Respiratory

COMMON LAB TESTS FOR RESPIRATORY DISORDERS 1. Blood a. arterial Blood gases f. serum electrolytes b. blood cultures g. RAST c. hemoglobin h. immunoglobulins d. hematocrit i. cultures Profile II e. CBC 2. Urine a. UA b. culture and sensitivities c. casts 3. Throat: sputum culture and sensitivites 4. Skin 5. Sputum specimen 1. standard precautions are required 2. microbiologic examination of secretions from the respiratory tract 3. may be obtained from patient expectoration or via suctioning 4. client should brush teeth and gargle before specimen collection 5. indications: suspected pneumonia and malignancy

6.
. . . . .

tests include a Gram stain and culture and sensitivity Arterial Blood gases

pH 7.35-7.45 PCO2 35-45 mm Hg HCO3- 22-26 mEq/L PO2 arterial 80-100 mm Hg Oxygen saturation 95-100%

Pulmonary function tests use a spirometer and record how efficiently lungs exchange oxygen and carbon dioxide b. client sits upright, wears noseclip and breathes into mouthpiece. c. uses i. to diagnose lung disease ii. to evaluate the extent of functional disability iii. to evaluate lung function pre-operatively iv. to evaluate how lungs respond to bronchodilators d. measurements:

a.

Thoracentesis a. b.

c.

than 80% insertion of large bore needle into pleural space of predicted norm. uses i. to obtain pleural fluid for analysis ii. to remove pleural fluid iii. to instill medications nursing interventions i. position client either sitting upright with arms and shoulders on overbed table, or in side lying position ii. stress that client must stay very still during procedure iii. explain that client will feel some pressure iv. strict asepsis, standard precautions v. post-procedure, place client on unaffected side for at least 1 hour vi. check vital signs frequently vii. watch for signs of pneumothorax, subcutaneous emphysema or shock viii. obtain and label specimens for analysis

*Abnormal Values: values less

Pulse oximetry

a.

measures oxygen saturation; less accurate than arterial blood gas (ABG) b. monitors oxyhemoglobin saturation noninvasively

c.

technique probe clips to end of finger or earlobe and passes a light through tissue ii. light is absorbed by photodetector iii. oximetry calculated from how much light RBCs absorb iv. arterial saturation is displayed; normal SaO2 more than/or equal to 93% d. pulse oximetry unreliable if there is i. bright light shining on sensor ii. tremor or seizure on extremity where probe is placed iii. poor perfusion to location where probe is placed iv. cardiac arrest v. intravascular dye circulating in the blood stream vi. abnormal hemoglobin, such as carboxyhemoglobin and methemoglobin e. if pulse oximetry shows significant changes, verify its results with ABG (arterial blood gas) assay i.

Pilocarpine test (iontophoresis) or sweat test a. glands b. c. d. e. f. i. ii. measures sodium and chloride excretion from sweat often first test performed for diagnosing cystic fibrosis usually performed on infants pilocarpine is administered to stimulate sweat glands perspiration is analyzed for sodium and chloride content normal findings sodium < 90 mEq/L chloride < 60 mEq/L Artificial airways Adult endotracheal tubes a. b. polyvinyl tube with inflatable cuff inserted through nose or mouth distal end should be a few centimeters above the carina cuff around tube is filled with air i. creates a seal in trachea ii. air pressure in cuff < 25 cm H20 or client risks pressure necrosis in the tracheal mucosa size of tube varies with size of child or adult pediatric tubes may not be cuffed when tube is inserted, check for placement i. listen for bilateral breath sounds ii. look for bilateral chest movement iii. chest x-ray iv. measure exhaled carbon dioxide v. measure pulse oximetry nursing interventions i. explain procedure to client ii. regularly assess tube placement and security, breath sounds, and bowel sounds iii. mark tube length with teeth, or lips if edentulous (toothless) iv. suction to maintain airway patency; observe secretions for color, consistency, and amount v. assure inspired air is warmed and humidified since upper airway is bypassed vi. provide oral hygiene and care for area around the tube as indicated vii. observe for skin breakdown around tube site viii. observe for possible complications of aspiration; oral/nasal pressure sores; accidental extubation; and oral, nasal and pharyngeal damage

c.
d.

e. f. g.

h.

Tracheostomy a. b. surgical opening through the neck into the trachea indications i. head and neck surgery ii. long term airway access; for long-term mechanical ventilation iii. emergency airway post-op complications i. tube dislodgement ii. subcutaneous emphysema iii. bleeding iv. infection

c.

d.

e.

components of tracheostomy tubes i. outer cannula ii. inner cannula iii. obturator nursing interventions i. explain procedure to client ii. regularly assess tube placement and security iii. care for tracheostomy as ordered iv. suction to maintain airway patency (see below) v. provide adequate hydration vi. periodically clean inner cannula and stoma site vii. provide regular oral hygiene viii. change trach tube as ordered ix. watch for skin irritation/infection at insertion site x. teach client 1. trach care 2. suctioning procedure 3. findings of complications 4. how to handle accidental dislodgement/extubation with obturator

