NP2 Respiratory

Primary functions of the respiratory system:
– Provides oxygen for metabolism in the tissues
– Removes carbon dioxide, the waste product of metabolism.
Secondary functions of the respiratory system
– Facilitates sense of smell
– Produces speech
– Maintains acid-base balance
– Maintains body water levels
– Maintains heat balance
Upper Respiratory airway includes:
Nose, Sinuses, Pharynx, Larynx, epiglottis,
Nose:
Humidifies, warms and filters inspired air
Sinuses
Air-filled cavities within the hollow bones that surround the nasal passages and provide resonance during speech.
Phayrnx
– Passageway for the respiratory and nasal cavities
– divided into the nasopharynx, oropharynx, and laryngopharynx.
Larynx
– located just below the pharynx at the root of the tongue; commonly called the voice box
– Contains two pairs of vocal cords, the false and true cords.
– The opening between the true vocal cords is the glottis.
– The glottis plays an important role in coughing, which is th emost fundamental defense mechanism of the lungs.
Epiglottis
– Leaf-shaped elastic flap structure at the top of the larynx.
Lower respiratory airway:
Trachea, Mainstem bronchi, Bronchioles, Alveolar ducts and alveoli, Lungs, Accessory muscles and the respiratory process.
Trachea:
located in front of the esophagus; branches into the right and left main stem bronchi at the carina
Mainstem bronchi
– Begins at the carina
– The right bronchus is slightly wider, shorter and more vertical than the left bronchus.
– The main stem bronchi divide into secondary or lobar bronchi that enter each of the five lobes of the lung.
– Bronchi are lined with cilia, which propel mucus up and away form the lower airway to the trachea, where it can be expectorated or swallowed.
Bronchioles
– Branch form the secondary bronchi and subdivide in to the small terminal and respiratory bronchioles.
– The bronchioles contain no cartilage and depend on the elastic recoil of the lung for latency.
– There terminal bronchioles congaing no cilia and do not participate in gas exchange .
Aveolar ducts and alveoli
– Acinus (plural, acini) is a term used to indicate all structures distal to the terminal bronchiole.
– Alveolar ducts branch from the respiratory bronchioles
– Alveolar sacs, which arise form the ducts contain cluster of alveoli, which are the basic units of gas exchange
– Type II alveolar cells in the walls of the alveoli secrete surfactant, a phospholipid protein that reduces the surface tension in the alveoli; without surfactant, the alveoli would collapse.
Lungs:
– Located in the plural cavity in the thorax
– Extend form just above the clavicles to the diaphragm, the major muscle of inspiration.
– The left lung, which is narrower than the right lung to accommodate the heart is divided into two lobes.
– The respiratory structures are innervated by the phrenic nerve, the vagus nerve, and the thoracic nerves.
– The parietal pleura lines the inside of the thoracic cavity, including the upper surface of the diaphragm.
– The visceral pleura covers the pulmonary surfaces.
– A thing fluid layer, which is produced by the cells lining the pleura, lubricated stye visceral pleura and the parietal pleura, allowing them to glide smoothly and painlessly during respiration.
– Blood flows throughout the lungs via the pulmonary circulation system.
Accessory muscles of respiration:
include the scalene muscles, which elevate the first two ribs; the sternocleidomastoid muscles, which raise the sternum; and trapezius and pectorals muscles, which fix the shoulders.
The respiratory process:
– The diaphragm descends into the abdominal cavity during inspiration, causing negative pressure in the lungs.
– The negative pressure draws air from the aria of greater pressure, the atmosphere, into the area of lesser pressure, the lungs.
– In the lungs, air passes through the terminal bronchioles into the alveoli to oxygenate the body tissues.
– At the end of inspiration, the diaphragm and intercostal muscles relax the lungs recoil.
– As the lungs recoil, pressure within the lungs becomes higher than atmospheric pressure, causing the air, which now contains the cellular waste products carbon dioxide and water, to move form the alveoli in the lungs to the atmosphere.
– Effective gas exchange depends on distribution of gas (ventilation) and blood (perfusion) in all portions of the lungs.
Risk factors for respiratory disorders
– Allergies
– Chest injury
– Crowded living conditions
– Exposure to chemicals and environmental pollutants
– Family history of infectious disease
– Frequent respiratory illnesses
– Geographic residence and travel to foreign countries
– Smoking
– Surgery
– Use of chewing tobaccos
– Viral syndromes
Chest X-Ray film:
Provides information regarding the anatomical location and appearance of the lungs
**Women regarding pregnancy or the possibility of pregnancy before performing radiography studies. **
Pre-procedure:
– Remove all jewelry and other metal objects form the chest area. j
– Assess the client’s ability to inhale and hold his or her breath.
Postprocedure:
– Help the client get dressed.
Sputum Specimen:
