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RESPIRATORY DISORDERS General Respiratory Anatomy and Physiology 1.

respiratory The system is comprised of the upper airway and lower airway structures. 2. The upper respiratory system filters, moistens and warms air during inspiration. 3. The lower respiratory system enables the exchange of gases to regulate serum PaO2, PaCO2 and Ph. 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 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




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

Physiology y Basic gas-exchange unit of the respiratory system is the alveoli. y Alveolar stretch receptors respond to inspiration by sending signals to inhibit inspiratory neurons in the brain stem to prevent lung over distention. y During expiration stretch receptors stop sending signals to inspiratory neurons and inspiration is ready to start again. y Oxygen and carbon dioxide are exchanged across the alveolar capillary membrane by process of diffusion. y 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. y Chemoreceptors, a secondary feedback system, located in the carotid arteries and aortic arch respond to hypoxemia. These chemoreceptors also stimulate the medulla. Ph regulation y 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. y 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. y 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. y When arterial Ph rises or the arterial PaCO2 falls, hypoventilation occurs. DIAGNOSTIC PROCEDURE Pulmonary Function Test  Measures lung volumes, lung mechanics, and diffusion capabilities of the lungs  Also includes ventilation tests of forced expiratory volume, vital capacity and maximal voluntary ventilation measures  Functional Residual Capacity volume of air that remains in the lungs after a normal quiet exhalation

Residual Volume volume of air that remains in the lungs after a forceful exhalation Vital Capacity maximum volume of air that can be exhaled after a maximum exhalation Tidal Volume volume of air inhaled and exhaled with normal quiet breathing Inspiratory Reserve Volume maximum volume that can be inhaled following a normal quiet breathing  Expiratory Reserve Volume maximum volume that can be exhaled following a normal quiet breathing Pulse Oximetry  Passes a beam of light through the tissues, and a sensor attached to the finger tip, toe, or ear lobe measures the amount of light absorbed by oxygen-saturated hemoglobin  Non-invasive and continuously monitored Arterial Blood Gas Analysis  Measures PaO2, PaCO2, pH, Sa O2, and HCO3 Assesses ventilation and acid-base balance  Commonly uses the radial artery  Allen s test is performed before sample is drawn  Pre-heparinized syringe to prevent clotting of specimen  Apply pressure to site for 5-10 mins after withdrawing sample  Container with ice to prevent hemolysis of the specimen Ventilation Perfusion Scan  Assesses lung ventilation and perfusion  Radioactive gas (ventilation) or radioactive dye (perfusion) is administered and produces an image of the areas to test for ventilation  Confirms pulmonary embolism and other blood flow abnormalities  Remain still during the procedure Chest X Ray  Contraindicated in pregnant women  Performed for:  Routine screening procedure  Pulmonary disease is suspected  Monitor status of respiratory disorders  Confirm endotracheal or tracheostomy tube placement  After traumatic chest injury  Teach client to hold his breath and do deep breathing  Remove metals from the chest  Shield the gonads during the test MANTOUX TEST  PPD (Purified Protein Derivative) is used  Signifies exposure to Mycobacterium tubercle bacilli  Intradermal route of injection  (+) Mantoux test is induration of 10 mm or more  Induration of 5 mm is considered positive in immunocompromised patients.  Reading result 1. Read 48 72 hours 2. Measure induration only 3. Record in millimeters Fluoroscopy  Studies the lung and chest in motion    

