Nursing Management: Respiratory disorders and diseases

Terms in this set (61)

• Teach the patient undergoing complete laryngectomy that the natural voice and ability to sing, laugh, and whistle will be lost, but that special training can provide a means for communicating.
• Review equipment and teach importance of coughing and deep-breathing exercises.
- reduce anxiety and depression
- place patient in semi-fowler's or fowler's position
• Observe the patient for restlessness, labored breathing, apprehension, and increased pulse rate,
• Use opioids cautiously, providing adequate analgesia for turning, coughing, and deep breathing.
• Provide suctioning to remove secretions, avoiding disruption of the suture line.
• Monitor pulse oximetry.
• Encourage and assist the patient with early ambulation to prevent atelectasis, pneumonia, and deep vein thrombosis (DVT).
• Recognize that the laryngectomy tube (shorter than a tracheostomy tube but has a larger diameter) is the patient's only airway; humidification is required if no inner cannula is present. (Care is the same as for tracheostomy tube). Reassure the patient that excess mucus will diminish over time.
• Establishing an effective means of communication is the primary goal in the rehabilitation of the laryngectomy patient.
• Provide a magic slate; place IV in nondominant arm for ease of writing.
• Picture-word-phrase board or hand signals may be used for those who cannot write.
• Give patient adequate time to communicate
- NPO for several days after surgery
- Swallowing study to determine when able to start oral feedings
- when able to eat - diet of thickened liquids
- remain with patient during initiate oral feedings - keep suction setup at bedside if needed
• The nurse instructs the patient to avoid sweet foods, which increase salivation and suppress the appetite.
• The patient is instructed to rinse the mouth with warm water or mouthwash after oral feedings and to brush the teeth frequently.
• Changes in taste and olfactory sensation adapt, often with return of interest in eating.
- Monitor weight and laboratory data to ensure that nutritional and fluid intake are adequate.
- Skin turgor and vital signs are assessed for signs of decreased fluid volume.
- promote positive body image and self-esteem
• Exacerbations are characterized by a change in the patient's baseline dyspnea, cough, and/ or sputum production, which warrants a change in management.
• Exacerbations are associated with worsening prognosis and an accelerated decline in pulmonary function.
• Signs and symptoms may include increased dyspnea, increased sputum production and purulence, respiratory failure, changes in mental status, or worsening blood gas abnormalities.
• The primary causes of acute exacerbations include infection (bacterial and viral), heart failure, and response to pollutants and allergens.
• Prevention of exacerbations is associated with preservation of pulmonary function and a decrease in hospitalizations. Some pharmacological agents, such as inhaled long-acting beta adrenergics (LABAs) combined with steroids (Advair, Symbicort) and the anticholinergic agent Spiriva, have been associated with a prolonged time between exacerbations.
• Bronchodilators, inhaled or systemic corticosteroids, antibiotics, oxygen therapy, and intensive respiratory interventions may be used.
• Early treatment with antibiotics in patients needing hospitalization for an acute exacerbation may result in improved outcomes.
• Indications for hospitalization for acute exacerbation include severe dyspnea that does not respond adequately to initial therapy, confusion or lethargy, respiratory muscle fatigue, paradoxical chest wall movement, peripheral edema, worsening or new onset of central cyanosis, persistent or worsening hypoxemia, and the need for noninvasive or invasive assisted mechanical ventilation.
• Ventilatory support may be required until the underlying cause, such as infection, can be treated.
• Other complications of COPD include pneumonia, atelectasis, pneumothorax, and pulmonary arterial hypertension.
• Suspect pulmonary hypertension in patients complaining of dyspnea and fatigue disproportionate to pulmonary function abnormalities; enlargement of the central pulmonary arteries on chest X-ray, echocardiography suggestive of right ventricular enlargement, and elevated plasma B-type natriuretic peptide (BNP) may be present. Anticipate stabilization of the underlying lung disease, with administration of long-term supplemental oxygen and diuretics.
• Obtain information about shortness of breath (dyspnea), cough, and sputum production; change in sputum color, quantity, or thickness, or increased fatigue and a decreased ability to perform one's usual activities is noted.
• To assess progress of the disease, use a numerical scale based on 0 to 10 (with 0 being no shortness of breath and 10 being the worst) when quantifying dyspnea.
