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N209 Respiratory Disorders
Terms in this set (94)
Risk Factors for Respiratory Disease
Personal and Family History
Allergens and Environmental Pollutants
Increased mucus production, damages cilia and decreases cilia cleaning function, irritation and inflammation of bronchial walls, increased bacterial growth
CAUSES OF INCREASED AIRWAY RESISTANCE
Contraction of bronchial smooth muscle
Thickening of bronchial mucosa
Obstruction of airway
-Mucus, Tumor, Foreign Object
Loss of lung elasticity
oxygen and CO2 btwn alveoli and capillaries
blood flow through the pulmonary vasculature
Gerontologic Considerations Defense Mechanisms
Decreased cilia and increase mucus
Decreased cough and gag reflex
Gerontologic Considerations lung
Decreased airway size
Increased thickness of alveolar/bronchial walls
Decreased elasticity of alveolar sacs
Gerontologic Considerations Chest Wall and Muscles
Calcification of intercostal cartilage
Arthritis of costovertebral joints
Decreased Muscle Mass
signs and symptoms of respiratory disease
-Dyspnea/DOE: Sudden dyspnea: pneumothorax, obstruction, allergic, MI
-Paroxysmal Nocturnal Dyspnea
Common subjective feeling of difficult or labored breathing, SOB esp. with decreased lung compliance or increased airway resistance.
The right ventricle is affected because it must pump against increased pulmonary resistance.
Sudden Dyspnea in a healthy person may indicate pneumothorax, acute respiratory obstruction/ allergic reaction, or myocardial infarction.
Dyspnea on Exertion
DOE may be precipitated by minimal activity and may indicate CHF or MI
Inability to breathe easily except in an upright position. Commonly seen in heart failure and COPD. How many pillows? May be associated with wheezing
Sudden attacks of dyspnea at night r/t shifting of fluid into alveoli
Persistent, chronic coughing is reaction of lungs to constant recurring irritant and may indicate infection or disease. Coughing after eating may indicate aspiration
Productive Coughs: Thick, yellow, green is common with bacterial infection and rust-colored r/t pneumonia. Thin, mucoid sputum usually associated with viral bronchitis.
Coughing blood from respiratory tract r/t infection, cancer, pulmonary embolus. Or heart and blood vessel disease. May be frothy and > 7.0 pH
three most common symptoms of chronic respiratory disease are
dyspnea, cough, and sputum production
associated with pulmonary conditions may be sharp, stabbing, intermittent or dull, aching and persistent. Usually felt on the side of disease, associated with breathing
S/S of Respiratory Disease
Diminished or Absent Breath Sounds
high-pitched sound heard on inspiration and indicates upper airway obstruction. More acute than chronic sign
musical sound heard mainly on expiration (asthma) or inspiration (bronchitis)
are low-pitched continuous snory sounds related to partial obstruction, bronchoconstriction in lower airway
soft, high-pitched crackling sounds during inspiration due to delayed reopening of deflated airways or fluid in alveoli and doesn't clear with cough)
Lower lobes, to assess RML (right lateral location), Absent: pneumothorax
Sign of lung disease found in patients with chronic hypoxic conditions in respiratory or heart disease. (Figure 21-6 p. 499) Distal finger rounded and bulbous
Is a bluish coloring of the skin r/t amount of unoxygenated hemoglobin in the blood (< 5 g/dL) and is a late, unreliable indicator of hypoxia.
Central Cyanosis: Indicates a decreased in oxygen tension in the blood in pulmonary/cardiac disease
Peripheral Cyanosis: results from decreased blood flow to periphery such as fingers, toes, nose, earlobes and may be r/t peripheral vascular disease.
Occurs from overinflation of the lungs and results in an increase in the anteroposterior diameter of the thorax. Commonly seen in emphysema.
Pulmonary Function Tests
Arterial Blood Gas
Pulse Oximetry (94-99%)
Computed Tomography (CT)
Measure lung function, assess response to treatment, technician uses spirometer
arterial measurement of PaO2, PaCO2, pH, SaO2, arterial puncture, pressure to puncture site to prevent bleeding
noninvasive measurement of oxygen saturation of hgb. Sensor detects changes in oxygen saturation by light signals (SpO2); Unreliable in hypotension, anemia, hypothermia, peripheral vasoconstriction
Check for pathogens or malignant cells, cough/suction, sputum from lungs not spit, prevent contamination
assess abnormal tissue, fluid, tumors, foreign bodies, disease, take picture after full inspiration.