A radiopaque (non-iodine) based contrast agent is administered intravenously to help assess the structures assessed  Contraindicated in pregnant women  Remove all jewelries and underclothes and put on gown Gallium Scans  Radioactive gallium citrate taken up by tumors and areas of inflammation after 24-48 hours of injection  Painless except for local pain at injection site  Client is in supine and may remain dressed but must remove all metal objects Bronchoscopy  Direct inspection and observation of the larynx, trachea and bronchi through a flexible or rigid bronchoscope  Uses:  To collect secretions  To determine location or pathologic process  To remove aspirated foreign objects  To excise lesions  Nursing Care before bronchoscopy  Informed consent/permit needed  Atropine, valium and topical/local anesthetics  NPO 6-8 hours to prevent vomiting and aspiration  Remove dentures, prostheses, contact lenses to prevent losses of valuables  Nursing Care after bronchoscopy  Side-lying position to promote drainage  Check for return of gag reflex  Watch for signs of bronchial tree perforation (cyanosis, hypotension, tachycardia, arrythmias, hemoptysis, dyspnea) Laryngoscopy  Visual examination of the larynx and is used to diagnose laryngeal papillomas, nodules, polyps or cancer  Can be performed during bronchoscopy or as a separate procedure  2 approaches: Direct and Indirect Thoracentesis  Nursing Care before thoracentesis  Secure consent  Take initial VS  Position: upright leaning on overbed table, feet supported on foot stool  Instruct to remain still, avoid coughing during insertion of needle  Pressure sensation is felt upon needle insertion  Nursing Care after Thoracentesis  Turn to the unaffected side for at least 1 hour to prevent leakage of fluid in the thoracic cavity  Bed rest until VS are stable to prevent orthostatic hypotension Endoscopic Thoracotomy  Alternative to open-lung biopsy and thoracotomy for pleural surface disorders  Has 3 incisions: 1 for the insertion, the other 2 for specimen collection  Chest tube is inserted to promote lung reexpansion  Advantages: reduced anesthesia time, less pain and shortened hospital stay 

 Informed consent is important  Uses general anesthesia  Chest tube and deep breathing exercises post-operatively SPUTUM EXAM  TYPES  Sputum culture and sensitivity test to detect actual microorganism causing the infection  Sputum test for gross appearance indicate certain diseases  AFB staining for diagnosis of TB collected for 3 consecutive days  Cytological examination to detect cancer cells  3-day early morning specimen  Random sputum collection  Early morning sputum specimen is ideal  Rinse mouth with water (do not use astringents  Use sterile container  Collected before the first dose of antimicrobial  Instruct not to spit saliva DISTURBANCES OF THE UPPER AIRWAYS LARYNGEAL TUMORS  Types: Risk Factors:  Glottic 1. Cigarette smoking  Supraglottic 2. Chronic laryngitis  Subglottic 3. Vocal abuse 4. Alcohol abuse 5. Familial tendency to laryngeal cancer 6. environmental pollutants DIAGNOSTICS

hemoptysis halitosis Mass or Lump in the neck  Dysphagia  Dyspnea  Anorexia, anemia, weight loss Medical Management  Radiation  Chemotherapy  Surgery: Subtotal/Total Laryngectomy  Subtotal retains voice  Total absolute loss of voice Preop Care  Psychosocial support  Effects of total larynectomy  Loss of voice  Permanent tracheostomy  Loss of sense of smell  Inability to: Blow the nose, Sip through straw, Whistle, Gargle, Do valsalva maneuver (unable to lift heavy objects, constipation)  Effective means of communication to be used postop   

Postop Care  Care of a client with tracheostomy  Establish patent airway  Prevent infection (Cleanse stoma and tracheostomy at regular basis, Change dressings and ties as necessary)  Establish means of communication  Provide psychosocial support  Assist during speech therapy

Nursing Interventions  Suction nose frequently.  Promote pain relief.  Promote wound drainage.  Administer & monitor tube feedings as ordered.  Observe stoma/structure lines for signs of infection.  Enhance communication.  Support client during adaptation to altered physical status Provide client teaching  Tracheostomy/laryngectomy and stoma care  Avoid swimming  Control of dryness and crusting of the tongue.  Need for a humidifier at home.  Protect stoma while showering.  Avoid use of powder, spray, aerosol near tracheostomy  Cover stoma when coughing or sneezing.  Necessity of installing smoke detectors. EPISTAXIS  Causes:  Rheumatic Heart Disease  Irritation  Cancer  Trauma  Blood disorders  Foreign bodies  Hypertension Nursing Interventions  Sit-up, lean forward, head tipped to prevent aspiration of blood  Pressure over the soft tissues of the nose for at least 5 minutes  Cold compress/ice pack

