diagnostic and therapeutic

8/13/2019 Diagnostic and Therapeutic

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Health History

Reason the patient is seeking health care

Focuses on the physical and functional problemsCollects data on the causes/factors producing the

problem

Determines the duration of the problemImpact of the problem on the patients ability to

perform activities of daily living


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Signs and SymptomsDyspnea

CoughSputum production

Chest Pain

WheezingClubbing of fingers

Hemoptysis


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Thoracic PalpationRespiratory Excursion

Estimates thoracic expansion and may disclosesignificant info. About thoracic movement during

breathing.

Patient is instructed to inhale deeply while the thumbs

are placed along the costal margin on the anteriorchest wall.


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Tactile Fremitus

This is the detection of the resulting vibration on the

chest wall by touch.The vibrations are detected with the palmar surfaces

of the fingers and hands, or the ulnar aspect of the

extended hands, on the thorax.


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ThoracicPercussionThis determines whether the underlying tissue are

filled with air, fluid or solid material.

Ideally, the patient is in a sitting position with the

head flexed forward and the arms crossed on the lap.


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Thoracic Auscultation

This is useful in assessing the flow of air through the

bronchial tree and in evaluating the presence of fluidor solid obstruction in the lung.

Breath Soundsdistinguished by their location

Vesicular

Bronchovesicular

Bronchial


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Adventitious SoundsAbnormal condition that

affects the bronchial tree and alveoli.

Cracklesare discrete, noncontinous sounds that resultfrom delayed reopening of deflated airways.

Friction rubsresult from inflammation of the pleural

surfaces that induces a crackling, grating sound usually

heard in inspiration and expiration. Wheezes are commonly heard in patients with asthma,

chronic bronchitis and bronchiectasis.


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Pulmonary Function TestTo be able to assess respiratory function and to

determine the extent of dysfunction.They are useful for screening patients scheduled for

thoracic and upper abdominal surgery.

Trends of results provide information about disease

progression as well as patients response to therapy.


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Arterial Blood Gas StudiesThese aid in assessing

the ability of the lungs to provide adequate oxygen andremove carbon dioxide

the ability of the kidneys to reabsorb or excrete bicarbonate

ions to maintain normal pH

Obtained through an arterial puncture at the: Radial

brachial

femoral artery.


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Pulse OximetryA noninvasive method of continuously monitoring

the oxygen saturation of hemoglobin.

An effective tool to monitor for subtle or sudden

changes in oxygen saturation.


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Sputum StudiesObtained for analysis to identify pathogenic

organisms and determine whether malignant cells arepresent.

Expectoration is the usual method for collecting a

sputum specimen.

These are used

For diagnosis

Drug sensitivity testing

For guide treatment


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Imaging StudiesChest X-Ray

May reveal an extensive pathologic process in thelungs in the absence of symptoms.

Usually taken after full inspiration

Densities produced by fluid, tumors, foreign bodies,and other pathologic conditions can be detected by x-

ray examination.


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Computed Tomography

Images produced provide a cross sectional view of

the contrast.Can distinguish fine tissue density.

Contrast agents are useful when evaluating the

mediastinum and its contents

May be used to define pulmonary nodules and small

tumors adjacent to pleural surfaces


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Magnetic Resonance Imaging

Radiofrequency signals are used instead of a narrow-

beam x-ray.Much more detailed diagnostic image than CT scans.


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Fluoroscopic Studies

Used to assist with invasive procedures

Used to study the movement of the chest wall,mediastinum, heart, and diaphragm

To locate lung masses and detect diaphragm

paralysis.


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Pulmonary Angiography

The most commonly used to investigate

thromboembolic disease of the lungs.Involves rapid injection of a radiopaque agent into the

vasculature of the lungs for radiographic study of the

pulmonary vessels.


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Radioisotope Diagnostic ProcedureVentilation-Perfusion lung scan

Performed by injecting a radioactive agent into a peripheralvein.

Used to clinically measure the integrity of the pulmonary

vessels relative to blood flow and to evaluate blood flow

abnormalities.