Airway suctioning a. b. c. removing secretions from the airway sites for suction i. nasopharynx, oropharynx, trachea, or bronchi ii. through endotracheal tube or tracheostomy equipment i. use bulb syringe to suction nose/mouth of neonates, infants ii. catheter's outer diameter should be no larger than one-half inner diameter of endotrachial lumen iii. determining length of catheter 1. measure from tip of nose to base of ear to sternal notch 2. infant, young child: Insertion tolerance range: eight to 14 cm 3. older child, adolescent: Insertion tolerance range:14 to 20 cm iv. sterile procedure in institution; clean procedure at home. v. suction when rhonchus is heard vi. adjust vacuum pressure to between -80 and -120 mm Hg vii. insert suction catheter until resistance is met, then withdraw catheter an inch or two viii. apply suction intermittently when withdrawing catheter ix. rotate catheter during withdrawal x. from time of insertion, spend no more than five to ten seconds xi. re-establish ventilation and oxygenation xii. repeat procedure as indicated xiii. pharyngeal suctioning: less depth, less risk of complications than tracheal suctioning nursing interventions i. explain procedure to client ii. explain that coughing, sneezing or gagging is normal iii. place client in semi-fowler's position if condition allows iv. maintain standard precautions

d.

do not routinely instill saline into airway if secretions are thick, increase humidity of inspired air and fluid intake vii. provide patient with extra oxygen and extra deep breaths before, during and after procedure 1. if patient is receiving mechanical ventilation, use ventilator 2. if patient is breathing spontaneously, use manual resuscitation bag or instruct to deep breathe viii. compare client's respiratory status before and after suctioning ix. do not force catheter Oxygen delivery devices Nasal cannula a. used at flow rates five to six liters per minute (LPM) b. higher flow rates can be very uncomfortable and cause nasal bleeding c. delivered oxygen (FIO2) depends on liter flow, client's tidal volume and respiratory rate. Each liter is approximately 4% O2 added to 21% O2 found in room air. d. nursing interventions i. explain procedure to client ii. ensure prongs are in the nares iii. pad tubing around the ears, as indicated Simple face mask a. used at flow rates between 5 - 12 LPM b. must have at least 5 LPM to wash out carbon dioxide from exhalation; recommended flow is 8 to 10 LPM c. delivered oxygen (FIO2) depends on liter flow, client's tidal volume and respiratory rate d. not commonly used Venti-mask (venturi mask)

v. vi.

a.
b.

c. d.
e.

uses air-entrainment principle to deliver precise FIO2 due to entrainment, provides high rate of total flow available in a range of FIO2 depending on FIO2, flow rate four to ten LPM nursing interventions i. explain procedure to client ii. keep nasal cannula on stand-by for meals iii. assure venturi device does not become blocked by bedding iv. assess for dry mucous membranes v. oral care vi. skin care

Non-rebreather mask a. b. mask with added reservoir bag used at flow rates six to 15 LPM c. provides highest percentage of O2 available from any mask, from 60-100% d. used for sickest clients e. nursing interventions i. explain procedure to client ii. client requires close monitoring

iii. iv.

intubation may be needed assure reservoir bag does not completely collapse during peak inspiration 1. bag should deflate slightly when patient inhales and expand when client exhales. 2. if bag collapses at inspiration, increase liter flow to bag v. assure pop-off valves on mask are not stuck and work properly

Home oxygen therapy: three types a. b. c. from the air Positive pressure devices a. CPAP (continuous positive airway pressure) i. compressor provides air flow to client ii. baseline of noninvasive positive pressure is maintained throughout inspiration and exhalation iii. used primarily to treat sleep apnea at home for maintenance of patient upper airway BiPAP (bi-level positive airway pressure) i. provides a baseline of noninvasive positive pressure throughout inspiration and exhalation ii. provides positive pressure assist during client's own spontaneous inspiratory effort iii. used for clients in respiratory failure to rest client and improve oxygenation to avoid intubation compressed oxygen comes in tank or cylinder liquid oxygen in reservoir oxygen concentrator extracts and concentrates oxygen

b.

Ventilators 1.

a.
b. c. d. 2. a.

b.

3. a. breath b. minute

Machines' purpose support and maintain client ventilation improve ventilation improve oxygenation decrease work of breathing Ventilator control modes: assist and synchronized assist-control i. preset rate at preset tidal volume ii. if client initiates breath, machine delivers the preset tidal volume synchronized intermittent mandatory ventilation (SIMV) i. machine set to deliver a given rate at a preset tidal volume ii. clients can breathe on their own between machine breaths but will determine own tidal volume iii. used to gradually decrease machine support of breathing Ventilator settings tidal volume: amount of air delivered with each machine rate: number of breaths delivered by the machine in a FIO2: fraction of inspired oxygen %O2: percent of oxygen (e.g., 60%) Sighs: deep breaths (higher volume) delivered periodically by

c. d.
4. ventilator

5.

6.