SINUSITIS  Inflammation of the sinus PANSINUSITIS infection of more than one sinus  CAUSES:  URTI  Cigarette smoking  Allergic rhinitis  Impaired mucociliary action  DIAGNOSTIC TOOLS:  X-ray  CT Scan  Transillumation test

Clinical Manifestations  Pain  Maxillary: cheek, upper teeth  Frontal: above eyebrows  Ethmoid: in and around the eyes  Sphenoid: behind eye, occiput, top of the head  General malaise  Stuffy nose  Headache  Post-nasal drip  Persistent cough  Fever and Chills

Nursing Interventions  Rest  Increase fluid intake  Hot wet packs  Irrigation of maxillary sinuses with warm NSS Medical Interventions  Codeine, avoid ASA it increases the risk of developing nasal polyps  Amoxicillin or other anti-infectives: (acute 7 to 10 days; chronic -21 days)  Antihistamines or H1 blockers (Loratidine, Diphenhydramine, Brompheniramine)  Nasal Decongestants eg. Dimetapp  Expectorants and Mucolytic Agents, Antitussives eg. Codeine Surgery  Functional Endoscopic Sinus Surgery (FESS)  To reestablish sinus ventilation mucociliary clearance  Done as outpatient, local anesthesia or general anesthesia  Fiberoptic endoscopes are passed through the nasal cavity  Complications: bleeding, pain, scar formation, CSF leak, blindness  Nasal packing postop  Caldwell Luc Surgery (Radical Antrum Surgery)  Incision is done and diseased mucous membrane is removed  Do not chew on affected side  Caution with oral hygiene to prevent trauma to incision  Do not wear dentures for 10 days  Do not blow nose for 2 weeks after removal of packing  Avoid sneezing for 2 weeks after surgery  Ethmoidectomy/Sphenoidectomy  Osteoplastic flap surgery for frontal sinusitis PHARYNGITIS  Could be viral, bacterial or fungal  Beta-hemolytic streptococcus is most common  Risk Groups: alcoholics, smokers, live and work in dusty places, chronic cough, use their voices excessively  Clinical Manifestations: sore throat, difficulty swallowing, fever, malaise, cough, elevated WBC  Contagious by droplet spread  Management  Good handwashing  Antimicrobials as ordered  Bed rest

Nursing Interventions  Promote rest  Increase fluid intake  Warm saline gargle  Analgesic as ordered  Antimicrobial as ordered Surgery: Tonsillectomy/ Adenoidectomy  PreOp Care  Assess for URTI. Coughing and sneezing postop may cause bleeding  Check Prothromin time. Bleeding is a common postop complication  Postop Care  Prone, head turned to side, or lateral position (awake: semi Fowler s)  Oral airway until swallowing reflex returns  Monitor for hemorrhage  Frequent swallowing  Bright red vomitus  Increased PR  Throat discomfort between 4th to 8th postop day is expected. This is due to sloughing off of mucous membrane at the operative site  Stool: black/dark for few days due to swallowed blood  Plenty of rest for 2 weeks  Avoid colds, overcrowded public places; coughing and sneezing due to URTI may cause bleeding  Client Education:  Avoid clearing of throat. This may cause bleeding  Avoid coughing, sneezing, blowing nose for 1 to 2 weeks  2 to 3 L of fluids/day until mouth odor disappears  Avoid hard/scratchy foods until throat is healed  Report signs and symptoms of bleeding  Promote comfort  Ice collar  Acetaminophen  Avoid administration of ASA (causes bleeding)  Foods and fluids  Ice-cold fluids  Bland foods PERITONSILLAR ABSCESS  Extensive swelling of the soft palate and pharyngeal wall  May arise from acute streptococcal or staphylococcal tonsillitis  Clinical Manifestations: drooling, muffled sound, partial obstruction to swallowing  Management  Surgery if ruptured  Antibiotics as ordered  Saline or alkaline mouthwashes or gargles RHINITIS  Inflammation of nasal mucosa  Also called coryza or common cold  Classic manifestations: increased nasal drainage, nasal congestion and paroxysmal sneezing  Classifications: Acute, Allergic, vasomotor or drug-related  Management  Humidification  Decongestants as ordered  Increase oral fluids  Symptomatic treatment 

