positive airway pressure is another form of NIPPV in which a constant positive pressure is delivered to the airway during inspiration and expiration; used in patient’s with hypoxemic respiratory failure (ARDS, cardiogenic pulmonary edema). Not appropriate for pts with excessive secretions, decreased O2 requirements, facial trauma or hemodynamic instability.
  76. ARD Drug Therapy:
     Goals:
    • 1. Relief of bronchospasm
    • 2. Reduction of airway inflammation and pulmonary congestion
    • 3. Treatment of pulmonary infection
    • 4. Reduction of severe pain, anixiety and restlessness
  77.  Relief of Bronhospasm:
    shortcuting bronchodilators (albuterol, metaproerenol) although side effects: tachycardia. Prlonged use: increases risk of dysrhythmias and cardiac ischemia. Monitor ECGs. Bronchodilator effects can sometimes worsen hypoxemia by redistributed the inspired gas to areas of decreased perfusion. To avoid this, administer the brochodilater with an oxygen enriched gas mixture.
  78.  Reduction of Airway Inflammation:
    Corticosteroids for inflammation(solu-medrol/methylpernisolone) in conjuction with broncodilation agents
  79. . Reduction of Pulmonary Congestion:
    • Pulm interstitial fluid can accumulate b/c of direct or indirect injury to the alveolar capilalary membrane (ARDs) or from heart failure. The result is decrease alveolar ventilation and hypoxemia. IV diuretics (furosemide, morphine and nitroglycerin) are used to decrease pulm congestion caused by heart failure.
    • 1. If A Fib: calcium channel blockers (diltiazem and Beta adrenergic blockers (metroprolol) are used to decrease heart rate and improve CO.
  80.  Treatment of pulmonary infections & Reduction of Anxiety
    Pulm infections result in ecessive mucus production, fever, incrased oxygen consumption and inflamed fluid filled or collapsed alveoli. IV antibiotics (azithromycin or ceftriaxone) are often given to treat infections.

     Reduction of severe anxiety, pain, and agitation: axiety result from hypoxia, fear caused by the inability to breathe and a sense of loss of control. Sedation using propofol, opoids are used to decrease anxiety. Benzodiazepines (lorazepam/Ativan).
Card Set
Mod 6 Respiratory