Positive end expiratory pressure (PEEP) normal physiologic PEEP is equal or less than 5cm H2O b. provides a baseline of positive pressure throughout exhalation c. used to reduce airway collapse and intrapulmonary shunting Nursing interventions a. explain equipment to client b. monitor client's response to mechanical ventilation c. assure ventilator is working properly d. monitor artificial airway (as above) e. assess and provide for adequate nutrition f. monitor pulse oximetry and/or arterial blood gases as ordered

a.

Chest physiotherapy 1. Consists of coughing, chest wall percussion, vibration, and postural drainage 2. Designed to improve airway clearance 3. Used for clients with retained tracheobronchial secretions 4. Cough: natural clearing mechanism 5. Chest wall percussion, vibration a. percussion involves clapping chest with cupped hands b. vibration is downward vibrating pressure with flat hand; done during exhalation 6. Postural drainage a. gravitational clearance of airway mucous from various bronchial segments b. uses 10 different body positions 7. Percussion and vibration done in each position; simultaneously client coughs or nurse suctions to remove loosened secretions 8. Nursing interventions a. explain procedure to client b. place client in desired position according to lobe being drained c. percuss each area for at least three minutes d. encourage client to cough after each area is percussed and vibrated e. can cause fatigue Drainage Systems 1. a. both b. c. Chest tube tube placed in the pleural space to remove air, fluid, or tube placed anterior and superior to remove air tube placed posterior and inferior to remove fluid mediastinal tube i. drains blood or fluid from around heart ii. no tidaling in mediastinal drainage because tube is not placed in lung cavity Chest drainage devices collection chamber i. collects fluid ii. monitor rate and nature of drainage water seal chamber i. provides a one-way valve: air leaves chest, cannot reenter it ii. check for bubbling in this chamber: indicates air leak iii. if no bubbling, check water level in this chamber

d.

2. a. b.

iv. c.

d.

check for tidaling suction control chamber i. negative pressure transmitted to pleural space is determined by this chamber, not by the setting on the wall vacuum ii. wet chamber - suction level determined by water level iii. dry chamber - suction level determined by mechanical setting nursing interventions i. explain procedure to client ii. do not allow dependent loops to form in the tubing; position the tubing on the bed so that there is straight gravity drainage to the collection device iii. do not routinely strip or milk the tubing; allow for gravity drainage iv. do not routinely clamp the chest tube v. if the tube becomes dislodged and patient has air leak, I. apply non-occlusive dressing to allow air to leave the chest and prevent tension pneumothorax II. reinsert tube immediately vi. tube dislodged, but patient has no air leak I. apply occlusive dressing II. monitor carefully for respiratory distress III. depending on client's condition, tube may or may not need to be replaced

Tuberculin skin testing a. PPD (Purified protein derivative) is injected intradermally b. indicates whether client has been infected with Mycobacterium tuberculosis or has been in contact with infected individual c. site checked at 48 to 72 hours after administration d. contraindicated in clients with active tuberculosis, or previous BCG vaccine e. positive reaction: induration (elevated, red, and hard) of 10 mm or greater f. negative reaction: no change at site or some response, yet less than 10 mm and only elevated or red g. if positive reaction requires a chest x-ray

I.

General Respiratory Anatomy and Physiology

A. B. The respiratory system is comprised of the upper airway and lower airway structures. The upper respiratory system filters, moistens and warms air during inspiration. The lower respiratory system enables the exchange of gases to regulate serum PaO2, PaCO2 and Ph.

C.

II.

Upper Respiratory A. Nose and sinuses 1. Filters, warms and humidifies air 2. First defense against foreign particles 3. Inhalation for deep breathing is to be done via nose 4. Exhalation is done through the mouth

B.

C.

Pharynx 1. Behind oral and nasal cavities 2. Nasopharynx a. behind nose b. soft palate, adenoids and eustachian tube 3. Oropharynx a. from soft palate to base of tongue b. palatine tonsils 4. Laryngopharynx a. base of tongue to esophagus b. where food and fluids are separated from air c. bifurcation of larynx and esophagus Larynx 1. Between trachea and pharynx 2. Commonly called the voice box 3. Thyroid cartilage - Adam's apple 4. Cricoid cartilage a. contains vocal cords b. the only complete ring in the airway

5.

Glottis - opening between vocal cords

6.

Epiglottis - covers airway during swallowing

III.

Lower Respiratory and Other Structures A. Trachea 1. Anterior neck in front of esophagus 2. Carries air to lungs

B.

C.

Mainstem bronchi 1. Right and left 2. Right is more vertical, so right middle lobe is more likely to receive aspirate into it with the result of aspiraton pneumonia, which is more commonly found in elderly populations Conducting airways 1. Lobar bronchi a. surrounded by blood vessels, lymphatics, nerves b. lined with ciliated, columnar epithelial cell (

c.

cilia move mucus or foreign substances up to larger airways

D.