Specimen obtained by expectoration or tracheal suctioning to assist in the identification of organisms or abnormal cells
Pre-procedure:
– Determine specific purpose of collection and check with institutional policy for appropriate method for collection of a specimen.
– Obtain an early morning sterol specimens by suctioning or expectoration after a respiratory treatment if a treatment tis prescribed.
– Instruct the client to rinse the mouth with water before collection.
– Obtain 15mL of sputum.
– Instruct the client tot take several deep breaths and then cough deeply to obtain sputum.
– Always collect the specimens before the client begins antibiotic therapy.
Postprocedure:
– If a culture of sputum is prescribed, transport the specimen to the laboratory immediately.
– Assist the client with mouth care.
Laryngoscopy and bronchoscopy
Direct visual examination of the larynx, trachea, and bronchi with a fiberoptic bronchoscope.
Pre-procedure
– Obtain informed consent
– Maintain NPO status for the client from midnight before the procedure.
– Obtain vital signs
– Assess the results of coagulation studies.
– Remove dentures and eyeglasses
– Prepare suction equipment.
– Establish an intravenous (IV) access as necessary and administer medication for sedation as prescribed.
– Have emergency resuscitation equipment readily available.
Postprocedure:
– Monitor vital signs
– Maintain the client in a semi-Fowler’s position.
– Assess for the return of the gag reflex
– Maintain NPO status until the gag reflex returns
– Have an emesis basin readily available for the client to expectorate sputum.
– Monitor for bloody sputum.
– Monitor respiratory status, particularly if sedation has been administered.
– Monitor for complications, such as bronchospasm or bronchial perforation, indicated by facial or neck crepitus, dysrhythmias, hemorrhage, hypoxemia, and pneumothroax.
– Notify the health acre provider if fever, difficulty in breathing, other signs of complications occur following the procedure.
Endobronchial ultrasound (EBUS)
– Tissue samples are obtained form the central lung masses and lymph nodes, using a bronchoscope with the help of ultrasound guidance.
– Minimally invasive procedure performed on an outpatient basis.
– Tissue samples are used for diagnosing and staging lung cancer, detecting infections, and identifying inflammatory diseases that affect the lungs, such as sarcoidosis.
Post procedure, the client is monitored for signs of bleeding and respiratory distress.
Pulmonary angiography
An invasive fluoroscopic procedur in which a catheter i inserted through the antecubital or femoral vein int eh pulmonary artery or font exits branches.
Involves an injection of iodine or radiopaque contrast material.
Pre-procedure:
– Obtain informed consent.
– Assess for allergies to iodine, seafood, or out radiopaque dyes.
– Maintain NPO status of th client for 8 hours before the procedure.
– Monitor vital signs.
– Assess results of coagulation studies
– Establish an intravenous access.
– Administer sedation as prescribed
– Instruct the client to lie still during the procedure.
– Instruct the client that he or she may feel an salty taste following g injection of the dye.
– Have emergency resuscitation equipment available.
Post-procedure:
– Monitor vital signs
– Avoid taking blood pressures for 24 hours in the extremity used for the injection
– Monitor peripheral neuromuscular status of the affected extremity
– Assess insertion site for bleeding.
– Monitor for delayed reaction to the dye.
Thoracentesis
Removal of fluid or air form the pleural space via transthoracic aspiration
Pre-procedure:
– Obtain informed consent
– Obtain vital signs
– Prepare the client for ultrasound or chest radiograph, if prescribed, before procedure
– Assess results of coagulation studies
– Not that the client is positioned sitting upright with a the arm and shoulder supported by a table the bedside during the procedure
– If the client cannot sit up, the client is placed lying in bed toward the unaffected side, with that head of the bed elevated.
– Instruct the client not to cough, breathe deeply, or move during the procedure.
Post-procedure:
– Monitor vital signs
– Monitor respiratory status.
– Apply a pressure dressing, and assess the puncture site for bleeding and crepitus.
– Monitor for signs of pneumothroax, air embolism, and pulmonary edema.
Pulmonary function test
Test used to evaluate lung mechanics, gas exchange, and acid base disturbance through spirometric measurements, lung volumes and arterial blood gas levels.
Pre-procedure:
– Determine whether an analgesic that may depress the respiratory function is being administered.
– Consult with the HCP regarding withholding bronchodilators before testing.
– Instruct the client to void before the procedure and to war loose clothing.
– Remove dentures.
– Instruct the client to refrain form smoking or eating a heavy meal for 4 to 6 hours before the test.
Post-procedure:
Client may resume a normal diet and any bronchodilators an respiratory treatment that were withheld before the procedure.
Lung biopsy
A transbronchial biopsy and a transbronchial needle aspiration may be performed to obtain tissue for analysis by culture or cytological examination.
