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Med/Surg 2: Respiratory System

STUDY
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CT with contrast, check allergies to:
seafood and iodine
Pulmonary angiogram
to visualize pulmonary vasculature
contrast injected through central venous catheter into right side of heart an pulmonary artery
identifies circulation alterations (congenital, embolism, tumor)
ass for iodine/seafood allergy
Ventilation-perfusion scan
radioactive isotope injected to identify areas of ventilation and perfusion
lowered pulse ox accuracy with:
brightly lit environment, acrylic fingernails/nail polish, dark skin color
pulmonary function tests (PFTs)
spirometer to measure volumes and capacities during forced breathing
assesses effects of bronchodilator therapy
bronchoscopy
can be used on people on RA, O2, and mechanical ventilation
preprocedure: NPO 6-12 hous, informed consent obtained, analgesia/sedation, topical/local anesthesia applied to nasal, pharyngeal areas

post: assess for return of gag**, assess for laryngeal edema (hoarseness, stridor, dyspnea, vital signs, chest pain)
Thoracentesis
needle inserted into thoracic cavity to withdrawal pleural fluid for analysis or drain pleural effusion
sputum collection
expectoration, suctioning, saline-induced specimen, thoracentesis, lung needle biopsy, transtracheal aspiration
TB
acid-fast bacilli; collected 3 different days, following long sleep period is preferable (early morning) due to high concentrations. may also collect gastric specimen since TB is not effected by acid environment of stomach
10mm induration indicates exposure, 5mm in immunosuppressed
Airway management: opening airway
head tilt, chin lift
UNLESS suspected neck injury.. then jaw thrust
Endotracheal intubation
sized for individual
LUNG AUSCULTATION immediately after placement should yield bilaterally equal breath sounds
proper placement confirmed by x-ray as soon as possible
positioning for unilateral lung disease
"good lung down"
bad lung stays on top
positioning for acute respiratory failure
elevate head 45 degrees
acute respiratory distress sydrome
prone maybe attempted with pts on maximal mechanical ventilation with unresponsive hypoxemia (makes air gravitationally flow to air filled alveoli instead of previously dependent fluid filled alveoli)
caution with ET tube
O2 via nasal cannula at 1-6 L/min will give concentrations of:
24-44% O2
room air is 21%
each Liter increases % by about 4
COPD and oxygen
should receive low concentrations (1-2 L/min) to prevent respiratory depression due to loss of respiratory drive
face mask oxygen
levels similar to o2, mask should be greater than 5 L/min to minimize rebreathed CO2
concentration of 40-60%
face mask with O2 reservoir
constant flow of O2 into attached bag, minimizes CO2 rebreathing
6-10 L/min
60-100% o2
for those who need high concentrations but can't get ET
venturi mask
most control over exact concentration given
24, 28, 35, and 40% oxygen
COPD and chronic co2 retention
purpose of pursed lip breathing (during exhalation)
slows down exhalation speed and reduces airway collapse by increasing pressure
huff coughing
client attempts sequential coughing while saying "huff"
keeps glottis open during coughing
COPD benefitted
Chest PT
indication: greater than 30mL secretions per day, secretions with artificial airway, and atelectasis

contraindications: lung cancer, hemoptysis, bronchospasm
postural drainage
contraindicated 1 hour before and 3 hours after a meal to reduce risk of vomiting/aspiration
Tracheostomy precautions
use aseptic technique when suctioning or cleaning

keep trach tube obturator at head of bed for reinsertion if accidental dislodgment
manual ventilation bag connected to oxygen at bedside
unused trach tube at bedside for immediate use
airborne precautions
TB, rubeola, varicella
client in monitored negative air pressure room with door closed
N95 respirator for TB, and nonimmune/suseptible persons for rubeola and varicella
client wears surgical mask when transported
droplet precautions
large organisms spread when person coughs, sneezes, or talks
masks when working within 3 feet
client wears surgical mask when transported
air handling not necessary, door may remain open
other pts with same organism and no other infections may be in same room
post thoracic surgery norms
compare baseline vitals, lung sounds, expansion, oxygenation
75-100 mL of chest drainage over 1 hours is an average UPPER limit
proper analgesics facilitate lung expansion and ventilation
purpose of chest tube
reestablish negative intrathoracic pressure following surgery, trauma, pneumothorax
to drain blood, pleural effusion, or infected organism (empyema)
care of chest tube
occlusive dressing at insertion site
secure tube to system with heavy tape, and all connection tubing
apparatus below the level of the chest
NEVER clamp or milk
water seal chamber
prevents air and drainage from flowing back into the chest
filled to 2 cm marking
can fluctuate with breathing
CANNOT BE INTERUPTED
emergency treatment of tension pneumothorax
one-way valve (heimlich valve)
catheter-over-needled inserted into 2nd intercostle space, needle removed, hissing is heard as air escapes into atmosphere.
creates simple pneumothorax
chest tube and system after ASAP to fix this problem
positioning after lobectomy
back, or turned to either side
position after segmental resection
"good side down"
lying on back, turned onto nonoperative side
(positioning on operative side may put tension on sutures and cause bleeding)
positioning after pneumonectomy
lying on back, or operative side down
AVOID SHIFTS COMPLETELY TO EITHER SIDE
Chronic Obstructive Pulmonary Disease (COPD)
two types: emphysema, chronic bronchitis
emphysema ("pink puffers")
destruction of alveoli related to chronic inflammation resulting in decreased surface area for gas exchange
airway collapse due to loss of elasticity in system tissues

