Alteration in Gas Transport:

Care of the Patient with Respiratory Tract Problems

The Nursing Process and Respiration

Assessment

Client History
Why are you here? General overall health Any colds or congestion or allergy problems? Smoking history

Pack years: number of packs per day times number of years

How much time away from work or school have you missed because of this?

Assessment

Client History

Subjective symptoms
Dyspnea with ADLs? Childhood diseases

Asthma, pneumonia, allergies, croup Pneumonia, sinusitis, TB, HIV, emphysema, DM, HTN, cardiac disease Flu, pneumonia, BCG

Adult illnesses

Vaccine history

Assessment

Client History

Surgeries of upper or lower respiratory tract Injuries to upper or lower respiratory tract Hospitalizations Date of last

CXR, PPD, PFT

Recent weight loss Night sweats

Assessment

Client History

Sleep disturbances

How many pillows?

Family history Recent travel Occupation Leisure activities

Assessment

Client History

Drug use Recreational (marijuana, cocaine, crack) Prescription

ACE inhibitors Antihistamines Bronchodilators Chemotherapy Allergy medications Home remedies Herbals: Elecampane, Hyssop, Mullein, Licorice

OTC

Assessment

Client History

Allergies
Foods, drugs, substances Allergic response? Treatment?

Diet history

BMI

Obese? Malnourished? Body weight in pounds times 703 divided by height in inches squared

Food intake related to breathing issues?

Assessment

Client History

Occupation and Home Life

Environmental factors and exposure Type of heat used in the home Animals or pets in home Hobbies involving chemicals Pest infestation at home or work

Tie to asthma, wheezing related to roaches

Assessment

Major signs and symptoms

Cough
Type, duration, length Sputum production

Color, consistency, amount

Dyspnea
Rate of perception ADLs Paroxysmal nocturnal dyspnea Orthopnea

Assessment

Major signs and symptoms

Chest pain Wheezing Clubbing of fingers / nails Hemoptysis Cyanosis

Gerontologic Considerations

Vital capacity and respiratory muscle strength peak between 2025 and then decrease Age 40 and older surface area in alveoli is reduced Age 50 alveoli loses elasticity Loss of chest wall mobility>decrease in vital capacity

Gerontologic Considerations

Amount of respiratory dead space increases with age Decreased diffusion capacity with age lower oxygen level in arterial circulation

Risk Factors for Respiratory Disease

Smoking Personal / family history Occupation Allergens Recreational exposure

Physical Assessment

Nose and Sinuses

External nose
Deformities, tumors Nostrils: symmetry of size, shape

Nasal flaring Inspect for color, swelling, drainage, bleeding Mucous membranes

Nasal septum

Bleeding, perforation, deviation

Physical Assessment

Air movement

Occlude one nare

Via palpation Tenderness, swelling Tapping Penlight Frontal, maxillary

Sinuses

Physical Assessment

Pharnyx, Trachea, and Larynx

Posterior pharynx

Tongue depressor

One side at a time Observe rise and fall of palate and uvula (ah) Inspect for color, symmetry, discharge, edema, ulceration, tonsillar enlargement

Neck

Inspect for symmetry, alignment, masses, swelling, bruises, use of accessory neck muscles in breathing

Physical Assessment

Neck

Lymph nodes
Tender, movable inflammation Hard, fixed suggest malignancy

Trachea

Palpate for position, mobility, tenderness, masses

Larynx

laryngoscope

Physical Assessment

Lungs and Thorax

Inspection Palpation

Fremitus

99 Bubble wrap

Crepitus

Chest expansion Movement

Physical Assessment

Lungs and Thorax

Percussion

Pulmonary resonance

Air, fluid, solid masses Intercostal spaces only Diagphragmatic excursion Normal 1 -2 inches Deep breath / percuss No breath / percuss Normally higher on the right (liver)

Physical Assessment

Auscultation

Upright first Bare chest Open mouth breathing Full respiratory cycle Observe for dizziness

Physical Assessment

Normal breath sounds

Bronchial, bronchovesicular, vesicular Not heard peripherally

Additional sounds superimposed on normal sounds Indicate pathology Crackles, wheezes, rhonchi, pleural friction rub