Surgery: Nasal polypectomy (post-op)  Humidification  Mouth care  Nasal packing and ice compress  Increase oral fluids  Semi- or high Fowler s position DISTURBANCES OF THE LOWER AIRWAYS Asthma  Characterized by airway obstruction, inflammation and increased responsiveness to a variety of stimuli  Status asthmaticus is a severe life-threatening complication that is refractory to treatment.  Trigger Factors  Drugs and food additives  Allergens  Emotional stress  Respiratory infections  Exercise  Clinical Manifestations  Severely diminished breath  Wheezing sounds  Cough  Use of accessory muscles  Dyspnea  Tachycardia  Chest tightness  Ventricular dysrhythmias  Pulsus paradoxus (pulse becomes weaker as one inhales and stronger as one exhales) Medical Management  Bronchodilators  B-adrenergic drugs (metaproterenol, albuterol, isoproterenol, epinephrine, terbutaline)  Anticholinergics (ipratropium bromide, atropine)  Xanthines (theophylline)  Corticosteroids (hydrocortisone, prednisone)  Mast-cell stabilizers (cromolyn, nedocromil)  Leukotriene modifiers (montelukast, zafirilukast, zileuton)  Diagnostics  Pulmonary function test  Spirometry  ABG  Sputum specimen  Nursing Management  Administer medications and monitor closely  High fowler s position; slow rhythmic breathing  Adequate fluid intake  Provide extra humidity  If with respiratory acidosis- O2 as prescribed  Calm, quiet environment  Instruct patient to recognize trigger factors  Teach importance of hydration, adequate nutrition and exercise CHRONIC BRONCHITIS  CAUSES  Cigarette Smoking  Respiratory Tract Infection  Environmental Pollutants EMPHYSEMA  Presence of overdistended, non-functional alveoli which may rupture, resulting to loss of aerating surface  CAUSES:  Cigarette Smoking  Heredity  Aging Process 


Often marked Scanty, mucoid

smoking Absent or slight Copious, mucopurulent

MANAGEMENT  Rest to reduce oxygen demands  Increase fluid intake to liqeufy mucus  Good oral care  High calorie, high CHON, low CHO diet  Oxygen therapy of 2LPM  Avoid smoking, alcohol, pollutants  Chest physiotherapy  Mucolytics, expectorants, bronchodilators, steroids, antihistamines, antimicrobials as ordered Bronchiectasis  Extreme form of bronchitis that causes permanent, abnormal dilation and distortion of bronchi and bronchioles  Results from chronic inflammatory changes in the bronchial mucosa  Diagnosis: chest x-ray, bronchogram, CT scan  Clinical Manifestations  fever  Cough  Clubbing of fingers  Purulent sputum  Fatigue and malaise  Hemoptysis  Nasal stuffiness  Management:  Same as COPD Pulmonary Embolism  Causes  Fat embolism  Multiple trauma  PVD s  Clinical Manifestations  Restlessness  Dyspnea  Stabbing chest pain  Cyanosis  Tachycardia  Nursing Interventions  Oxygen therapy  Early ambulation postop  Monitor obese patient  Do not massage legs  DO s  Observe for bleeding  Use soft toothbrush, electric razor  Evaluate use of contraceptives