Bronchioles a. no cartilage; collapse more easily b. no cilia c. do not participate in gas exchange Alveolar ducts and alveoli 1. Lungs contain approximately 300 million alveoli 2. Alveoli surrounded by capillary network 3. Gas exchange area (blood takes O2, gives off CO2) 4. Gas exchange happens at alveolar-capillary membrane (al-cap memb) 5. Held open by surfactant which decreases surface tension to minimize alveolar collapse

2.

E.

Accessory muscles of respiration - use indicates additional effort needed to breathe 1. Scalene muscles - elevate first two ribs 2. Sternocleidomastoid - raise sternum 3. Trapezius and pectoralis - stabilize shoulders 4. Abdominal muscles - puts power into cough and used most often with chronic respiratory problems and acute severe respiratory distress

IV.

Physiology
A. B. C. D. E. F. G. Basic gas-exchange unit of the respiratory system is the aveoli. Alveolar stretch receptors respond to inspiration by sending signals to inhibit inspiratory neurons in the brain stem to prevent lung over distention. During expiration stretch receptors stop sending signals to inspiratory neurons and inspiration is ready to start again. Oxygen and carbon dioxide are exchanged across the alveolar capillary membrane by process of diffusion. Neural control of respirations is located in the medulla. The respiratory center in the medulla is stimulated by the concentration of carbon dioxide in the blood. Chemoreceptors, a secondary feedback system, located in the carotid arteries and aortic arch respond to hypoxemia. These chemoreceptors also stimulate the medulla Ph regulation I. Blood Ph (partial pressure of hydrogen in blood): a decrease in blood Ph stimulates respiration hyperventilation, both through the neurons of the brain's respiratory center and through the chemoreceptors in carotid arteries and aortic arch. II. Blood PaCO2 (partial pressure of carbon dioxide in arterial blood): an increase in the PaCO2 results in decreased blood Ph, and stimulates respiration as described above. III. Blood PaO2 (partial pressure of oxygen in arterial blood): a decrease in the PaO2 results in a decreased blood Ph, stimulating respiration as described above. IV. When arterial Ph rises or the arterial PaCO2 falls, hypoventilation occurs. Allergic rhinitis (hay fever) - sensitivity to allergens with whitish or clear nasal discharge I. Management - antihistamines, nasal steroid sprays Sinusitis

V.

Disorders of the Upper Respiratory System

A. B.

I.

II.

Medical condition I. inflammation of mucus membranes in the sinuses II. may be followed by infection with a yellowish-green discharge Management I. treatment with antibiotics, decongestants, antihistamines II. surgery to drain and open sinuses III. antral irrigation (sinus irrigation)

C.

IV. Caldwell-Luc procedure Upper airway obstruction (choking) I. Findings I. stridor (harsh, vibrating breath) II. no sound of air III. both hands of client around the throat IV. management: emergency treatment I. Heimlich maneuver II. cricothyrotomy (cut cricoid cartilage) III. tracheotomy/tracheostomy

D.

E.

Pharyngitis 1. Inflammation of mucous membranes of pharynx 2. Bacterial, viral, environmental causes 3. Treat findings; if culture shows bacteria, use antibiotics Tonsillitis 1. Inflammation and/or infection of tonsils 2. Acute form is usually bacterial

F.

G.

H.

3. Treat findings; if culture shows bacteria, use antibiotics Peritonsillar abscess 1. Complication of acute tonsillitis 2. Infection spreads to surrounding tissue 3. If swelling is massive, can endanger airway 4. Treat findings; if culture shows bacteria, use antibiotics Vocal cord disorders 1. Laryngitis a. inflammation of vocal cords and surrounding mucous membranes b. cause: something irritates the larynx c. occurs in viral and bacterial infections d. in children, called croup (larynx blocked by edema, spasm or both) e. treat findings, rest voice, remove irritants, gargle with warm salt water 2. Vocal cord paralysis a. injury, trauma or disease of larynx, laryngeal nerves or vagus nerve b. may result as a complication after thyroidectomy surgery c. assess how well client can protect airway d. can sometimes be surgically treated with Teflon injection Cancer of the larynx 1. Etiology a. most tumors of the larynx are squamous cell carcinoma b. more common among men, age 50 to 65 c. cigarette smoking and alcohol consumption are related especially in combination 2. Findings a. persistent sore throat b. dyspnea c. dysphagia d. increasing persistent hoarseness e. weight loss f. enlarged cervical lymph nodes g. neck pain/lump in neck (late) 3. Management a. radiation therapy b. chemotherapy c. surgery: removal of all or part of larynx to treat cancer I. total laryngectomy: no voice, permanent stoma in neck with no risk of aspiration from oral cavity II. radical neck dissection: when cancer has metastasized to surrounding tissues - total laryngectomy and radical neck dissection to remove adjacent cancerous tissue 4. Nursing interventions a. arrange for clients with larnygectomies to meet with members of support groups b. establish a method for communication before surgery c. maintain airway; have suction equipment at bedside d. observe for signs of hemorrhage or infection e. teach about trach and stoma care f. assist with period of grieving

VI.