Adventitious breath sounds

Physical Assessment

Voice sounds

Assessed when abnormalities noted Increased when sound travels through solid or liquid

Consolidation of lung, pneumonia, atelectasis, pleural effusion, tumor, abscess

Bronchophony: 99 loud and clear Whispered Pectriloquy: 1, 2, 3 loud Egophony E heard as an A

Physical Assessment

Skin and Mucous Membranes

Pallor, cyanosis, nail beds

Muscle development, general body build Muscles of neck, chest

General Appearance

Endurance

How does the client move in 10 20 steps? Speaking exertion

Diagnostic Assessment

Need to know:

Normal / abnormal for: RBC Hgb / Hct WBC / leukocytes / neutrophils Eosinophils Basophils Lymphocytes Monocytes ABGs Sputum studies Skin (PPD) testing

Diagnostic Testing

Chest xrays Digital Chest Radiography CT V/Q Scan Pulse Oximetry PFTs

Diagnostic Testing

Pulmonary Function Tests (PFTs)

Used generally in chronic conditions Assesses respiratory function Determine extent of dysfunction Measures lung volumes, ventilatory function, and mechanics of breathing, diffusion, and gas exchange Assesses response to therapy Screening test in hazardous industries

Diagnostic Testing

Arterial Blood Gases (ABGs)

Measures blood pH and arterial oxygen and carbon dioxide levels Assesses ability of lungs to provide adequate oxygen and removal of carbon dioxide Assesses ability of kidneys to maintain normal pH

Diagnostic Testing

Pulse Oximetry

Noninvasive method of monitoring oxygen saturation of hemoglobin Unreliable in cardiac arrest and shock, dyes or vasoconstictor meds used, severe anemia, or high carbon monoxide level

Diagnostic Testing

Cultures

Throat or sputum Sputum

Best to obtain early AM Rinse mouth, takes deep breaths, coughs, and expectorates Deliver specimen to lab within 2 hours

Diagnostic Examination

Endoscopy

Bronchoscopy, laryngoscopy, mediastinoscopy Check for patent airway every 15 minutes post procedure for two hours Local anesthetic Patient must remain still Usually at bedside Post procedure: CXR r/o mediastinal shift, monitor VS, auscultate breath sounds

Thoracentesis

Lung biopsy

Diagnosis

Upper Airway Medical Diagnosis

Rhinitis Viral rhinitis Acute sinusitis Chronic sinusitis Acute pharyngitis Chronic pharyngitis Tonsillitis and adenoiditis

Diagnosis

Upper Airway Medical Diagnosis

Peritonsillar abscess Laryngitis

Ineffective airway clearance Acute pain Impaired verbal communication Fluid volume deficit Knowledge deficit

Upper Airway Nursing Diagnosis

Planning and Implementation

Upper airway

Maintain patent airway Promote comfort Promote communication Encourage fluid intake Teach self care

Encourage appropriate hand washing

Planning and Implementation

Managing potential complications

Sepsis Sepsis Meningitis Otitis media

Evaluation

Maintenance of patent airway Reports feelings of comfort Demonstrates ability to communicate Maintains adequate fluid intake Identifies strategies to prevent infections Becomes free of s/sx of infection Demonstrates adequate knowledge

Upper Airway Obstruction and Trauma

Medical Diagnosis

Sleep apnea
Obstructive Central Mixed

Epistaxis Nasal Obstruction Fractures of the nose Laryngeal Obstruction Laryngeal Carcinoma

Upper Airway Obstruction and Trauma

Nursing Diagnosis

Knowledge deficit Anxiety Ineffective airway clearance Impaired verbal communication Nutritional imbalance Alteration in body image Self care deficit Sleep deprivation Risk for injury Fatigue

Planning and Implementation

Sleep apnea

Avoid ETOH Decrease body mass CPAP Uvulopalatopharyngoplasty Tracheostomy Pharmacologic Management Low flow O2 Triptil Education

Planning and Implementation

Epistaxis

Dependent on location of site

Generally anterior

Pinch outer portion / sit upright Silver nitrate / gelfoam / electrocautery Topical vasoconstrictors Monitor VS Estimate amount of blood loss Dont forget standard precautions