An open lung biopsy is performed in the operating room.
Pre-procedure:
– Obtain informed consent.
– Maintain NPO status of the client before the procedure.
– Inform the client that a local anesthetic will be used for a needle biopsy but a sensation of pressure during needle insertion and aspiration may be felt .
– Administer analgesics and sedative as prescribed.
Post-procedure:
– Monitor vital signs
– Apply a dressing to the biopsy site and monitor for drainage or needing.
– Monitor for signs of respiratory distress, and notify the HCP if they occur.
– Monitor for signs of pneumothorax and air emboli, and notify the HCP if they occur
– Prepare the client for chest radiography if prescribed.
Ventilation-perfusion lung scan
The perfusion scan evaluated blood flow to the lungs.
The ventilation scan determines the latency of the pulmonary airways and detects abnormalities in ventilation.
A radionuclide may be injected for the procedure.
Pre-procedure:
– Obtain informed consent
– Assess the client for allergies to dye, iodine or seafood.
– Remove jewelry around the chest area.
– Review breathing methods that may be required during testing
– Establish an intravenous access.
Administer sedation if prescribed.
– Have emergency resuscitation equipment available.
Postprocedure:
– Monitor the client for reaction to the radionuclide.
– Instruct the client that the radionuclide clears from the body in about 8 hours.
Skin test
Uses an intradermal injection to help diagnose various infectious diseases.
Two – step testing recommends for health care workers getting repeated testing and those with decreased response to allergens
Response decrease in immunocompromised patients
– Reactions: induration greater than or equal to 5mm considered positive.
Arterial blood gases (ABGs)
Measurement of the dissolved oxygen and carbon dioxide in the arterial blood helps indicated the acid-base state and how well oxygen is being carried to the body.
Preprocedure and postprocedure care and analysis of result refer to Ch. 10
Pulse oximetry
is a noninvasive test that rester the oxygen saturation of the client’s hemoglobin.
– The capillary oxygen saturation is recorded as a percentage.
– The normal value is 96% to 100%
– After a hypoxic client uses up the readily available oxygen (measured as the arterial reserve oxygen, that oxygen attached to the hemoglobin, is drawn on to provide oxygen to the tissues.
– A pulse oximeter reading can alert the nurse to hypoxemia before clinical signs occur.
Procedure:
– A sensor is placed on the client’s finger, toe, nose, ear lobe, or forehead to measure oxygen saturation, which then is displayed on a monitor.
– Maintain the transducer at hear level
– Do not select an extremity with an impediment to blood flow.
**A pulse oximetry reading lower than 91% necessitates HCP notification; if the reading is lower than 85%, oxygenation to body tissues is compromised, and a reading lower than 70% is life-threatening Agency procedures and health care provider prescriptions are followed regarding actions to take for specific readings.
Types of Oxygen
– Nasal Cannula
– Venti-mask
– 100% non-rebreather mask
– Face mask
– Face tent
– Tracheotomy
– Ventilator
Why Asthma makes it hard to breath:
Air enters the respiratory system form the nose and mouth and travels through the bronchial tubes.
– In an asthmatic person, the muscle of the bronchial tubes tighten and thicken and the air passages become inflamed and mucus filled, making it difficult of the air to move.
Classification of Asthma:
step 1: Mild intermittent
Step 2: Mild persistent
Step 3: Moderate persistent
Step 4: Severe persistent
Step 1: mild intermittent
Symptoms less than or equal to 2 times a week
Asymptomatic and normal PEFR between exacerbations
Exacerbations brief (hours to days)
Intensity of execrations varies
Night time symptoms:
less than or equal to 2 times a month
Step 2: Mild persistent
Symptoms greater than times a week but less than 1 times a day
Exacerbations may affect activity
Nighttime symptoms
Greater than 2 time a month
Step 3: Moderate persistent
Daily Symptoms
Daily use of inhaled short-acting B2 agonist Exacerbations affect activity
Exacerbations at least 2 times wk and may last for days.
Step 4: Sever persistent
Continual symptoms
Limited physical activity
Frequent exacerbations
Asthma symptoms
Dyspnea
Expiratory wheezing **may not have**
Hacking nonproductive cough
Chest tightness
Restlessness
Tachypnea
Goals of Asthma treatment
– Maintain control of symptoms with the least amount of medication
– Reducing both impairment form the disease and risk form adverse effects of medication
– Maintenance of normal activities
– Infrequent need for rescue inhalers
Medical Management of Asthma:
– Avoid the cause of triggers
– compliance to allergy drug regime
– Medications
– Exercise program
– Allergy proof environment
– Patient and Family Education
Long-Term Control for Asthma
Anti-inflammatory Drugs:
Corticosteroids (inhaled or Oral) Advair
Cromolyn (Intal and nedocromil (Tilade)
Leukotriene modifiers Singulair
Omalizumab (Xolair)