Cross-section views, fine tissue density, pulmonary nodules/small tumors, usually NPO, check iodine allergy if contrast used
CT Pulmonary Angiography
check for emboli, dye injected to see pulmonary vessels, assess site for bleeding post procedure
Assess blood flow to lungs (PE), tumor, abscess, inject/inhale radioactive dye
Diagnostic Evaluation pt 2
Magnetic Resonance Imagine (MRI)
Positron Emission tomography (PET)
similar to CT except magnetic fields/radiofrequency signals used. More detailed image for evaluation of diseased structures.
radioisotope study distinguish normal tissue/necrotic, malignant nodules, show regional blood flow.
radioisotope lung scan detects inflammation, abscesses, adhesions, tumors.
Direct exam of larynx, trachea, bronchi, obtain biopsy, bronchial washings, remove foreign body, NPO, requires sedation, no fluids until gag reflex returns
Collect sample tissue to dx cancer/pathology, via bronchoscopy or needle bx, for needle...pt must hold breath
Obtain pleural fluid, aspirate fluid, position on side, monitor VS, assess for pneumothorax
PULSE OXIMETRY (SpO2)
Non-invasive method of continuously monitoring the oxygen saturation of hemoglobin
Unreliable in cardiac arrest, CPR, shock, hypothermia, vasoconstrictor medications, anemia, high carbon monoxide levels, and severe arterial disease, nail polish, shivering, and excessive movement
Assess your PATIENT with your equipment
Pulse Ox sensor detects....
changes in oxygen saturation levels by monitoring light signals generated by the Oximetry and reflected by blood pulsing through the tissue at the probe site
things to look for:
Is oxygen connected, appearance of patient, Respiratory status, presence of factors that would make reading unreliable, and the HR on the pulse Oximetry should match patient's HR
earliest sign of hypoxia
change in mental status
normal SPO2 values
Assess your patient in comparison to your pulse Oximetry.
Ineffective Airway Clearance: the state in which the patient experiences a threat to respiratory status related to inability to cough effectively.
Major Characteristics: ineffective cough or absent cough. Inability to remove secretions.
Ineffective Breathing Patterns: state in which the individual experiences an actual/potential loss of adequate ventilation r/t to altered breathing pattern.
Major Characteristics: changes in respiratory rate or pattern from baseline. Changes in pulse rate, rhythm, quality
Impaired Gas Exchange: state in which the individual experiences an actual/potential decreased passage of gases between alveoli of lungs and the vascular system.
Major Characteristics: Dyspnea, signs of hypoxemia such as restlessness, irritability, confusion.
Activity Intolerance: an altered physiologic response to activity such as dyspnea, tachypnea, sob, change in pulse/BP
Closure or collapse of alveoli and often diagnosed with chest x-ray and clinical signs/symptoms
ATELECTASIS risk factors
Immobilized or bed rest
Shallow breathing pattern
Excessive secretions or mucous plugs
Airway obstruction (Chronic)
ATELECTASIS Clinical Manifestations
S/S of pulmonary infection (fever)
Acute atelectasis signs and symptoms
Marked respiratory distress and anxiousness
ATELECTASIS ASSESSMENT AND DIAGNOSTIC FINDINGS
Decreased Lung Sounds
Crackles over affected area
Tachypnea, dyspnea and mild to moderate hypoxemia are hallmarks of the severity of atelectasis.
EARLIEST INDICATOR OF HYPOXIA IS A CHANGE IN LEVEL OF CONSCIOUSNESS
Increased work of breathing
Decreased breath sounds or absent breath sounds and crackles
Patchy infiltrates or consolidated areas on CXR
Frequent Turning and Proper Positioning
Avoid Over Sedation
Inflammation of lung parenchyma caused by infection such as bacteria, fungi, and viruses.
classification of pneumonia
Occurs in community or within first 48hrs of hospitalization
Approximately 1 million cases/year in patients > age 65
Occurs after first 48hrs of hospitalization
is the most lethal nosocomial infection and is the leading cause of death in patients with infection
Causes: decreased immunity, comorbid conditions, supine positioning, aspiration, coma, prolonged hospitalization, exposure to sources of bacteria (equipment, lines, equipment, HOSPITAL STAFF!