Planning and Implementation

Nasal Obstruction

Deviation of nasal septum Submucous resection Generally outpatient Promote drainage Alleviate discomfort Frequent oral hygiene

Planning and Implementation

Fractures of the nose

Bleeding from site Bruising Clear fluid CSF Glucose positive Surgical reduction ~ one week post injury Ice therapy Control anxiety Oral hygiene

Planning and Implementation

Laryngeal Obstruction

Often fatal Acute laryngitis, urticaria, scarlet fever, anaphylaxis, foreign bodies Edema: SQ Epi 1:1,000 / corticosteroid Abdominal thrust (Heimlich) Emergent tracheotomy

Planning and Implementation

Laryngeal Cancer

Risk factors: chart 22-5 Dependent upon tumor staging (chart 22-6) Laryngectomy Radiation Speech therapy Potential complications: respiratory distress, hemorrhage, infection, wound breakdown

Laryngeal Cancer

Educate preoperatively Reduce anxiety Maintain patent airway Encourage speech therapy Maintain adequate nutrition Promote positive body image Teach self care

Evaluation

Adequate level of knowledge Lessened anxiety Clear airway Acquires effective communication Appropriate intake Positive self and body image Complication free Adheres to home therapy

Chest and Lower Respiratory Tract

Medical Diagnosis

Atelectasis Patho: figure 23-1 Acute tracheobronchitis Pneumonia MUST know table 23-1 and charts 23-2, 23-3 Review older adult considerations / risk factors

Assess any older adult with AMS for pneumonia May not have cough or fever

Nursing Diagnosis

Ineffective airway clearance Activity intolerance Fluid volume deficit Altered nutrition Knowledge deficit Impaired gas exchange Pain Fatigue

Planning and Implementation

Avoid potential complications:

Continuing symptoms Shock Respiratory failure Atelectasis Pleural effusion Confusion Superinfection

Planning and Implementation

Improve airway patency

Hydration Humidification Oxygen therapy CPT

Long recovery periods

Promote rest

Conserve energy Promote fluid intake

Planning and Implementation

Maintain adequate nutrition

Determine caloric needs with RD help

Educate client Teach self care

Evaluation

Adequate airway patency Optimal rest patterns Maintains appropriate nutrition and hydration status Knowledgeable of disease and treatment Adheres to treatment strategies Complication free

Inhalation Injury Smoke and Carbon Monoxide

Produce local injuries by inflammation, irritation, and damage to pulmonary tissues Systemic injuries S &S of CO poisoning

Mild headache, visual disturbances, irritability, nausea Severe confusion, hallucinations, ataxia, coma

Therapeutic Management

100% oxygen Artificial ventilation Hyberbaric chamber more rapid Tx of CO poisoning Possible intubation Steroids, antibiotics, bronchodilators Monitor rate and depth of respirations at least every hour

Planning and Intervention

VS assessment / monitoring Respiratory assessment Pulmonary physiotherapy Mechanical ventilation Psychological care of child and parents

Pulmonary Tuberculosis

Risk factors (chart 23-4) CDC recommendations (chart 23-5)

Classification of disease

0-5; class 3 clinically active

Older adult
AMS, fever, anorexia Delayed reactivity or recall phenomenon with PPD

Airborne precautions!!

Close the door!

Nursing Diagnosis

Ineffective airway clearance Knowledge deficit Activity intolerance Potential for treatment non adherence Impaired gas exchange Fatigue Alteration in nutrition Social isolation

Planning and Implementation

Medical Management

Drug resistance is major problem Table 23-2 lists current recommended first line drug therapy Therapy lasts up to 12 months HIV infection has increased prevalence Drug therapy should be dispensed in two week intervals

Planning and Implementation

Potential Complications

Malnutrition Medication side effects Drug resistance

Determine which clients should participate in directly observed therapy (DOT)

Miliary TB Decreased effectiveness with oral contraceptives

Planning and Implementation

Promote airway clearance Encourage patient adherence Promote adequate nutrition Encourage rest Educate patient regarding routes of transmission and disease manifestations

