respiratory n415 linda winn, rn, msn ed., ba ed
TRANSCRIPT
RespiratoryN415
Linda Winn, RN, MSN Ed., BA Ed.
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
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