Gallium scan

Used to detect inflammatory conditions, abscesses,

adhesions and the presence, location and size of tumor.


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Radioisotope Diagnostic Procedure

Positron Emission Tomography

Used to evaluate lung nodules for malignancy

It can detect and display metabolic changes in tissue

It can distinguish normal tissue from tissues that are

diseased

Differentiate viable from dead or dying tissue

Show regional blood flow

Determine the distribution and fate of medication in the

body


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Endoscopic Procedures

Bronchoscopy

Is the direct inspection and examination of the larynx,trachea and bronchi through either a flexible fiberoptic

bronchoscope or a rigid bronchoscope.

Purposes:

To examine tissues or collect secretions

Determine the location and extent of the pathologic process and

obtain a tissues sample

Determine if the tumor can be resected surgically

To diagnose bleeding sites.


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Endoscopic ProceduresBronchoscopy

Used to:Remove foreign bodies from the tracheobronchial tree

Remove secretions of obstruction

Treat postoperative atelectasis

Destroy and excise lesions

Possible reactions of Bronchoscopy:

Reaction to the local anesthetic

Infection

Aspiration

Bronchospasm

Hypoxemia

Pnuemothorax

Bleeding

perforation


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Endoscopic ProceduresBronchoscopy

Nursing InterventionsSigned consent

NPO 6 hours prior

NPO after the procedure only if gag reflex is is still absent

Assess for confusion and lethargy post procedureReport any sign of shortness of breath or bleeding immediately.


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Endoscopic ProceduresThoracoscopy

Primarily indicated in the diagnostic evaluation of pleuraleffusions, pleural disease and tumor staging.

Small incisions are made into the pleural cavity in an

intercostal space

After the procedure, a chest tube may be inserted and thepleural cavity is drained by negative-pressure water seal

drainage.


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BiopsyPleural Biopsy

Accomplished by needle biopsy of the pleura or bypleuroscopy

Performed when there is pleural exudate of undetermined

origin and when there is a need to culture or stain the tissue

to identify tuberculosis or fungiLung Biopsy

Performed to obtain lung tissue for examination to identify

the nature of the lesion


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BiopsyLung Biopsy

Nonsurgical lung biopsy techniques

Transcatheter bronchial brushinga fiberoptic bronchoscope is

introduced into the bronchus under fluoroscopy.

This is useful for cytologic evaluations of lung lesions and for

the identification of pathogenic organismsTransbronchial lung biopsyuses biting or cutting forceps

introduced by a fiberoptic bronchoscope.

Percutaneous needle biopsyaccomplished with a cutting needle

or by aspiration with a spinal type needle that provides a tissue

specimen for histologic study.


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Biopsy

Lung Biopsy

Nursing Intervention

Monitor patient for shortness of breath, bleeding and infection

Report for pain, shortness of breath and bleeding to the puncture

site

Provide care and teaching to the patient


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Biopsy

Lymph Node Biopsy

A biopsy of these nodes may be performed to detect lymphnode spread of pulmonary disease and to establish a

diagnosis or prognosis.

Mediatinoscopy

The endoscopic examination of the mediastinum for explorationand biopsy of mediastinal lymph nodes that drain the lungs.

Valuable whether the pulmonary lesion is resectable

Anterior mediastinotomy

Provides better exposure and diagnostic possibilities

Incision is made in the second or third costal cartilage


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Oxygen Therapy

Indications

Patients respiratory rate or pattern Changes in the patients signs and symptoms

Long standing hypoxia producing fatigue, drowsiness,

apathy inattentiveness and delayed reaction time

Cautions in Oxygen Therapy

Oxygen toxicity may occur when too high a concentration

of oxygen is administered for an extended period

Administration of a high concentration of oxygen removes

the respiratory drive that has been created largely by the

patients chronic low oxygen tension.


