RespiratoryN415

Linda Winn, RN, MSN Ed., BA Ed.

http://www.nlm.nih.gov/medlineplus/tutorials/bronchoscopy/htm/_no_50_no_0.htm

Respiratory Assessment

Resp Assessment

• Breathing Pattern I:E ratio Kussmaul Rate

• Dyspnea Orthopnea PND – Paroxysmal nocturnal dyspnea

• Cough and Sputum Frequency Dry / moist Amount Color Thickness Odor

Assessment (Cont.)

• Inspection Symmetry Skin color – lip color / finger clubbing WOB – accessory muscles

• Auscultation Adventitious sounds

• Chest pain

• History Diagnoses Smoking

• Quick, Focused Assessment

Breath Sounds Link

• Normal and Adventitious breath sounds

http://faculty.etsu.edu/arnall/www/public_html/heartlung/breathsounds/contents.html

Diagnostics & Labs

Labs

• H/H

• Sputum AnalysisC&SGram StainAcid-Fast smear (AFB)Cytology

• ABG’s

• O2 Sats

Diagnostic Tests• CXR

• CT Chest

• MRI

• V/Q Scan

• Bronchoscopyhttp://www.nlm.nih.gov/medlineplus/tutorials/bronchoscopy/htm/_no_50_no_0.htm

• Thoracentesis

• PFTs – Pulmonary Function TestsSpirometry

COPD

Chronic Obstructive Pulmonary Disease

• Obstruction to expiratory air flow

• 15 million Americans have COPD

• 4th leading cause of death

• Women approaching men in incidence and surpassed men in number of deaths

COPD

• 2 Types of COPDEmphysema Chronic Bronchitis (most common)

• can have either or both

• Asthma no longer considered a type of COPD

COPD

•Etiologysmoking: 90% of people with COPD

•only15% of smokers get COPD•smokers 10 x more likely to die from COPD

environmental: •Pollution•Toxins•second hand smoke

develops slowly

•Common Signs and SymptomsDyspnea and Wheezing

•Video Cliphttp://www.nlm.nih.gov/medlineplus/tutorials/copd/htm/_no_50_no_0.htm

Impact of Smoking

COPD

COPD video clips

http://video.about.com/copd/COPD.htm

(skip through the ads )

Emphysema - Pathophysiology

• Abnormal permanent enlargement of the gas exchange airways with destruction of alveolar walls

• bronchioles too narrow or collapse

• slows air movement during exhalation & traps air in lungs

• increases work of breathing

surface area for gas exchange

• Blebs, Bulla

Chronic Bronchitis

• Definitionchronic productive cough for 3

months in each of the last 2 years

• Pathophysiologyhypertrophy of mucous secreting

glands & chronic inflammation of small airways excessive sputum production

impaired ciliary movement & excessive sputum can increase risk of infection

bronchial walls can become narrowed or obstructed

Thicker mucus

http://www.mayoclinic.com/health/asthma/MM00001

Assessment Findings• Early

SOB Dyspnea Activity intolerance Hypoxemia Chronic cough with sputum Prolonged expiration

• Wheezing on forced expiration Altered Breathing Techniques

• Pursed-lip breathing• Tripod breathing position

• Later Hyperinflation of lungs barrel chest Diminished lung & heart sounds Central cyanosis (chronic hypoxemia) CO2 retention

Asthma

Asthma Videos

http://www.mayoclinic.com/health/asthma/MM00001

http://www.nlm.nih.gov/medlineplus/tutorials/asthma/htm/_no_50_no_0.htm

Asthma

• Exaggerated bronchoconstriction response to stimuli Airways overreact to triggers causing

narrowing

• Chronic inflammatory disorder of airways

• 1 in 20 Americans; 5000 deaths/year

• Common triggers: allergies: dust, mold, sulfites, dander cold, dry air exercise stress

Common Triggers

• Allergens: dust, mold, sulfites, dander

• Cold, dry air

• Exercise

• Stress

• Environmental

• Wheezing after exposure to triggers, coughing, chest tightness

• Rapid, shallow respirations, dyspnea, or absent breath sounds, accessory muscle use