Disorders of Lower Respiratory System (LRS): Obstructive

A. General facts: process in chronic obstructive pulmonary diseases 1. Block airflow out of lungs 2. Trap air, with impairment of gas exchange 3. Increase the work of breathing Emphysema 1. Destroys alveoli

B.

C.

D.

E.

2. Narrows and collapses small airways 3. Overall lung loses elasticity 4. Traps air 5. As alveolar walls die, there is less surface for vital gas exchange Chronic bronchitis 1. Definition a. inflammatory response in the lung b. affects few alveoli, mostly airways 2. Findings a. lungs chronically produce fluids b. inflammation and mucus narrow the airways Asthma 1. Definition/etiology a. reversible obstruction of airways b. inflammation of airways c. airways hypersensitive to variety of stimuli d. bronchospasm is a minor component e. disease waxes and wanes, remissions and exacerbations 2. Findings a. orthopnea, expiratory wheezing b. barrel chest, cyanosis, clubbing of fingers c. distention of neck veins d. edema of extremities e. increased PCO2 and decreased PO2 f. polycythemia g. use of accessory muscles to breathe 3. Diagnostics a. physical examination with history of findings b. arterial blood gases c. chest x-ray 4. Complications a. hypoxemia b. hypercapnia c. variety of respiratory infections d. cor pulmonale e. dysrhythmias Management for obstructive disease 1. Antibiotics and corticosteroids for infection or chronic inflammation or actue exacerbation 2. Bronchodilators - long acting for control, short acting for emergency relief 3. Mucolytics 4. Expectorants 5. Respiratory program: postural drainage, exercise, nebulizer, high protein diet. See Postural Drainage

Hyper (over as in hyperactive) Hypo (under as in hypodermic, under skin)

Ca (sounds like carbon dioxide) Ox (sounds like oxygen)

Hypercapnia = Too much carbon dioxide in arterial blood Hypoxemia = Not enough oxygen in arterial blood

F. Nursing interventions common to obstructive diseases 1. Assess client's risk of respiratory failure 2. Assess for degree of respiratory effort - an increase in work to breathe, dyspnea, or use of accessory muscles

3. Assess oxygenation with pulse oximeter if hemoglobin level is within normal limits 4. Measure arterial blood gases (ABG) to evaluate gas exchange 5. Administer oxygen as indicated 6. If risk of respiratory failure, anticipate ventilation 7. Assist with secretion removal as indicated 8. Pace client activities to reduce oxygen demand 9. Teach diaphragmatic breathing, pursed-lip breathing and energy conservation methods 10. Position in a high Fowler's to ease breathing effort 11. Provide for nutritional consults as indicated 12. Reinforce the plan for small, frequent high carbohydrate meals 13. Provide referrals for: a. depression associated with disease b. pulmonary rehabilitation c. smoking cessation support groups 14. For asthma, teach clients that aspirin or exposure to unknown allergens may stimulate an asthma attack

VII.

LRS Disorders: Restrictive

A. In general: these disorders prevent full lung expansion via three mechanisms 1. Lung stiffening 2. External compression 3. Muscle weakness Pulmonary fibrosis- lung stiffening 1. Occupational lung diseases a. coal worker's pneumoconiosis - risk increases with length of exposure to coal dust (>15 years), intensity of exposure, and silica content of dust b. silicosis: workers who will have inhaled silica dust 2. Asbestosis a. inhalation of asbestos fibers b. disease may develop 15 to 20 years after exposure c. high risk for mesothelioma - lung cancer specific to asbestos Pulmonary sarcoidosis - lung stiffening 1. Etiology a. unknown origin b. characterized by formation of tubercles, most often in the lungs c. may progress to fibrosis 2. Findings a. dyspnea b. anxiety 3. Diagnostics a. chest x-ray b. biopsy of affected tissue 4. Management a. antitussives b. oxygen therapy c. removal of toxic substances d. proper use of personal protective equipment to decrease lung damage Nursing interventions common to all types of pulmonary fibrosis 1. Prevent infection or exposure to infection 2. Pace clients' activities to reduce oxygen demands and dyspnea 3. Reinforce the need for small, frequent meals 4. Encourage daily activities within pulmonary tolerance a. provide referrals for: I. depression associated with disease II. smoking cessation support groups

B.

C.

D.