Aspiration Pneumonia: bacterial infection from aspiration of bacteria that normally resides in the upper airways, aspiration of gastric contents, food, tube feeding, etc. which leads to inflammation and
and bacterial growth. Patients at highest risk: stroke, dysphagia, elderly
Ventilator Associated Pneumonia (VAP)
RISK FACTORS FOR ASPIRATION
Brain Injury and Edema
Dorsal recumbent positioning (Flat)
Misplaced or Nonfunctioning NGT
RISK FACTORS for PNEUMONIA
Residence in a long-term care facility
Diseases and Disorders
CLINICAL MANIFESTATIONS OF PNEUMONIA
Sudden onset of chills and Fever
Pleuritic Chest Pain
Tachypnea and use of accessory muscles
SOB and Orthopnea
Lung Sounds: Crackles
MANAGEMENT OF PNEUMONIA
Aggressive Pulmonary Toilet/hygiene
Intubation and Mechanical Ventilation
Complications include hypotension, sepsis, septic shock, and respiratory failure.
The need for oxygen is assessed by ABG analysis, pulse oximetry and clinical evaluation.
Oxygen is considered a medication, and except in emergency situations it is administered only when ordered by physician
Oxygen saturation between 94-99% is goal and a higher fraction of inspired oxygen (FiO2) adds no further significant amounts of oxygen to the hemoglobin
In fact, increased amounts of oxygen may produce toxic effects on the lungs, and cells
Oxygen Toxicity: can occur when 50% or higher concentrations are given longer than 48 hours.
S//S of toxicity include substernal pain, dyspnea, restlessness, fatigue, and progressive respiratory failure.
abnormal accumulation of fluid in the lung tissue, the alveolar space, or both. It is a severe, life-threatening condition
causes of pulmonary edema
PULMONARY EDEMACLINICAL MANIFESTATIONS
Anxious or Agitated
Altered LOC if hypoxemia severe
Increased respiratory distress
*Frothy, blood tinged secretions
Crackles in lung bases
The patient experiences increasing respiratory distress characterized by dyspnea, air hunger, and central cyanosis.
Patients are usually anxious, agitated, or confused based on severity of hypoxemia. SpO2 will reflect hypoxemia and may drop significantly.
As fluid leaks into the alveoli and mixes with air, a foam or froth forms and patient coughs up or nurse suctions out foamy blood tinged secretions.
Obstruction of the pulmonary artery or one of its branches by a thrombus that originated in the venous system or in the right side of the heart; causes V/Q deadspace
Embolism is a clot that has originated from the venous system and traveled and lodged somewhere else.
PREVENTION OF PULMONARY EMBOLUS
Avoid Venous Stasis
Sequential Compression Devices
Active leg exercises
Avoid constrictive clothing
CLINICAL MANIFESTATIONS OF PULMONARY EMBOLISM
*Anxiety and Apprehension
Cough and Hemoptysis
PULMONARY EMBOLISM MANAGEMENT
Medications for pain and hypotension
-Heparin or Lovenox SQ
Monitoring VS, Labs, Bleeding
Chronic inflammatory disease of the airways that causes hyper-responsiveness, mucosal edema, and mucus production
Inflammation -> recurrent episodes of asthma with cough, chest tightness, wheezing, and dyspnea. Asthma is reversible with treatment or spontaneously
Etiology: Allergies and Airway Irritants
Seasonal, Weather, Environmental
Foods, Exercise, Medications
CLINICAL MANIFESTATIONS OF ASTHMA
Expiratory → Throughout
CHRONIC OBSTRUCTIVE PULMONARY DISEASE COPD
preventable and treatable disease that involves airflow limitation that is progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases
Chronic Bronchitis and Emphysema
A disease of the airways characterized by a cough and sputum production for a least 3 months
Smoke or other pollutants irritate the airways, resulting in inflammation and hypersecretion of mucus.
Viral, bacterial and mycoplasmal infections often produce acute episodes of bronchitis during the winter months.
COPD PATHOPHYSIOLOGY Emphysema
*Destruction of walls of over-distended alveoli
*Decreased alveolar surface area with capillaries
Decreased pulmonary bed and increased resistance
Right sided heart failure
Decreased oxygen diffusion leads to hypoxemia
*Impaired elimination of CO2 (Hypercapnia)
COPD RISK FACTORS
-Depresses ciliary cleansing
-Irritates goblet cells and mucus glands
-Increased mucus, irritation, infection, damage
-CO binds with hemoglobin ->carboxyhemoglobin
COPD CLINICAL MANIFESTATIONS
Dyspnea on Exertion (DOE)
Frequent Respiratory Infections
Barrel Chest (Emphysema)
Supraclavicular retractions, elevated shoulders, leans forward during inspiration
Increased Dyspnea and decreased SpO2
Symptoms usually worsen over time. Dyspnea may be severe and often interfere with the patient's activities. As COPD progresses, dyspnea may occur at rest and
Weight loss is common because dyspnea interferes with eating and work of breathing is energy depleting.