Bronchodilators:
Long-acting inhaled B2-adrenergic agonists
Long-acting oral B2-adrenergic agonist
Theophyline

Quick-Relief Medications
Bronchodilators:
Short-acting inhaled B2-adrenergic agonist Zopenex, albuterol
Anticholinergic a (inhaled) Atrovent

Anti-inflammatory Drugs:
Corticosteroids (systemic)* Prednisone, medrol, solumedrol

Chronic Bronchitis
Characterized by inflammation of the bronchi and bronchioles, fused by an irritant
– Chronci bronchitis hinders airflow and gas exchange (chronic cough greater than 2 years)
– inflamed airways produce copious amounts of mucous, resulting in a chronic productive cough. Chronic inflammation and obstruction of air passages with mucous.
Cough and sputum production are persistent and significant. Dyspnea and carbon dioxide retention appear late in the course of the disease.
Symptoms of Chronic Bronchitis
– Productive cough
– Dyspnea and wheezes
– Cyanosis
– Use of accessory muscles to breathe
– Pulmonary hypertension
– Well-nourished or obese
Symptoms of emphysema
Anorexia
Fatigue
Tripod seating
Pursed lip breathing
Barrel chest
Polycythmeia
Dyspnea
Prolonged expiratory phase
Cough (with infection only usually)
Pink or ruddy complexion (pink puffer)
Emphysema
Characterized by abnormal permanent enlargement of gas exchange airways (acini)
– Destruction of air sacs (alveoli)
– Can be due to deficiency of alpha 1- antitrypsin
– Causes lungs to lose elasticity
– Characterized by inability to exhale
– Gradual onset
Medical Management of Emphysema:
– Avoid smoking or stop smoking
– Bronchodilators
– Mucolytics
– Antibiotics
– Immunizations for pneumonia and flu
– Hydration
– Chest physiotherapy
– Oxygen therapy
– Lung volume reduction surgery
– Corticosteroids
– Cough suppressants
– Activity management
– Nutritional support
– Gold initiative
Tuberculosis
– Highly communicable disease
Mycobacterium tuberculosis
– Transmitted via aerosolization (airborne route)
– Bacillus multiplies freely in bronchi and alveoli
– Since 1985, an increase in TB cases has occurred (and a resistant strain developed)
Risk factors for TB
– HIV/AIDS patients (impaired immune system)
– Elderly
– Increasing number of immigrants
– Increasing poverty/homeless
– Chronic diseases
– Racial or ethnic groups (American Indian)
– Medication non compliance (TB meds)
Classification of Tuberculosis (TB)
Class 0: No TB exposure
Class 1: TB exposure, no infection
Class 2: Latent TB infection, no disease
Class 3: TB clinically active
Class 4: TB, but no clinically active
Class 5: TB suspect
TB class 0
No TB exposure, not infected (no history of exposure, negative TB skin test
TB class 1
TB exposure, no evidence of infection (history of exposure, negative TB skin test
TB class 2
TB infection without disease (significant reaction to TB skin Test. negative bacteriologic studies, no x-ray finding compatible with TB no clinical evident of TB
TB class 3
TB infection with clinically active disease (positive bacteriologic studies or both a significant reaction to TB skin test and clinical or x-ray evidence of current disease)
TB class 4
No current disease (history of previous episode of TB or abnormal, stable s-ray ringing in a person with a significant reaction to TB skin test, negative bacteriologic studies if done; no clinical or x-ray evidence of current disease)
TB class 5
TB suspect (diagnosis pending) person should not be in this classification for more that 3 months.
TB diagnositc Test
– History of exposure
– Symptoms
– chest x-ray
– Sputum for acid fast bacillus (AFB)
– Mantoux Test (PPD injection)
– PCR assay
– QuantiFERON-TB (QFT)
Symptoms of TB
– Persistent cough
– Progressive fatigue
– Weight loss
– Night sweats
– Low grade fever
– Coughing up blood (hemoptysis)
– Anorexia
Medical Management of TB
Long term drug therapy
– Patient teaching g and compliance with drugs
– Negative airflow isolation room
– Duckbill mask or HEPA filter mask
– Social service consult
– Weekly sputum specimens at first then every 2-4 weeks.
Drug Therapy for TB
First Line:
isoniazid (INH)
rigamipin (Rifadin)
pyrazinamide (PZA)
ehabutol (Myambutol)
Peak flow meter:
Green Zone (80%-100%) of personal best) signals good control. Take the usual daily long-term control medicines. Keep taking those medicines even when in the yellow or red zones.
Yellow Zone: (50%-79%) of personal best) caution: asthmas is getting worse. Add quick -relief medicines
Red Zone: (below 50% of personal best ) signals medical alert! Add or increase quick-relief medicines, and call the doctor/ go to ER now.
Pulmonary fungal infections
– Seen typically in immunocompromised clients
– Most common Histoplasmosis, candidiasis, and pneumocystis pneumonia (PCP)
Diagnostic studies for Pulmonary fungal infections are;
– Sputum specimens
– skin testing
– Serology
– Biopsy
Signs and symptoms of Pulmonary fungal infections
Similar to pneumonia
– Malaise
– Respiratory symptoms: cough, crackles, fevers & chills, pleuritic chest pain
Similar to TB
– Night sweats, malaise, cough, fevers
Medical Management of Pulmonary fungal infections
Depends on type of the organism and symptoms
– One drug is Amphotericin B
– Must be given long term IV
– Many side effects: can be decreased w/ premeds
Anti-fungal antibiotic both PO and IV
All must have blood monitoring, labs and renal function testing.
Metered-Dose Inhaler (MDI)
Shake well
Inspiration: slow
Spacer: Yes at least with inhaled corticosteroids
No external device
Inhale 2 /dose
Cleaning: Use water for plastic case
Dry Powder Inhaler (DPI)
Do not shake
Inspiration: Rapid
No spacer permitted
Counting device: preloaded
Inhalations: Often 1 / dose
Cleaning: avoid moisture
Inhaler Patient teaching:
1. Hold inhaler 1 to 2 inches in front of your mouth (about the width of two finger)
2. Use a spacer or holding chamber. These come in many shapes
3. Put the inhaler in your mouth. Do not use for steroids
Nursing Interventions for Asthma
– Assess triggers
– Monitor peak flows and lung sounds
– Educate client on proper use of medications
– Administer oxygen and humidification per orders
– Place in high fowlers
– Increase fluid intake
– Encourage compliance to prophylactic medications
Chronic Obstructive Pulmonary Disease
Known as COPD
Includes the terms:
– Chronic bronchitis
– Chronic obstructive bronchitis
– Emphysema
Panlobualar and centrilobular
Complications of asthma
Status asthmaticus: life threatening complication of sever bronchospasms
– Can be fatal if not recognized and treated properly ( acute condition: NPIV)
Risk factors for COPD
– Cigarette smoking
– Second hand smoke
– Tobacco use in general
– Air pollution
– Occupational dust and chemicals
Mask/Cannula Teaching guide: Home oxygen use
– Ensure that the straps are not too tight
– Remove 2-3 times a day to wash and dry skin where straps touch the skin; massage skin
– Pad any pressure points
– Observe tops of ears for skin breakdown form pressure pints
Oral and nasal mucous membranes: Home Oxygen use
– Assess oral and nasal mucous membranes 2-3 times / day
– Use water based gel on lips and nasal mucosa
– Provide frequent oral hygiene
– Provide humidification vial humidifier or nebulizing device.
Decreasing Risk for infection: Home Oxygen Use
– Remove mask or collar and cleanse with water 2-3 times /day
– Cleanse skin carefully at this time and observe for cuts, scratches and bruises
– Change disposable equipment frequently
– Remove secretions that are coughed out
Decreasing Risk of Fire Injuries: Home Oxygen use
– Post “No smoking” warning signs in home where they can be seen
– Do not use electric razors, portable radios, open flames, wool blankets, or mineral lis in the area where oxygen is in use
– Do not allow smoking in the home.
Wheezes
are musical sounds that can be heard by the patient and the nurse. Indicates some degree of airway obstruct, such as asthma, foreign body aspiration, and emphysema. Wheezing is caused by bronchial constriction or secretions in the airway. Ex: Asthma, COPD…There is a narrowing of the airway.
Rhonchi
sounds like continuous rumbling, snoring, or rattling sounds from obstruction of large airways with secretions; most prominent on expiration; change often evident after coughing or suctioning. Caused by having secretions in the larger airways. Ex. COPD, cystic fibrosis, pneumonia, bronchiectasis
Crackles/Rales
Coarse Crackles-similar sound to blowing through straw under water; increase in bubbling quality with more fluid. Fine Crackles- similar sound to that made by rolling hair between fingers just behind ear. Caused by having secretions in the terminal bronchi or alveoli. Soft sound and hard to hear. Happens at the end of expiration. Usually bubbly or crackly sounding.
How would you estimate thoracic expansion?
Place your hands over the lower anterior chest wall along the costal margin and move them inward until the thumbs meet at midline. Ask the patient to breathe deeply. Observe the movement of the thumbs until they meet over the spine. Check expansion anteriorly or posteriorly, but it is not necessary to check both.
Bronchoscopy
a technique in which a flexible scope is inserted into the airways.
Instruct patient to be on NPO status for 6-12 hr before the test. Obtain signed permit. Sedative if ordered.
After procedure, keep patient NPO until gag reflex returns and monitor for laryngeal edema; monitor for recovery from sedatives. Blood-tinged mucus is not abnormal. If biopsy was done, monitor for hemorrhage and pneumothorax.
Chest X-Ray
Used to screen, diagnose, and evaluate change in respiratory system. Most common views are anterior-posterior (AP and lateral.
Instruct patient to undress to waist, put on gown, and remove any metal between neck and waist.
Auscultation
When you hear a sound early in the respiratory cycle. It is coming from the upper lobe. If you hear toward the end it is coming from the lower lobe or alveoli or bronchioles.
If the sounds are diminished. Listen to the trachea. It acts like a megaphone.
Wheezing
Caused by Bronchial constriction or secretions in airway. Ex. COPD, Asthma
– narrows the airways
is heard predominately on expiration.
– when the patient exhales you get an elastic recoil.
– meaning they get smaller
1st on expiration then on inspiration.
Meds
– Give them Bronchial-dilators to open the airway up and help move secretions.
Asthma
disease of the big airways
COPD
disease of small airways
– supplemental Oxygen
– have to be careful that the patient doesn’t stop breathing
– monitor rate and rhythm
Crackles or Rales
caused by having secretions in the terminal bronchi or alveoli
– soft sound and hard to hear
– happens at the end of expiration.
– Bubbly or crackly sound.
Pleural friction Rub
caused by having inflammation in the pleural space.
– Pleural space is the space between the chest wall and the lung.
– Stick stuff creates a noise
– Sounds dry like old leather
– symmetrical sounding.
– loudest over the chest wall
Monitoring respiratory patients
Respirator rate and rhythm
– – Pulse oximeter
– ABGs
– PO2 FO2
– Lab data
Respiratory Problems priority
1. must get a Blood gas
2. 12 Lead EKG
3. Pulse oxmeter: monitors and validates (if there is light from outside it will interfere with pulse ox.
PO2/FIO2
– Should be greater than 300
– Tells us about the alveolar capillary membrane and whether or not it is intakes.
– If fluid builds up in the alveolar capillary membrane the PO2/FIO2 goes down.
Magnetic resonance imaging (MRI)
Used for diagnosis of lesions difficult to assess by CT scan (lung apex) and for distinguishing vascular form nonvascular structures.
Same as for chest x-ray and CT scan, except contrast medium is not iodine based. If closed MRI used and patient has claustrophobia, provide with relaxation or other modes to cope. Patient must remove all metal jewelry, watch) before test. Patients with Pacemakers and implantable cardiverter-difrillaotrs cannot under go MRI.
CT of the chest with contrast
Used to visualize pulmonary vasculature and locate obstruction or pathologic conditions (pulmonary embolus). Contrast medium is injected through a catheter threaded into pulmonary artery or right side of the heart. Series of x-rays are taken after contrast medium is injected into pulmonary artery. Chest CT is replacing angiography as ti is less invasive.
Same as fro chest x-ray.
check pressure dressing site after procedure. Monitor blood pressure, pulse, and circulation distal to injection site. Report and record significant changes.
Can help detect cancer.