caused by smoking
occupational factors (coal, glass, asbestos)
hereditary deficiency of alpha1-antitrypsin
symptoms of emphysema
difficulty exhaling (airways obstructed with edema or mucus)
lung hyperinflation causes alveolar air trapping and frequent infections

barrel chest appearance
excess accessory muscle use due to WOB
under weight (lot of energy to breathe, less eating)
pursed lip breathing (COPD)
persistent tachy due to poor oxygenation
diminished breath sounds, wheezes, crackles
progresses with disease
emphysema diagnostic findings
respiratory acidosis later (CO2 retentions, high pCO2)
CXR hyperinflated lungs, flattened diaphragm
PFTs: low vital capacity and forced expiratory volume
emphysema therapy
remove polutants
bronchodilators
beta adrenergic agonists
anticholinergics: ipratropium (atrovent) (most effective bronchodilator for COPD)
corticosteroids
oxygen/nebulizers
chest pt
fluids
oral care
immunization against pneumonia q5 years and influenza
chronic bronchitis "blue bloaters"
form of COPD
chronic airway inflammation
chronic productive cough lasting at least 3 months during 2 years
chronic inflammation causes hyperplasia of mucous glands (excessive sputum production)
cilia disappear, airwar clearance function lost
goblet cells develop in terminal bronchioles, also increasing sputum
repeat infections due to increased sputum and decreased airway clearance
polycythemia develops (increased RBC) in response to hypoxemia
chronic bronchitis symptoms
frequent cough
foul smelling sputum
WOB
frequent pulmonary infections
obesity and bluish-red skin
dyspnea and activity intolerance
increased anterior-posterior chest diameter
increased risk for DVT with polycythemia
chronic bronchitis diagnostics
CXR: enlarged heart, congested lungs, normal-flattened diaphragm
^RBC, Hemoglobin, Hematocrit
asthma causes
intrinsic etiologies: uncertain; physical/psychological stress, exercise-induced
extrinsic etiologies: allergic reaction to irritants
air pollutants
sinusitis
cold/dry air
medications
food additives
hormonal influences
gastroesophageal reflux
asthma
widespread spasms of bronchiole smooth muscle with airway edema
excessive secretion of thick mucous
hyperinflation of lungs and air trapping
asthma symptoms
severe dyspnea, accessory muscle use
WHEEZING WITH EXPIRATION, if severe may be no wheezing
cough
chest tightness
prolonged expiration
mild to greatly diminished breath sounds
increased HR & BP
restlessness, anxiety, agitation
diagnostics during asthma attack
respirator alkalosis (mild), decreased po2
elevated eosinophil & IgE count (allergic immunoresponse)
asthma meds
inhaled beta agonists, bronchodilators, anti-inflammatory agents, corticosteroids, and o2