As work of breathing increases, accessory muscles are recruited to help in breathing.
Higher risk for infections and respiratory failure.
Emphysema patients have Barrel Chest thorax due to chronic hyperinflation and more fixed position of the ribs in the inspiratory position and loss of lung elasticity.
-Antibiotics if infection present
TCDB / IS / Suction PRN
Nurses play a key role in educating patients about risk reduction such as smoking, breathing exercises, activity pacing, self-care activities, physical conditioning, oxygen therapy at home, nutrition, and coping.
Smoking cessation is the single most cost-effective intervention to reduce progression of COPD. Nursing Care Plan for the patient with COPD in chapter
Goal of oxygen delivery is to increase PaO2 to at least 60mmHg and SaO2 to at least 90%. Many COPD patients' drive to breathe is a decreased blood oxygen. Delivery of high oxygen levels may decrease drive to breathe resulting in hypoventilation, increase in PaCO2 and acute respiratory failure secondary to carbon dioxide narcosis.
Bronchodilators relieve bronchospasm by altering smooth muscle tone and reduce airway obstruction by allowing increased oxygen distribution throughout the lungs and improving alveolar ventilation.
Corticosteroids improve symptoms but do not slow the decline in lung function.
Antibiotics are useful when respiratory infection present
Vaccines such as influenza and Pneumococcal are recommended for patients > age 65 and reduce the incidence of flu and pneumonia, hospitalizations, and death.
Pulmonary Toilet: TCDB, IS, Suctioning as indicated,
#1 cancer killer in the US
In approximately 70% of cases there are mets to lymph and other sites by the time of diagnosis (16% survive 5 years)
Most common risk factor: smoking
Small cell lung CA vs. NSCLC (Non small cell lung cancer)
Lung Cancer: Assessment
Often asymptomatic until late
Most common: dry, persistent cough
Persistent lung infection
Potentially curable if detected early
Most are in glottic area (vocal cords)
-Constant voice strain/laryngitis
Laryngeal CA: Assessment
Cough or sore throat
Lump in the neck
Ulceration, and coughing up blood
Cervical lymph adenopathy
Most common problem nasal polyps cause is nasal obstruction
Can lead to dryness of oral mucosa, sleep deprivation, chronic infection
Medical treatment: surgery (rhinoplasty), corticosteroids, antibiotics, antihistamines
Nursing care: elevate HOB after surgery, oral hygiene
Can cause two-fold problem:
1. obstruct airway
2. be drawn down into bronchi
Assessment: decreased O2 sat, s/sx resp. distress, x-ray, CT scan
Medical management: removal of foreign body (directly or with abdominal thrust procedure), tracheotomy; if in bronchi, removal by bronchoscopy or thoracotomy
Caused by the rupture of blood vessels in the mucous membranes of the nose
Medical treatment: pressure, topical medications, nasal packing, cauterization
Nursing care: monitor airway, breathing, VS, Education
Deviated Nasal Septum
When severe, it can block one side and reduce airflow, causing difficulty breathing, nosebleeds and other symptoms
Assessment: history of nosebleeds, noisy breathing during sleep, pain, infections
Medical treatment: decongestants, antihistamines, steroids, surgery
Most common fracture of maxillofacial complex.
Assessment: S/S skull fracture. Assess clear drainage w/ dextrostix.
Medical management: Closed vs. open reduction
Nursing care: apply ice, pain control, oral care
Most common fracture in the body
Assessment: assess for septum fracture and hematoma after swelling subsides, assess any clear drainage (Dextrostix)—fracture of cribriform plate could cause leakage of CSF, which contains glucose while nasal mucus does not, s/sx spinal or skull fracture
Medical management: antibiotics, analgesics, reduce fracture, surgery (rhinoplasty, septorhinoplasty, and septal hematoma drainage—can lead to permanent deformity if not treated)
Nursing care: apply ice, provide reassurance, oral care
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