• Assess for the presence of other medical problems , allergies, history of smoking in pack years, current smoking, a history of past exacerbations and pulmonary hospitalizations including a history of intubations, a description of how the patient spends a usual day, sleep quality and amount, problems with mood (anxiety and/ or depression), and what self-care measures the patient is currently using.
• Observe breathing pattern and body position; accessory muscle use, shoulder elevation, use of the tripod position (leaning forward with the arms braced on the knees), and increased respiratory rate are indicative of respiratory distress
• Assess for quality (good aeration or diminished) of breath sounds, the presence of adventitious sounds (crackles or wheezes), and whether the adventitious sounds clear with cough.
• Review laboratory data: Pulmonary function tests, tests of oxygenation, and radiological studies.
- Promoting Smoking Cessation
• Assess underlying causes and manage dyspnea with bronchodilators, assisting with activities of daily living, providing oxygen therapy for hypoxemia, and teaching strategies for relieving increased shortness of breath and for limiting future episodes.
• Assist patient with breathing retraining; pursed-lip breathing helps slow exhalation and is thought to prevent the collapse of the small airways, decreasing hyperinflation. It may promote relaxation and allow patients to gain control of their breathing and reduce feelings of panic. A simple explanation to patients is that pursed-lip breathing makes "more room to breathe."
• Suggest the use of a small hand-held fan directing flow onto the cheek to reduce the sensation of dyspnea.
• Teach relaxation techniques, such as progressive muscle
• Teach patients how to pace activities with their breathing and plan for dyspnea-producing activities. For climbing stairs, climb more slowly and only during exhalation; use a pause-breathe in, exhale and climb one to two steps.
• When dyspnea is not adequately responsive to medications and breathing techniques, opioids may be needed; concerns over physical dependence, addiction, and respiratory depression should be addressed. Opioids should not be withheld in very severe patients for whom palliative care is the goal. •
Monitor for hypoxemia with pulse oximetry and arterial blood gas measurements; administer supplemental oxygen as indicated. Maintain oxygen saturation at 90% or higher to protect vital organ function.
• Teach importance of adhering to the oxygen prescription; the presence or absence of dyspnea is an unreliable symptom of hypoxemia.
• Monitor for cognitive impairment, which is increased in hypoxemic patients; administer long-term oxygen to improved cardiac and cognitive function and prognosis.
• Teach patient the number of hours per day to wear oxygen, the dose of oxygen (usually given as number of liters per minute), and special instructions for using oxygen for sleep and exercise.
• Monitor patients with chronic bronchitis and those experiencing an acute exacerbation for increased sputum, quantity, viscosity, and weakness or fatigue, which impairs effective airway clearance.
• Assist patient in eliminating or reducing pulmonary irritants including cigarette smoking, second-hand smoke, aerosol cleaning and household products, and cooking fumes.
• Teach directed or controlled coughing and to drink enough fluid to prevent dehydration.
• Provide chest physiotherapy with postural drainage and/ or mechanical percussion and vibration and suctioning.
• Observe for exercise intolerance secondary to exacerbations, hospitalizations, and systemic corticosteroids (associated with myopathy, especially of legs), which add to decreased activity, muscle weakness, and fatigue.
• Assist patient with early mobilization during acute exacerbation, including those in intensive care.
• Teach patient to alternate high-energy with low-energy activities throughout the day; consider use of walking aids and consultation with occupational and physical therapists.
• Nutrition therapy is aimed at assessing the nutritional status of the patient, treating the underlying cause, and stabilizing weight and body composition. Patients may be underweight, of normal weight but have decreased muscle mass, or be overweight because of increased fat mass or increased fluid retention.
• Provide oral nutritional supplements to increase body weight and respiratory function. Caution patients to avoid negating the effectiveness of supplements by using them as meal substitutes.
• Time bronchodilators before meals; assist severely dyspneic patients during meal times to minimize energy spent eating; teach patients to eat small, frequent meals to help them avoid becoming too full; and encourage the choice of calorie-rich foods when indicated.
• Consider referring patients to dieticians and encouraging progressive periods of exercise aimed at increased muscle mass. Overweight patients may need the help of nutrition education by a dietician to help them lose weight safely. Exercise should be encouraged to help patients increase muscle mass.
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