III.

occupational rehabilitation

E. Disorders of fluid in pleurae 1. Pleural fluid disorders - all treated with water seal chest drainage systems

2. Pneumothorax: air between the pleurae a. open pneumothorax: hole in the chest wall, communicates with the lung b. closed pneumothorax: hole in lung, chest wall intact c. tension pneumothorax - a nursing and medical emergency i. closed pneumothorax ii. air is forced into the pleural space with a continued pressure build up iii. shifts mediastinum away from affected side with results of a compressed heart iv. treated with chest tube insertion v. cardiac and respiratory arrest if not treated d. examples of the above

3. Pleural effusion a. fluid (transudate or exudate) in the pleural space b. if small, no treatment c. if larger, treated with chest tube insertion

d. repeated pleural effusion may be treated with pleurodesis to scar tissue and decreased fluid secretions 4. Hemothorax a. blood in the pleural space b. treated with thoracentesis or chest tube 5. Empyema a. purulent drainage in the pleural space b. often from a chronic condition such as lung cancer c. treated with chest tube inserton 6. Chylothorax a. lymphatic fluid in pleural space b. treated with thoracentesis or chest tube F. Musculoskeletal diseases associated with difficulty breathing 1. Guillain-Barre syndrome - follows a viral infection a. ascending paralysis that may affect muscles of respiration as paralysis ascends b. muscles so weak that client cannot breathe deeply, a nursing and medical emergency c. may progress to respiratory failure i. may require intubation ii. mechanical ventilation iii. course of illness varies from a few months to years 2. Myasthenia gravis a. sporadic, progressive weakness of skeletal muscle b. cause: lack of acetylcholine with results of a myoneural junction malfunction c. may not be able to chew and swallow well i. may aspirate ii. may lose protective airway reflexes d. repeated muscle movements, especially towards days end, can exacerbate acute respiratory failure All of these musculoskeletal disorders EXCEPT Guillain-Barre feature the letter M: -Myasthenia gravis -Poliomyelitis -Amyotrophic Lateral Sclerosis -Muscular dystrophies

3. Poliomyelitis a. viral infection b. if disease strikes the respiratory muscles the result may be respiratory failure c. may not swallow well i. may aspirate ii. may lose protective airway reflexes 4. Amyotrophic lateral sclerosis (ALS; Lou Gehrig's Disease) a. affects motor neurons; autonomic, sensory and mental function unchanged b. manifests as a chronic, progressive irreversible disorder c. begins usually in distal ends of upper extremities d. often leads to respiratory failure within two to five years e. results in ethical issue i. whether clients want mechanical ventilation ii. whether nutritional support is desired

if they would rather die when disease becomes this severe f. results in clients' inability to communicate or physically move from voluntarily and/or clients lack involuntary reflexes, such as blinking or gag reflex 5. Muscular dystrophies a. progressive symmetrical wasting of voluntary muscles with no nerve effect b. as thoracic muscles weaken, breathing becomes more difficult c. may not swallow well; risk for aspiration with loss of protective airway reflexes 6. Interventions common to musculoskeletal disorders a. monitor carefully for changes in condition b. assess regular swallowing and ability to protect the upper airway c. discuss client preference for mechanical ventilation or nutritional support: does client wish it? d. assist with coughing and secretion clearance as indicated e. prevent infection f. assess for with appropriate referrals for depression that is often associated with these diseases g. administer medications specific to the disease condition h. assist/provide occupational or/and physical rehibilitation as indicated i. maintain adequate nutrition j. with terminal disorders, provide for referrals for family

iii.

VIII.

LRS Disorders: Infectious A. Pneumonia 1. Definition/etiology a. acute infection of lung parenchyma b. cause: bacterium, virus, protozoan, mycobacterium, mycoplasma, or rickettsia c. pneumonia is the leading cause of death from infectious causes d. may affect only a region of lung: lobar pneumonia, bronchopneumonia e. may be the result of: i. primary infection ii. secondary to other lung damage iii. aspiration 2. Risk factors for pneumonia a. pre-existing pulmonary disease b. abdominal and thoracic surgery c. mechanical ventilation d. advanced age e. decreased ability to protect airway or cough effectively f. artificial airway g. chronic illness and debilitation h. depressed immune function i. cancer 3. Diagnostics a. chest radiograph b. sputum culture, sensitivity and microscopic analysis, Gram stain, cytology c. ABG as indicated by clinical condition 4. Management a. antimicrobials, depending on pathogen b. antipyretic c. expectorants

5.

d. antitussives e. supplemental oxygen, as indicated f. IV fluids to treat dehydration Nursing interventions a. monitor finger oximeter if hemoglobin levels within normal limits b. promote hydration to liquify secretions c. teach effective coughing techniques to minimize energy expenditure d. suction if necessary e. teach the need to continue entire course of antimicrobial therapy which is usually seven to ten days f. teach that findings are expected to be less within 48 to 72 hours of initial therapy g. encourage pneumonia vaccine for high-risk groups B. Pulmonary tuberculosis (PTB) 1. Etiology a. mycobacterium tuberculosis b. bacilli lodge in alveoli c. pulmonary infiltrates d. can spread throughout body via blood e. multi-drug resistant PTB is becoming more prevalent f. PTB incidence is rising with increasing homelessness and AIDS 2. Findings a. weakness with fatigue b. anorexia with weight loss c. night sweats d. chest pain e. productive cough 3. Diagnostics a. sputum and gastric contents, analysis for the presence of acid-fast bacilli b. chest x-ray for presence of active or calcified lesions, "coin" lesions c. tuberculin testing i. tine, mantoux tests checked 48 to 72 hours for induration positive if >10 mm induration in healthy persons; positive if >5 mm induration in clients who are immunosuppressed d. establishes if there is an antibody response to the tubercle bacillus e. if positive, indicates prior exposure to bacillus, not an active disease 4. Management a. long-term, six to 24 months, antimicrobial therapy with isoniazid (INH) (Hyzyd) or rifampin (Rifadin), with ethambutol HCL (Etibi) in some cases b. bed rest or chair rest until findings abate c. surgical resection of involved lung if medication is not effective d. high carbohydrate, high protein diet with frequent small meals 5. Nursing interventions a. with active infection, client must be isolated with airborne precautions when in the hospital b. teach client

i. ii. iii. iv.