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Oxygen Therapy

Intermittent Positive-Pressure Breathing

A form of assisted or controlled respiration produced byventilatory apparatus in which compressed gas is delivered

under positive pressure into a persons airways until a

preset pressure is reached

Indications:Difficulty in raising respiratory secretions,

Reduced vital capacity with ineffective deep breathing and

coughing

Unsuccessful trials of simpler and less costly methods for loosening

secretions, delivering aerosol, or expanding the lungs.


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Oxygen Therapy Complications:

Pneumothorax

Mucosal drying

Increased intracranial pressure

hemoptysis

Gastric distentionVomiting with possible aspiration

Psychological dependency

Hyperventilation

Excessive oxygen administration

Cardiovascular problems

Mini-Nebulizer Therapy

A hand-held apparatus that disperses a moisturizing agent

or medication


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Oxygen Therapy Indications:

Usually for patients with COPD to dispense inhaled medications

Commonly used at home on a long-term basis

Incentive Spirometry (Sustained Maximal

Inspiration)

A method of deep breathing that provides visual feedbackto help the patient inhale slowly and deeply to maximize

lung inflation and prevent or reduce atelectasis.

Indications:

Used post-surgery, especially thoracic and abdominal surgery To promote the expansion of the alveoli

To prevent or treat atelectasis


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Chest PhysiotherapyPostural Drainage ( Segmented Bronchial Drainage)

Uses specific position that allow the force of gravity toassist in the removal of bronchial secretions

Patient remains in each position for 10-15 minutes

Instructed to breathe in slowly through the nose and then

breathe out slowly through pursed lipsTo help keep the airways open so that secretions can drain while in

each position

Usually performed two to four times daily before meals and

at bedtimeTo prevent

Nausea

Vomiting

Aspiration


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Chest PhysiotherapyChest Percussion

Carried out by cupping the hands and lightly striking the

chest wall in a rhythmic fashion over the lung segment to

be drained.

Performed cautiously in the elderly

Vibration The technique of applying manual compression and tremor

to the chest wall during the exhalation phase of respiration.


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Airway ManagementEmergency Management of Upper Airway

Obstruction

Causes:

Food particles

Vomitus

Blood clots

Any particle that enters and obstructs the larynx or trachea

Enlargement of tissue in the wall of the airway

Pressure on the walls of the airway

Altered level of consciousness

Nurse should assess for:Inspection

Palpation

Auscultation


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Airway ManagementEndotracheal Intubation

Provides a patent airway when the patient is havingrespiratory distress that cannot be treated with simpler

methods.

Method of choice in emergency care

A means of providing an airway for patients who cannotmaintain an adequate airway on their own

Cautions:

The cuff around the tube should be inflated

Low cuff pressure can cause: Risk for aspiration pneumonia

High cuff pressure can cause:

Tracheal bleeding

Ischemia

Pressure necrosis


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Airway ManagementEndotracheal Intubation

Disadvantages:Causes discomfort

Cough reflex is depressed

Depressed swallowing reflex

May develop ulceration and stricture of the larynx or trachea

Inability to talk or communicate

Nursing Alert:

Inadvertent removal of an endotracheal tube can cause laryngeal

swelling, hypoxemia, bradycardia, hypotension, and even death.


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Airway Management


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Airway ManagementTracheostomy

A surgical procedure in which an opening is made into the

trachea.

May either be temporary of permanent

Uses:

To bypass upper airway obstruction

Allow removal of tracheobronchial secretions

Permit long-term use of mechanical ventilation

Prevent aspiration of oral or gastirc secretions in the unconscious or

paralyzed patient

Replace an endotracheal tube

Ai M t


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Airway ManagementTracheostomy

Complications:

Early complications Bleeding pneumothorax

Air embolism

Aspiration

Subcutaneous or mediastinal emhysema

Recurrent laryngeal nerve damage

Posterior wall penetration

Long term complications

Airway obstruction from accumulation of secretions or protrusion of cuff over

the opening of the tube

Infection

Rupture of the innominate artery Dysphagia

Tracheophageal fistula

Tracheal dilation

Tracheal ischemia

Necrosis


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