teach pt to use peak flow daily for self-assessment
restrictive pulmonary diseases
pleural effusion, empyema, chylothorax
pleural effusion
accumulation of fluid in the pleural space, fluid comes from capillaries
transudative pleural effusion: fluid contains small amount of protein
occurs with heart failure, liver disease and chronic renal disease
exudative: fluid contains large amount of protein
inflammatory response causes it; pulmonary tumors, infections, emboli, pancreatitis, ruptured esophagus
empyema
pleural fluid containing pus
associated with pneumonia, lung abscess, tuberculosis
chylothorax
lymph fluid in pleural space (disruption during surgery or trauma to lymph vessels)
produces fat malabsorption from GI tract
restrictive pulmonary disease symptoms
same as pneumonia
chest wall pain
fever, persistent cough, night sweats, and w eight loss with empyema ( like pneumonia )
visible on xray if greater than 250 mL
thoracentesis to differentiate source of fluid
pneumothorax
spontaneous pneumo: rupture of bleb lets air in pleural space
primary pneumothorax: happens to otherwise healthy individual; most often tall, slender males age 20-40
Secondary pneumothorax: rupture of overdistended alveoli in COPD pt
tension pneumothorax: disruption of chest wall or lungs causes accumulation of air in pleural space (causes pressure on mediastinum, other lung, and lessens venous return to the heart)
traumatic pneumo: blunt or penetrating trauma to pleura, bronchi, or lung
iatrogenic pneumo: disruption of pleura, bronchi, or lung tissue during instrumentation for central venous line placement, lung biopsy, or thoracentesis
tension pneumo
MEDICAL EMERGENCY
chest tube placement immediately to release air and restore cardiac function
hemothorax
blood accumulation in pleural space
pneumo/hemothorax manifestations
dyspnea
tracheal deviation to unaffected side
diminished breath sounds on affected side
dullness on affected side
unequal chest expansion (reduced on affected side)
crepitus (grating, crackling, popping sounds) over chest
atelectasis
alveolar collapse due to airway obstruction and increased pressure in alveli
low-grade fever
diminished breath sounds over area
diminished rate and depth of respiration
most common pneumonia organism
gram-positive streptococcus pneumoniae bacteria
viral pneumonia symptoms
low-grade fever
nonproductive cough
WBC normal-low elevation
CXR: minimal changes evident
less severe than bacterial
bacterial pneumonia symptoms
high fever
productive cough
WBC: high elevation
CXR: obvious infiltrates
most severe clinical course
mycobacterium tuberculosis
any tissue can be infected, most often the lung
gram-positive acid fast bacillus, airborn droplet transmission
cell mediated immunity reacts, produces a granuloma lesian wth Ghon tubercle that oozes liquified necrotic material containing the disease which can be expelled into the air
TB manifestations
frequent cough with copious frothy pink sputum (starts with nonproductive cough early in the morning)
NIGHT SWEATS
anorexia
weight loss
TB tests
mantoux first
CXR shows Ghon tubecles
acid-fast bacillus sputum cultures provide definitive diagnosis
TB prophilactic medications
Isoniazid (INH) for 6 months if no evidence of disease process
INH for 12 months if abnormal chest xray or high-risk population (HIV or drug induced immunosuppression)
Active TB medications
1) INH, rifampin (Rifadin), pyrazinamide (Tebrazid) and ethambutol (Myambutol) or streptomycin daily or 2-3 times weekly for a minimum of 6 months, therapy continued at least 3 months after first negative sputum culture
minimum of 9 months with HIV, continued at least 6 months after first negative sputum culture
INH side effects
hepatotoxicity, peripheral neuritis (numbness, take vitamin B6), hematologic effects (anemia, agranulocitosis, bleeding), hypersensitivity
Rifampin side effects
monitor CBC, LFTs and renal status
orange discoloration of body fluids
Pyrazinamide side effects
hepatotoxicity, high uric acid levels (assess for gout)
Ethambutol side effects
optic neuritis (esp. red/green color discrimination)
pulmonary embolism
risk factors; immobility, hypercoagulability, trauma to the endothelial layer of vessels, long bone fractures (fat emboli), pregnancy
pulmonary emboli manifestations
restlessness, anxiety, agitation
tachycardia, tachypnea, hypotension, fever
chest pain
hemoptysis (cough up blood)
mental status change, decreased LOC
cyanosis
lung crackles on auscultation
afib
tests for pulmonary emboli
spiral/helical CT scan or pulmonary angiogram
bronchogenic carcinoma (lung cancer)
leading cause of death by malignancy
small cell or non-small cell
often starts in bronchus and migrates
smoking
lung cancer symptoms (occur late in disease)
persistent cough (with or without hemoptysis)
localized chest pain
dyspnea
unilateral wheeze
swallowing difficulty
anorexia
weight loss
enlarged neck lymph nodes
tests
mass on cxr
ct or mri can differentiate mass
sputum culture has tumor cells
bronchoscopy for biopsy
medical management
surgical resection (pneumonectomy, lobectomy, segmentectomy, wedge resection)
chemotherapy
radiation therapy
laser therapy
immunotherapy
cancer of the larynx
most laryngeal tumors are benign
most common form of malignant laryngeal cancer is squamous cell carcinoma
causes: cigarette and alcohol consumption
manifestations for laryngeal cancer
hoarseness
palpable jugular nodes
change in voice
pain when swallowing
unexplained earache
tests for laryngeal cancer
biopsy, xray, mri, ct, barrium swallow
treatment
radiation therapy
brachytherapy (placement of radioactive source next to tumor site)
chemotherapy
laryngectomy
radical neck dissection
blunt thoracic trauma
injury to chest wall without disruption of pleura
rib fractures, flail chest, soft tissue rupture (diaphragm, trachea, bronchi, major blood vessels), tension pneumo, contusion of heart and lungs
penetrating thoracic trauma
injury involving disruption of the pleura
internal wounds communicate with external atmosphere
open air-sucking wounds
pneumothorax/hemothorax
tissue wounds (heart/lungs/major vessels)
symptoms of flail chest
(multiple rib fractures in two places, seperated from bony skeleton)
paradoxical chest expansion (with breathing)
rupture of diaphragm
abdominal contents dislocate upward into thoracic cavity
decreased control of breathing
symptoms of trauma
chest pain
shallow breathing with splinting
tachycardia, tachypnea, hypotension
crepitus over chest
possible unequal chest expansion