More people are infected than have active TB

Teach self care

Evaluation

Maintain patent airway Adequate level of knowledge Adheres to treatment regimen Participates in self care Maintains optimal rest patterns Complication free

Lung Abscess

Causative factors

Bacterial pneumonia Oral aspiration / obstruction Airway clearance Knowledge deficit Alteration in nutrition

Nursing Diagnosis

Planning and Implementation

Administer AB therapy Monitor for adverse effects CPT TCDB Appropriate nutritional intake Emotional support Educate regarding self care

Pleural Condition Diagnoses

Medical Diagnosis

Nursing Diagnosis

Pleural Conditions Pleurisy Pleural effusion Empyema

Anxiety Pain Knowledge Deficit Self Care Deficit Alteration in Nutrition Airway Clearance

Planning and Implementation

Pleural friction rub, decreased fremitus, absent breath sounds Pain relief, comfort measures TCDB Thoracentesis Implement medical regimen Monitor chest tube drainage Empyema long healing process

Diagnosis

Pulmonary Edema

Life threatening Generally, abnormal cardiac function flash pulmonary edema post surgery Crackles in bases, increasing throughout
Airway clearance Cardiac function anxiety

Nursing Diagnosis

Planning and Implementation

Administer O2 Assist with ventilation as appropriate Medication administration Monitor patient response Educate and prepare patient and family

Diagnosis

Acute Respiratory Failure

Difference between acute and chronic Chronic: COPD / neuromuscular dx Acute: VP mismatch, alveolar hypoventilation, PaO2 < 50
Similar to other airway constrictive disease states

Nursing Diagnosis

Planning and Implementation

Assist with intubation / mechanical ventilation Monitor response Prevent complication Enable communication Educate family and patient

Diagnosis

Acute Respiratory Distress Syndrome

Inflammatory trigger

Nursing Diagnosis

Airway clearance Anxiety Pain Nutritional alterations

Planning and Implementation

Close monitoring Ventilator support CPT Frequent assessment Education Rest and comfort measures

Pulmonary Hypertension

Causes: Chart 23-7 Nursing Management

Identify high risk patients Educate regarding s/sx Oxygen therapy

Cor Pulmonale

Right ventricle enlargement Generally, from COPD S/ Sx generally r/t underlying disease state Treatment related to addressing underlying disorder

Pulmonary Embolism

Risk factors: Chart 23-8 Home care: Chart 23-9 Diagnosis: CXR, ECG, V/P scan, ABGs Nursing diagnosis

Knowledge deficit Anxiety Airway clearance Pain Decreased cardiac output Risk for injury (bleeding)

Planning and Intervention

Improve respiratory and vascular status Anticoagulation therapy Thrombolytic therapy Surgical intervention

Rare

Minimizing risk most important step Monitor therapy Manage pain

Sarcoidosis

Hypersensitivity response Biopsy required for diagnosis Corticosteroid therapy May involve other body systems

Occupational Lung Diseases

Medical Diagnosis

Silicosis Coal workers pneumoconiosis Asbestosis

Prevention is key Educate clients to wear a mask Consider also hobbies

Diagnosis

Lung and Chest Carcinoma: to be covered in oncology section Chest Trauma: to be covered during trauma seminar Aspiration: similar to pneumonia and obstructive disorders

High risk in patients with altered LOC Do not force feed clients!

Chronic Obstructive Pulmonary Disease

Airflow limitation Irreversible Chronic bronchitis, emphysema Risk factors: Chart 24-1 Three primary symptoms:

Cough Sputum production Dyspnea

Assessment

Spirometry evaluation of airflow obstruction

Ratio of FEV: FVC Less than 70%

Health history overview: chart 24-2 Assessment: chart 24-3 Stages of COPD: table 24-1 Crackles

Nursing Diagnosis

Impaired gas exchange Ineffective airway clearance Ineffective breathing pattern Activity intolerance Knowledge deficit Ineffective coping Anxiety Alteration in nutrition Fatigue

Planning and Implementation

Potential complications:

Respiratory insufficiency Chronic respiratory failure Acute respiratory failure Atelectasis Pulmonary infection Pneumonia Pneumothorax Pulmonary hypertension