Abdominal surgery Immobility hypercoagulability

Dilated pupils Apprehension/fear Diaphoresis Dysrhythmias hypoxia  Relieve pain  Head of bed elevated  Heparin (2 weeks) then  coumadin (3-6 months) DONT s  Take ASA with Coumadin  Restrictive clothings on legs  Prolonged sitting/standing  Smoking  Bruises, constipation  contact sports

LUNG CANCER  Predisposing Factors  Cigarette smoking  Asbestosis


Emphysema Smoke from burnt wood


Frank hemoptysis


pleural effusion, bronchitis Unexplained dyspnea


Nursing Interventions  Protection from infection  Patent airway  Adequate nutrition  Oxygen/Aerosol therapy  Chest tube managemen  Deep breathing Exercises  Relief of Pain Prevention  Quit smoking  Early detection/screening  Chest x-ray once a year SURGERY  Pneumonectomy  Position in semi-fowler s, turned slightly on affected side for lung expansion  Avoid full side-lying position to prevent mediastinal shift  Lobectomy  Segmentectomy Wedge Resection removal of entire tumor regardless of segment Decortication stripping off of fibrinous membrane enclosing the lung Thoracoplasty removal of ribs usually after pneumonectomy to reduce the size of the empty thorax thereby prevent mediastinal shift For lobectomy, segmentectomy, wedge resection, decortication, thoracoplasty:  Chest tube in place postop  Position in semi-Fowler s position or on unaffected side to allow expansion of affected lung

PNEUMONIA - An infection of the pulmonary tissue, including the interstitial spaces, the alveoli, and the bronchioles; edema associated with inflammation stiffens the lung, decreases lung compliance and vital capacity, and causes hypoxemia  Major Classification  Community Acquired Pneumonia- occur either in the community or 48-72 hours before hospitalization  Hospital Acquired Pneumonia- also called nosocomial infection, onset of symptoms more than 72 hours after hospitalization  Aspiration Pneumonia- pulmonary consequences resulting from the entry of endogenous or exogenous substances into the lower airway.  Risk Factors  Smoking, Cancer, COPD  Aging  Immunosuppressed patients  Fatigue  Prolonged immobility  Overexposure to extreme heat or

 Viral- mucopurulent Consolidated or diffused/patchy appearance on chest x-rays Respiratory acidosis Chest pain, pleural effusion, dullness on percussion, decreased breath sounds, decreased focal fremitus  Diagnostics  Blood culture  Complete Blood Count  Sputum examination  Based on history and s/s  Arterial Blood Gas (ABG)  Dull percussion on affected lung  Chest X-Ray  Management  Bedrest  Position in Semi-fowler s to facilitate in breathing and lung expansion  Early ambulation as tolerated  Suction airway using sterile technique  Chest physiotherapy  Antibiotics as ordered Atelectasis  Collapse of lung at any structural level  CAUSES  Insufficient Pulmonary Surfactant  Reduction of Lung Distention  Increased Elastic Recoil Forces  Localized Airway Distention  Manifestations  Tachypnea  Hypoxemia  Tracheal shift towards the affected side  Dullness on percussion  Cyanosis  Diminished breath sounds  Management:  Incentive spirometry  Frequent position changes  Oxygen therapy  Early ambulation  Tracheal suctioning  Deep breathing exercises Disorders of fluid in pleurae Pleural fluid disorders - all treated with water seal chest drainage systems   

Pneumothorax: air between the pleurae y open pneumothorax: hole in the chest wall, communicates with the lung y closed pneumothorax: hole in lung, chest wall intact y tension pneumothorax - a nursing and medical emergency