What is the purpose of a peak flow meter?
is the instrument used at home. It is a hand-held device through which one blows forcefully and quickly after taking a deep breath. It measures milliliters of volume. Spirometry changes at home can warn of early lung transplant rejection or infection. Feedback form a peak flow meter can increase the sense of control when a persons with asthma learn to modify activities and medications in response to changes in peak expiratory flow rates.
How to Use Your Peak flow meter
Five Steps:
1. Move the indicator to the bottom of the numbered scale.
2. Stand up.
3. Take a deep breath, filling lungs completely.
4. Place the mouthpiece in your mouth and close your lips around it. Do not put your tongue inside the hole
5. Blow out as hard and fast as you can in a single blow.
**Write down the number you get. But if you cough or make a mistake, do not write down the number. Do it over again.
**Repeats steps 1-5 two more times, and write down the best of the three blows in your asthma diary.
What is a flutter valve, and what purpose does it serve?
Used to evacuate air from the pleural space. This device consists of a one-way flutter valve within a rigid plastic tube. Its is attached to the external end of the chest tube. The valve opens whenever the pressure is greater than atmospheric pressure such as during expiration and closes when intrathoracic pressure is less than atmospheric pressure such as during inspiration. The flutter valve can be used for emergency transport and for a small to moderate sized pneumothorax. It also allows for mobility of the patient as the drainage bag can be hidden under the clothes while the patient ambulates. Patients can also go home with a hemilich valve in place.
Used for patient with chronic pleural effusions.
What are the best positions for a person experiencing dyspnea? What positions are recommended for the patient with COPD?
Tripod Position especially useful for COPD patients- Leaning forward with arms and elbow supported on over-bed table.
– head of bed elevated 30-40 degrees to allow maximum lung expansion and a more forceful cough.
What are some considerations for providing teaching to the hypoxemic patient?
Long-term O2 therapy (more than 15 hours/day) to treat hypoxemia. Benefits of LTOT include improved mental acuity, lung mechanics, sleep and exercise tolerance; decreased hematocrit; and reduced pulmonary hypertension. Some patients fear becoming
addicted” to O2 and are reluctant to use it. Tell them that it is not “addicting” and that it needs to be used because of the positie effects on the heart, lungs, and brain. The goal of O2 therapy is to maintain SaO2 greater than 90% during rest, sleep, and exertion.
When can we discontinue airborne isolation precautions for the hospitalized patient who has a recent history of TB?
Airborne infection isolation is indicated for the patient with pulmonary or laryngeal TB until the patient is noninfectious (defined as effective drug therapy, improving clinically, and three negative AFB smears)
What teaching do we provide the newly diagnosed TB patient regarding transmission of tuberculosis?
Teach patients to cover the nose and mouth with paper tissues every time they cough, sneeze, or produce sputum. The tissues should be thrown into a paper bag and disposed of with the trash, burned or flushed down the toilet. Emphasize carful hand washing after handing sputum and soiled tissues. If patients need to be out of the negative-pressure room. they must wear a standard isolation mask to prevent exposure to others.
What teaching is necessary for the patient who has been prescribed medication for tuberculosis?
Teach the patient and caregiver about compliance with the prescribed regimen. This is very important as most treatment failures occur because the patient neglects to take the drug, discontinues it prematurely, or take it irregularly. Notification of the public health department is required. The public health nurse will be responsible for follow-up on household contacts assessment of the patient for compliance.
– Because about 5% of individuals experience relapses, teach the patient to recognize the symptoms that indicate recurrence of TB. If the symptoms occur, the patient should seek immediate medical attention. Instruct the patient about certain factors that could reactivate TB, such as immunosuppresive therapy, malignancy, an prolonged debilitating illness. If the patient experiences any of these events, the health care provider must be told so that reactivation of TB can be closely monitored. In some situations, it is necessary to put the patient on antiTB therapy
What blood studies do we expect will be ordered for the respiratory patient and why?
Arterial Blood Gas (ABGs) – Measurement of the dissolved oxygen and carbon dioxide in the arterial blood helps indicate the aid-base state and how well oxygen is being carried to the body.
Culture and sensitivity study
Single sputum specimen is collected in a sterile container. Purpose is to diagnose bacterial infection, select antibiotic and evaluate treatment. Takes 48 to 72 hours for results.
Instruct patient on how to produce a good specimen. If patient cannot produce specimen, bronchoscopy may be used
Gram statin test
Staining of sputum permits classification of bacteria into gram-negative and gram-positive types. Results guide therapy until culture and sensitivity results are obtained.
Instruct patient to expectorate sputum into container after coughing deeply. Obtain sputum (mucoidlike), not saliva. Obtain specimen in early morning after mouth care because secretions collect during night. If unsuccessful, try increasing oral fluid intake unless fluids are restricted. Collect sputum in sterile container (sputum trap) during suctioning or by aspirating secretions form the trachea. Send specimen to lab promptly.
Acid-fast smear and culture
Assess sputum for acid-fat bacilli (mycobacterium tuberculosis)
A series of three early-morning specimens is used.
Instruct patient how to produce a good specimen (see gram stain) Cover specimen and send to laboratory for analysis.
Mantoux Test or The tuberculin skin test