v. C.

proper techniques to prevent spread of infection: hand washing, etc. to report bloody sputum not to use over the counter (OTC) medications without health care provider's approval importance of taking medications as prescribed adherence to treatment regimen return at scheduled times for lab testing of liver enzymes an increase in B6 to minimize peripheral neuropathies, a common side effect of drug therapy family and close contacts must be tested for disease

Lung abscess 1. Localized area of lung infection 2. Usually follows pneumonia, TB or aspiration 3. Treatment consists of draining and culturing abscess and antimicrobial therapy

IX.

LRS Disorders: Miscellaneous

A.

Pulmonary embolism 1. Definition/etiology a. clot blocks blood from the "bed" of arteries that feed the lung b. client is breathing but gases are not exchanged ventilation without perfusion c. hypoxemia results d. can be mild or immediately fatal, based on the size and location of clot(s) e. usually clot has traveled from deep veins in the leg or pelvis 2. Diagnostics a. ventilation/perfusion (V/P) scan, also called V/Q scan b. ABG c. EKG 3. Management a. oxygen via mask b. anticoagulation - heparin in acute and coumadin for chronic risk c. thrombolytics d. filter surgically placed in vena cava for long term care

B.

C.

Acute respiratory distress syndrome (ARDS) 1. Definition/etiology a. alveolar capillary membrane becomes more permeable to fluids b. increased extravascular lung fluid c. pulmonary compliance decreases d. intrapulmonary shunt increases e. refractory hypoxemia - does not respond to oxygen therapy f. usually seen after lung injury or massive multi-system organ disease 2. Findings a. restlessness, anxiety b. dyspnea c. tachycardia d. cyanosis e. intercostal retractions 3. Diagnostics a. clinical presentation and history of findings b. hypoxemia on ABG despite increasing inspired oxygen level c. chest x-ray shows diffuse infiltrates 4. Management a. optimize oxygenation I. mechanical ventilation II. sedation may be required III. paralytic agents may be necessary b. antibiotics, as indicated c. corticosteroids 5. Nursing interventions a. plan for frequent rest periods b. monitor trends in oxygenation status, ABGs, respiratory effort c. observe for behavioral changes and vital signs; confusion and hypertension may indicate cerebral hypoxia Lung cancer 1. Definition/etiology a. types of lung cancer I. squamous cell carcinoma SQUAMOUS CELL CARCINOMA

A. Risk factors
1. Is most often associated with cigarette smoking 2. Exposure to environmental carcinogens e.g. uranium, asbestos B. Characteristics 1. Accounts for 30-35% of lung cancer cases 2. Is more common among men 3. Findings occur earlier because of bronchial obstructive characteristics (arises from bronchial epithelium) 4. Causes cavitating pulmonary lesions 5. Usually metastasizes locally C. Therapy 1. Life expectancy is better than small cell carcinoma 2. Surgical resection is often attempted

II.

small-cell (oat cell) carcinoma

SMALL CELL CARCINOMA

A. Risk Factors
1. Cigarette smoking 2. Environmental carcinogens B. Characteristics 1. Accounts for 15% to 25% of lung cancers 2. Spreads early 3. Very malignant form 4. Is often associated with endocrine disturbances C. Therapy 1. Poorest prognosis 2. Average survival is less than one year

III.

adenocarcinoma ADENOCARCINOMA

A. Risk Factors
1. Not related to cigarette smoking 2. Lung scarring 3. Chronic interstitial fibrosis B. Characteristics 1. More common among women 2. Accounts for about half of all lung cancers 3. Usually located in peripheral section of lungs 4. Often no clinical signs or findings until well advanced C. Treatment 1. Does not respond well to chemotherapy 2. Most often, surgical resection is attempted

IV.

large cell carcinoma

LARGE CELL CARCINOMA

A. Risk Factors
1. Cigarette smoking 2. Environmental carcinogens B. Characteristics 1. Occurs in 15-25% of all lung cancers 2. Frequently metastases via blood 3. Usually peripheral rather than centrally located in the lung lobes C. Therapy 1. Usually client is not a candidate for surgery due to the high frequency of metastasis 2. Tumors often responds to radiation therapy but frequently recurs

b.

prognosis is generally poor

2.