Hemothorax y blood in the pleural space y treated with thoracentesis or chest tube Empyema y purulent drainage in the pleural space y often from a chronic condition such as lung cancer y treated with chest tube inserton Chylothorax y lymphatic fluid in pleural space y treated with thoracentesis or chest tube Flail Chest  result from direct blunt chest trauma and causes a potential for intrathoracic injury  pain with movement and chest splinting result in impaired ventilation and inadequate clearance of secretions  blunt chest trauma associated with accidents, which may result in hemothorax and rib fractures; loose segment of the chest wall becomes paradoxical to the expansion and contraction of the rest of the chest wall  Clinical Manifestations  Pain at injury site that increases with inspiration  Tenderness at site  Shallow respirations  Client splints chest  Fractures noted on chest x-ray  Paradoxical respirations (inward movement of a segment of the thorax during inspiration with outward movement during expiration)  Management:  Position the client in high Fowler s  Administer humidified air as prescribed  Monitor for increased respiratory distress  Encourage coughing and deep breathing  Administer pain medication as prescribed  Maintain bed rest and limit activity to reduce oxygen demands  Prepare for intubation with mechanical ventilator Tuberculosis  Reportable, communicable, inflammatory disease that can occur in any part of the body, especially the lungs  Infectious but may be cured or arrested by medications  Transmitted by droplet infection  Client Education:  Cover nose and mouth when coughing, sneezing or laughing  Wash hands after any contact with body substances, masks or soiled tissues  Wear masks when advised  Take medications regularly as prescribed  Primary TB drugs with Side Effects  Second-line TB drugs  Isoniazid (INH) - peripheral neuritis,  Capreomycin sulfate (Capastat hepatotoxicity sulfate)  Administer Vitamin B6  Kanamycin (Kantrex) (Pyridoxine)  Ethiomide (Trecator-SC)  Streptomycin ototoxicity,  Amikacin (Amikin) nephrotoxicity  Quinolones  Rifamficin jaundice, red-orange  Cycloserine (Seromycin) secretions  Para-aminsalicylic acid (Tubasal)  Ethambutol optic neuritis

Immunity: none since the virus do not commonly infect humans Treatment: oseltamavir (Tamiflu) and zanamavir; resistant to amantadine and rimantadine Vaccination: none Clinical manifestations:  initial symptoms of fever (38 C or higher)  cough  sore throat  muscle aches  eye infections  pneumonia and other severe respiratory diseases (such as acute respiratory distress)  rhinorrhea  Watery diarrhea  Personal protective equipment:  Interventions:  Protective clothing, preferably  Isolate suspected patients coveralls plus an impermeable  Give the patient a mask apron or surgical gowns with long  Maintain a minimum distance of 1 cuffed sleeves plus an impermeable meter from the patient apron;  Heavy-duty rubber work gloves that may be disinfected;  Standard well-fitted surgical masks (N95 respiratory masks);  Goggles;  Rubber or polyurethane boots Histoplasmosis  Systemic fungal disease caused by inhalation of dust contaminated by Histoplasma capsulatum  Common in Western countries  Not spread from human to human  Fungus seen in pigeon and chicken manure  Diagnosis  Chest x-ray  Histoplasmin skin test (read same as PPD)  Management  Amphotericin B  Teach farmers to wet down chicken coops before shoveling manure so fungal spores will not become airborne  Clinical Manifestations  Symptoms similar to tuberculosis or pneumonia  Cough  Fever  Joint pain  malaise  Sometimes asymptomatic Acute Respiratory Distress Syndrome  Refractory hypoxemia  Sudden progressive pulmonary  Reduced lung compliance  edema  Diffuse pulmonary infiltrates  Noncardiac origin  Severe dyspnea  Clinical Manifestations    

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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 th alarm continues to sound and the client e 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 inh l s, the key is technique. It is critical to teach clients the right technique and observe how well they use the inhaler.

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 Tac y ea  Dys ea  Re ac s  Ce al cyanos s  Dry cough  Fine crac les  Fever  Alteration in level of consciousness  ABG Pa O2 Pa CO2 Manage ent  Oxygen therapy (8-10 LPM)  Se i- to high-Fowler s position  Chest physiotherapy  Increase fluid intake  Meticulous eye care  If on Positive End Expiratory Pressure (PEEP) ventilation, administer Ativan/Morphine to reduce resistance