Planning and Implementation

Promote smoking cessation Improve gas exchange

Medication administration Measure improve in flow rates CPT Controlled coughing Huff coughing Increased fluids

Airway clearance

Planning and Implementation

Improving breathing patterns

Inspiratory muscle training Diaphragmatic breathing Pursed lip breathing Standing against wall Over bedside table with pillows Determine limitations Determine client preferences Pacing activities Exercise training

Improving activity tolerance

Planning and Implementation

Self care strategies

Realistic goal setting Heat / cold extremes

Heat increases oxygen demands Cold promotes bronchospasms

Lifestyle modification

Coping strategies Self care teaching

Evaluation

Knowledgeable of smoking dangers Improved gas exchange Achieves maximal airway clearance Improves breathing pattern Demonstrates strategies for activity tolerance and self care Effective coping Avoids complications

Bronchiectasis

Separate from COPD now Management similar to COPD CPT Smoking cessation Postural drainage Energy conservation measures

Asthma

Chronic inflammatory disease Sxs: cough, chest tightness, wheezing, dyspnea Is reversible Most common chronic disease of childhood Predisposing factors:

Allergens Airway irritants Exercise Stress Sinusitis Medications Viral respiratory tract infections GERD

Asthma

Nursing Diagnosis

Anxiety Airway clearance Breathing patterns Fluid volume deficit Knowledge deficit

Assessment

Health history Comorbid conditions Sputum cultures / serum samples

Elevated levels of eosinophils

ABG / pulse ox

Hypoxemia during attacks Hypocapnia and respiratory alkalosis PaCO2 May rise initially Return to baseline indicative of impending respiratory failure

Planning and Intervention

Prevention is key Pharmacology

Long acting: corticosteroids, antiinflammatory agents Quick relief: relief of acute symptoms, bronchodilators Table 24-4 details medications Oxygen therapy is often indicated during acute attacks Can be mixed with helium (Heliox) to improve delivery to the alveoli

Planning and Intervention

Peak flow monitoring

Daily is recommended

Monitor respiratory status Thorough history of allergens Medication administration Fluid administration

Intake and output recording

Preparation for mechanical ventilation

Planning and Intervention

Prevention of complications

Status asthmaticus Respiratory failure Pneumonia Atelectasis Airway obstruction Dehydration

Status Asthmaticus

Attack that does not respond to conventional therapy Close monitoring first 12-24 hours Volume status closely monitored Energy conservation No respiratory irritants Nonallergenic pillow

Cystic Fibrosis

<40% reach adulthood Airflow obstructive disease with genetic component Elevated sweat chloride

Steatorrhea Control of infections key Nursing interventions similar to other obstructive diseases Lung transplantation small number End of life care important

>60 mEq/L

Respiratory Procedures

Inhalation therapy

Oxygen therapy Humidification Aerosol therapy Artificial ventilation Continuous positive airway pressure (C-PAP)

Oxygen Therapy

Nasal cannula / mask / tent Apply to anyone who is hypoxic or with stridor Considerations

Avoid open flames and electrical appliances Monitor response Adverse effects to premature infants retina Caution with COPD Oxygen toxicity Use humidification Check skin integrity

Aerosol Therapy

Used to deposit medications directly into airways Types

Hand-held nebulizers Metered-dose inhaler (MDI) Spacer device

Close the door when administering

Chest Physiotherapy (CPT)

Postural drainage in conjunction with adjunctive techniques

Manual percussion, vibration, squeezing the chest, cough, forceful expiration, and breathing exercises Percuss over rib cage Used in increased sputum production

Considerations

CPT

Contraindications

Pulmonary hemorrhage Pulmonary embolus ESRD Increased intracranial pressure Minimal cardiac reserves

Artificial Ventilation

Nasotracheal Orotracheal Tracheostomy Considerations

In children, tubes have more acute angle and are softer to mold to contours of trachea

Smoking Cessation

Anyone who smokes is an increased risk for pulmonary problems Assist clients interested in smoking cessation programs Teach all clients who smoke the warning signs of lung cancer

Thats All, Folks!

Any questions or comments?