3.

largely preventable if smokers stop and nonsmokers avoid second hand smoke Findings a. hoarse voice b. changes in breathing c. persistent cough or change in cough d. blood-streaked or bloody sputum e. chest pain or tightness in chest wall f. recurring pneumonia, pleural effusion g. weight loss Diagnostics a. medical imaging examinations b. cytological sputum analysis c. bronchoscopy d. biopsy - most definitive diagnostic tool for lung cancer 4. Management a. nonsurgical i. chemotherapy ii. radiation therapy iii. laser therapy to de-bulk tumor iv. thoracentesis and pleurodesis b. surgical i. thoracotomy wedge resection - part of a lobe segmental resection- part of a lobe lobectomy - one or more lobes pneumonectomy - entire right or left lung 5. Nursing interventions a. post-operative care i. chest drainage ii. routine post operative care monitor respiratory status frequently teach effective deep breathing and cough techniques refer to physical therapy for exercises for shoulder on affected side relieve pain iii. optimize oxygenation iv. provide opportunities for the client to talk about cancer; as needed, refer to support groups v. teach information as based on treatment plan and prognosis vi. optimize nutritional status

c.

D.

Cor pulmonale 1. Definition/etiology a. right ventricular hypertrophy and subsequent chronic heart failure b. cause: heart must pump against great resistance from lung's blood vessels: called increased pulmonary vascular resistance (PVR) c. increased PVR results from chronic lung disease d. may be due to primary pulmonary hypertension as well 2. Diagnostics a. pulmonary artery pressure readings via a catheter b. echocardiogram c. chest radiograph d. ABG e. EKG

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Management a. administer oxygen as ordered b. if hemoglobin within normal limits (WNL), monitor oxygenation with finger or pulse oximeter c. bed rest, as needed d. monitor effects of medications I. cardiac glycosides II. pulmonary artery vasodilator III. diuretics IV. restricted fluid intake as indicated e. nursing interventions I. monitor for changes in oxygenation status II. pace activities in clients who tire easily

E.

Respiratory failure 1. Definition: lungs cannot maintain arterial oxygen levels or eliminate carbon dioxide a. PaCO2 > 50 mm Hg b. PaO2 < 50 mm Hg c. clients with chronic lung disease precautions i. look for drop from baseline function ii. this is a nursing and medical emergency iii. clients are always hypoxemic 2. Etiology a. lung diseases that harden the alveolar-capillary membrane to trap O2 b. neuro-muscular or musculoskeletal disorders i. respiratory drive dulled or blunted ii. muscles too weak to breathe 3. Diagnostics: ABG 4. Management a. oxygen per mask b. mechanical ventilation c. monitor for improvement in the underlying cause for the respiratory failure

Points to Remember

Oxygen is essential for life. So, before all else, keep airways open and ease breathing effort. Clients with chronic lung disease use more oxygen and energy to breathe. This can create a vicious cycle in which the client works harder, and continually requires more oxygen and more energy. Nursing interventions for clients with chronic lung disease should include pacing of activities, because these clients have little reserve for exertion. Quality of life for clients can be significantly improved if clients routinely use diaphragmatic breathing and pursed-lip breathing. Clients with asthma must understand the different types of inhalers and when to use each type. Some rescue inhalers are for acute dyspnea. Other inhalers are for maintenance or preventative types of drugs. A finger or pulse oximeter reading is simply one element of an assessment. It is not the whole picture. Cyanosis, a late finding, is determined by oxygenation and hemoglobin content. Clients with anemia may be severely hypoxemic and never turn blue, but rather "ashen". Clients with polycythemia may be cyanotic with adequate tissue oxygenation.

The serious public health issue of pulmonary TB requires control and reporting of any incidence and recent contacts that the client had so prophalactic therapy for two to three months can be initiated. When caring for a client after a chest tube insertion, an occlusive dressing is placed around the chest tube insertion site and the connections of the chest tube system are taped to prevent air leaks at connections. An occlusive dressing is one that is totally covered, as well as the edges with non-porous tape. This dressing is typically not changed and not expected to have any drainage on it. When caring for a client on a ventilator, if an alarm sounds, first, assess the client. See if the alarm resets or if the cause is obvious. If the alarm continues to sound and the client develops distress, disconnect the client from the ventilator, use a manual resuscitation bag to ventilate with 100% oxygen and page or call the respiratory therapist immediately. If the ventilator tube disconnects, the low pressure alarm will sound. If the high pressure alarm sounds on the ventilator, the nurse should check for some type of obstruction or occlusion of the airway: mucous plugs, biting of the tube by the client, tube slips into right main stem bronchus, or increased secretions. To maximize therapeutic effect of inhalers, the key is technique. It is critical to teach clients the right technique and observe how well they use the inhaler. Smoking cessation is critical to reduce the risk and severity of lung disease. Second-hand smoke enhances the risk of children to develop asthma or other chronic lung diseases. Best approach to pulmonary embolus is prevention. The use of intermittent compression stockings prevents clots in the deep veins. Clients with pulmonary TB need intensive community follow up to ensure that they continue with pharmacological treatment once discharged from the hospital. Clients who stop therapy too soon are the source for the more deadly multi-drug resistant forms of pulmonary TB.