• Postural changes to aid breathing

• Activity intolerance

• Anxiety

• Severity of symptoms vary

• Changes in peak expiratory flow rate

Assessment Findings

In the Zone

•Green ZonePEFR 80% of baselineno sx; meds may be by MD

•Yellow ZonePEFR 50-80% baselinemay have Ø to mod sxhaving attack or meds adjusted

•Red Zone 50% baselinesevere sxmedical alert; call MD

Potential Nursing Diagnoses

•Ineffective Airway Clearance

•Impaired Gas Exchange

•Ineffective Breathing Pattern

•Activity Intolerance

•Altered Nutrition

•Aspiration, risk for

•Pain

•Anxiety

•Fear

•High risk for infection

Pneumonia

Nursing Management

•Monitor VS LOClung soundssputum amount and character

•Maintain airwayPursed-lip breathingcough routinespositioning for max lung expansionSuctioningavoid cough suppressants unless cough frequent & non-productive

Nursing Management• Monitor activity tolerance

help pt conserve energy plan rest periods O2 prn

• Good oral hygiene

• Decrease anxiety remain with patient during anxious episodes,

relaxation techniques, O2 prn

• Nutrition

• Hydration

Collaborative Treatment

• Immunizations flu & pneumonia vaccinations

• Bronchodilators

• Inhaled steroids

• Antibiotics

• Oxygen therapy

• Pulmonary Rehabilitation

• Smoking Cessation

Patient Education

• Monitor color, amount, thickness of sputum

• Self care: at-home meds & treatments; avoid triggers

• Prevention Pneumococcal vaccine, flu shot

• Frequent oral hygiene

• Encourage fluids

• Environmental hazards altitude, smog, allergies, smoke

• Follow up medical care

• American Lung Association www.lungusa.org

COPD – Cor Pulmonale

• Long-term complication

Respiratory RN Diagnoses

• Impaired Gas Exchange

• Ineffective Airway Clearance

• Others

Pulmonary Tuberculosis

Tuberculosis

•Incidence

•Risk Factors

•Mode of TransmissionMycobacterium tuberculosis

•Development of TB

http://www.nhs.uk/Conditions/Tuberculosis/Pages/Introduction.aspx

http://www.nlm.nih.gov/medlineplus/tutorials/tuberculosis/htm/_no_50_no_0.htm

Text copy:

http://www.nlm.nih.gov/medlineplus/tutorials/tuberculosis/id359106.pdf

Diagnostic Tests• PPD

• CXR

• AFB

• Bronchoscopy

• WBC

Assessment Findings

• Classic Sx:Weight LossLow-grade feverNight sweatsProductive Cough

Treatment

• Medications INH – IsoniazidRifampin (Rifadin)Ethambutol (Myambutol)Pyrazinamide (PZA)

• Multi-drug approach

• Not transmittable after 2-3 weeks of treatment

Nursing Care

• In-hospital Care Negative pressure Room Respiratory isolation N-95 mask

• Fit testing Transporting Patient

• Public Health Nurse DOT

O2 Levels

PaO2 SaO2• Needs O2 <55 <88%

• May be OK 40 75%

Short-termWith COPD

• Critical <40 <75%

ABG’s

• Acid – Base Balance

• Nursing Considerations in drawing ABG’sAllen’s Test IcePressure

ABG Normal Values

• pH 7.35-7.45

• pCO2 35-45

• HCO3 22-26

• PaO2 80-100 mm Hg

SaO2 >95%

ABG Evaluation

• Step 1 – pO2

• Step 2 – pH Acidotic or Alkalotic?

• Step 3 – pCO2 Respiratory cause?

• Step 4 – HCO3 Metabolic cause?

• Step 5 – Compensated or Uncompensated

ABG examples

• pH 7.39• pO2 59• pCO2 59• HCO3 31

• Diagnosis?• What is this typical of?

Group Activity 1

• pH 7.3• pCO2 25• HCO3 16• pO2 85

• Interpretation: _______________

Group Activity 2

• pH 7.33• pCO2 47• HCO3 24• pO2 76

• Interpretation: _______________

Group Activity 3

• Create ABG for pt with

Metabolic AcidosisMetabolic Alkalosis with compensation