using purified protein derivative (PPD) is widely used to determine if a person is infected with M. tuberculosis. The is administered by injecting 0.1 mL of PPD intradermally on the dorsal surface of the forearm. The test is read by inspection and palpation 48 to 72 hours later for the presence or absence or induration.
The indurated area (if present) is measured and recorded in millimeters with 0 for no induration. induration (not redness) at the injection site means the person has been exposed to TB and has developed antibodies. The reaction occurs 2 to 12 weeks after the initial exposure to the organisms.
If a person has a positive reaction, he or she should not be tested again since the sensitivity to tuberculin persists throughout life.
Bacille Calmette-Guerin (BCG) vaccine
is a live, attenuated strain of Mycobacterium bovis. The vaccine is given to infants in parts of the world where there is a high prevalence of TB. In the United States, it is typically not recommended because of factors such as the vaccines’ variable effectiveness against adult pulmonary TB and potential interference with TB skin test. reactivity. The BCG vaccination can result in a positive reaction on the TST. This reaction will decrease over time.
What is the purpose of mixing two drugs together in a medication such as Advair Diskus (combined fluticasone and salmeterol).
The fluticaone is a steroid that relieves inflammation.
The salmeterol is a bronchodilator and opens the airways.
These two are used together to for chronic asthma.
They are not recommended for an Acute asthma attack.
Are there recommendations made to the asthma patient to withhold any medications prior to any diagnostic respiratory testing?
When Pulmonary function test are done, the patient is asked to withhold taking any bronchodilator medications for 6 to 12 hours before the test. PFTs can be done before and aft eh administration of a bronchodilator to determine the degree of the response.
How is pursed lip breathing correctly done, and what is its purpose?
Exhalation through mouth with lips pursed together to slow exhalation
COPD, asthma; suggests increase breathlessness
Strategy taught to slow expiration, decrease dyspnea
Teach the patient:
1. Use PLB before, during and after any activity causing you to be short to breath.
2. Inhale slowly and deeply through the nose.
3. Exhale slowly through pursed lips, almost as if whistling.
4. Relax your facial muscles without puffing your cheeks- like whistling-while you are exhaling.
5. Make breathing out (exhalation)three times as long as breathing in (inhalation).
6. The following activities can help you get the “feel of PLB;
– Blow through a straw in a glass of water with the intent o forming small bubbles.
– Blow a lit candle enough to bend the flame without blowing it out.
– Steadily blow a table-tennis ball across a table.
– Blow a tissue held in the hand until gently flaps
7. Practice 8-10 repetition of PLB three or four times a day.
What diagnostic test do you expect will be ordered for a patient to confirm a diagnosis of COPD?
The diagnosis is confirmed by spirometry whether or not the patient has chronic symptoms. COPD can be classified as mild, moderate, severe and very severe. The FEV1/FEV less than 70% establishes the diagnosis of COPD, and the severity of obstruction (as indicated by FEV1) determines the stage of COPD.
The diagnosis of COPD is confirmed by pulmonary function tests. Goals for the diagnostic workup are to confirm the diagnosis of COPD via spirometry evaluation the severity of the disease, and determine the impact of the disease on the patient’s quality of life.
When providing care for the patient with history of asthma, which symptoms must be communicated immediately to the healthcare provider?
Diminished or absent breath sounds may indicate a significant decrease in air movement, and it is an ominous sign indicating impending respiratory failure.
In the midst of an asthma attack, the patient develops bradycardia and a decrease in wheezing. What are the nursing considerations?
The patient may be have an adverse reaction to B-Adrenergic blockers.
What are some common characteristics of patients diagnosed with pulmonary fungal infections? What medications do we expect to see used for treatment of pulmonary fungal infections?
Similar to TB, insidious, possible involvement of skin, possible meningitis, necrotizing pneumonia; in individual with asthma, allergic bronchopulmonary aspergillosis may require corticosteroid therapy. Hypoxemia, abscess or empyema formation,
Treated with broad-spectrum antibiotic therapy. Systemic or inhaled. Ex. Amphotericin B remains the standard therapy for treating serious systemic fungal infections. It must be given intravenously to achieve adequate blood and tissue levels because the GI tract does not absorb it well.
Symptoms of COPD
Typically develop slowly around 50 years of age after heavy cigarette smoking.
– Cough, sputum production
– dyspnea
– Chronic intermittent cough usually occurs in the morning (can occur many years before actual airflow limitation.
Dyspnea is progressive, usually occurs with exertion, and is present every day.
In late stages of COPD, dyspnea may be present at rest. The person become more of a chest breather, relying on the intercostal and accessory muscles. However, chest breathing is not efficient breathing.
– Wheezing and chest tightness
– Weight loss and anorexia (even though consuming adequate calories)
– Fatigue
– Hemoptysis can occur during respiratory tract infections.
Respiratory Assessment History:
Health Perception- Health Management
(describe daily activity)
Nutritional-Metabolic
(Any Weight loss, difficulty eating)
Elimination
(does your respiratory problem make it difficult for you to get to the toilet)
Activity-Exercise:
Are you ever short of breath during exercise? At rest?
Sleep-Rest
Do breathing problems cause you to awaken during the night?
Cognitive-Perceptual
Do you have any pain associated with breathing
Do you have difficulty remembering things
Self-Perception-Self Concept
Describe how your respiratory problems have changed your life.
Role Relationship
Has your respiratory problem caused any difficulties in your work, family or social relationships?
Sexuality-Reproductive

Coping- Stress Tolerance
How do you leave your home
Values-Belief
What do you believe causes your respiratory problems?

Respiratory Assessment Physical Exam:
Back to front: Examine back first.

Inspect: Beauty is symmetry

A new angle: the angle will be larger if the chest wall is chronically expanded because of an enlargement of the intercostal muscles, as can happen with COPD.

Inspect skin, tongue mouth, fingers and nail beds may also provide information about respiratory status

••When patient is in Respiratory distress immediately assess his airway, breathing and circulation (ABCs)

Getting the Blues: Skin color varies considerably among patient, but in all cases patient with a bluish tint to his skin and mucous membranes is considered cyanotic. A late sign of hypoxia.

Clubbing clues: fingers, possible sign of hypoxia

Palpate: Making sure there is no extra air: the chest wall should feel smooth, warm and dry. Crepitus indicates subcutaneous air in the chest, an abnormal condition. Crepitus feels like puffed-rice cereal crackling under the skin and indicates that air is leaking from the airways or lungs.

There should not be pain.

Good – and – Bad Vibrations
Check for tactile Fremitus is the vibration of the chest wall produced by vocalization.

Measure up: to check for symmetry and expansion, place your hands on the front of the chest wall, with your thumbs touch each other at the second intercostal space. AS the patient inhales deeply, watch your thumbs. They should aspirate simultaneously and equally.

Percussion: Resonance, Hyper-resonance, Tympany, Dull, Flat

Auscultation: Adventitious sounds include crackles, rhonchi, wheezes and pleural friction rub.

Positron emission tomography (PET)
Used to distinguish benign and malignant pulmonary nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan, which uses an IV radioactive glucose preparation, can demonstrate increased uptake of glucose
What further diagnostic testing may be expected for a 35 year old patient newly diagnosed with emphysema, who has no history of smoking?
alpha-1 antritrypsin test.
When a hospitalized patient with COPD is receiving oxygen, what are the nursing considerations for O2 use?
For the hospitalized COPD patient, one of the most important nursing considerations is to ensure that the patient’s oxygen saturation is maintained at at least 90% or above (confirmed by the respiratory therapist drawing an arterial blood gas (ABG) typically from the radial artery, and backed up by pulse oximetry measurement).
What is a possible relationship between beta-blocker and asthma?
Propranolol (Inderal) in particular is a common beta-blocker which can cause potentially dangerous bronchospasm in a patient, and this phenomenon presents extra concern for the patient diagnosed with asthma, who already has asthma-related tendency toward bronchospasm.
What medications do you expect that the nurse will be offering teaching about correct use, for the patient who is newly-diagnosed with persistent asthma?
Ipratropium
Glucocorticoids
Beta2 – adrenergic agonists
Leukotriene modifiers
DuoNeb – medicated nebulizer (Combination of albuterol and ipratropium.
In the midst of an asthma attack, the patient develops bradycardia and a decrease in wheezing. What are the nursing considerations?
This is a developing emergency situation because a decrease in wheezing here indicates a decrease in air movement, and with this decrease in ventilation and decrease in heart rate, this patient is quickly headed for respiratory arrest (respiratory code). Respiratory arrest will require life-saving endotracheal (ET) intubation and the pt. being placed on a mechanical ventilator in the ICU. So in this case the nurse needs to call a code and be ready to assist the code team.

This is generally an avoidable emergency because of the asthma-management options available, including the medications listed above, and use of a peak-flow meter.
(there could be a relationship between a respiratory emergency and beta-blockers, if a question indicates the person is asthmatic and has taken a beta-blocker, particularly propranolol).

Glucocorticoids are used on a _______schedule to suppress inflammation in chronic asthma rather than being used to abort an attack.
fixed.
In which disorders are beta2-adrenergic agonists contraindicated?
Tachydysrhythmias.
Tachycardia associated with digitalis toxicity.