8b respiratory finalwithdx

7/29/2019 8B Respiratory Finalwithdx

1/27

Respiratory

COMMON LAB TESTS FOR RESPIRATORY DISORDERS

1. Blood

a. arterial Blood gasesb. blood culturesc. hemoglobind. hematocrite. CBC

f. serum electrolytesg. RASTh. immunoglobulinsi. cultures Profile II

2. Urinea. UAb. culture and sensitivitiesc. casts

3. Throat: sputum culture and sensitivites4. Skin5. Sputum specimen

1. standard precautions are required2. microbiologic examination of secretions from therespiratory tract3. may be obtained from patient expectoration or viasuctioning4. client should brush teeth and gargle before specimencollection5. indications: suspected pneumonia and malignancy

6. tests include a Gram stain and culture and sensitivity

Pulmonary function tests

a. use a spirometerand record how efficiently lungsexchange oxygen and carbon dioxide

b. client sits upright, wears noseclip and breathes intomouthpiece.c. uses

i. to diagnose lung diseaseii. to evaluate the extent of functional disabilityiii. to evaluate lung function pre-operativelyiv. to evaluate how lungs respond to

bronchodilatorsd. measurements:

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%
http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23


2/27

Thoracentesisa. insertion of large bore needle into pleural spaceb. uses

i. to obtain pleural fluid for analysisii. to remove pleural fluidiii. to instill medications

c. nursing interventionsi. position client either sitting upright with arms andshoulders on overbed table, or in side lying position

ii. stress that client must stay very still duringprocedure

iii. explain that client will feel some pressureiv. strict asepsis, standard precautionsv. post-procedure, place client on unaffected side for

at least 1 hourvi. check vital signs frequentlyvii. watch for signs of pneumothorax, subcutaneous

emphysema or shockviii. obtain and label specimens for analysis

Pulse oximetry

a. measures oxygen saturation; less accurate than arterialblood gas (ABG)

b. monitors oxyhemoglobin saturation noninvasively

c. techniquei. probe clips to end of finger or earlobe and passes alight through tissue

ii. light is absorbed by photodetector iii. oximetry calculated from how much light RBCs

absorb

iv. arterial saturation is displayed; normal SaO2 morethan/or equal to 93%

d. pulse oximetry unreliable if there isi. bright light shining on sensor ii. tremor or seizure on extremity where probe is

placediii. poor perfusion to location where probe is placediv. cardiac arrestv. intravascular dye circulating in the blood streamvi. abnormal hemoglobin, such as carboxyhemoglobin

and methemoglobine. if pulse oximetry shows significant changes, verify itsresults with ABG (arterial blood gas) assay

*Abnormal Values: values less

than 80% of predicted norm.


3/27

Pilocarpine test (iontophoresis) or sweat test

a. measures sodium and chloride excretion from sweatglandsb. often first test performed for diagnosing cystic fibrosisc. usually performed on infants

d. pilocarpine is administered to stimulate sweat glandse. perspiration is analyzed for sodium and chloride contentf. normal findings

i. sodium < 90 mEq/Lii. chloride < 60 mEq/L

Artificial airways

Adult endotracheal tubes

a. polyvinyl tube with inflatable cuff b. inserted through nose or mouth

c. distal end should be a few centimeters above the carinad. cuff around tube is filled with air

i. creates a seal in trachea

ii. air pressure in cuff < 25 cm H20 or client riskspressure necrosis in the tracheal mucosa

e. size of tube varies with size of child or adultf. pediatric tubes may not be cuffedg. when tube is inserted, check for placement

i. listen for bilateral breath soundsii. look for bilateral chest movementiii. chest x-ray

iv. measure exhaled carbon dioxidev. measure pulse oximetryh. nursing interventions

i. explain procedure to clientii. regularly assess tube placement and security,

breath sounds, and bowel soundsiii. mark tube length with teeth, or lips if edentulous

(toothless)iv. suction to maintain airway patency; observe

secretions for color, consistency, and amountv. assure inspired air is warmed and humidified since

upper airway is bypassedvi. provide oral hygiene and care for area around the

tube as indicatedvii. observe for skin breakdown around tube siteviii. observe for possible complications of aspiration;

oral/nasal pressure sores; accidental extubation; and oral,nasal and pharyngeal damage

Tracheostomy

a. surgical opening through the neck into the tracheab. indications

i. head and neck surgery

ii. long term airway access; for long-term mechanicalventilationiii. emergency airway

c. post-op complicationsi. tube dislodgement

ii. subcutaneous emphysemaiii. bleedingiv. infection


4/27

d. components of tracheostomy tubesi. outer cannulaii. inner cannulaiii. obturator

e. nursing interventionsi. explain procedure to client

ii. regularly assess tube placement and securityiii. care for tracheostomy as orderediv. suction to maintain airway patency (see below)v. provide adequate hydrationvi. periodically clean inner cannula and stoma sitevii. provide regular oral hygieneviii. change trach tube as orderedix. watch for skin irritation/infection at insertion sitex. teach client

1. trach care2. suctioning procedure3. findings of complications

4. how to handle accidentaldislodgement/extubation with obturator

Airway suctioning

a. removing secretions from the airwayb. sites for suction

i. nasopharynx, oropharynx, trachea, or bronchiii. through endotracheal tube or tracheostomy

c. equipmenti. use bulb syringe to suction nose/mouth of neonates, infants

ii. catheter's outer diameter should be no larger thanone-half inner diameter of endotrachial lumen

iii. determining length of catheter 1. measure from tip of nose to base of ear tosternal notch2. infant, young child: Insertion tolerancerange: eight to 14 cm3. older child, adolescent: Insertion tolerancerange:14 to 20 cm

iv. sterile procedure in institution; clean procedure athome.

v. suction when rhonchus is heard

vi. adjust vacuum pressure to between -80 and -120mm Hg

vii. insert suction catheter until resistance is met, thenwithdraw catheter an inch or two

viii. apply suction intermittently when withdrawingcatheter

ix. rotate catheter during withdrawalx. from time of insertion, spend no more than five to

ten secondsxi. re-establish ventilation and oxygenationxii. repeat procedure as indicatedxiii. pharyngeal suctioning: less depth, less risk of

complications than tracheal suctioningd. nursing interventions

i. explain procedure to clientii. explain that coughing, sneezing or gagging is

normaliii. place client in semi-fowler's position if condition

allowsiv. maintain standard precautions
http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23


5/27

v. do not routinely instill saline into airwayvi. if secretions are thick, increase humidity of inspired

air and fluid intakevii. provide patient with extra oxygen and extra deep

breaths before, during and after procedure1. if patient is receiving mechanical ventilation,

use ventilator2. if patient is breathing spontaneously, usemanual resuscitation bag or instruct to deepbreathe

viii. compare client's respiratory status before and aftersuctioning

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 causenasal bleeding

c. delivered oxygen (FIO2) depends on liter flow, client's tidalvolume and respiratory rate. Each liter is approximately 4% O2 added to21% O2 found in room air.d. nursing interventions

i. explain procedure to clientii. ensure prongs are in the naresiii. pad tubing around the ears, as indicated

Simple face mask

a. used at flow rates between 5 - 12 LPMb. must have at least 5 LPM to wash out carbon dioxide fromexhalation; recommended flow is 8 to 10 LPM

c. delivered oxygen (FIO2) depends on liter flow, client's tidalvolume and respiratory rated. not commonly used

Venti-mask (venturi mask)

a. uses air-entrainment principle to deliver precise FIO2b. due to entrainment, provides high rate of total flow

c. available in a range of FIO2d. depending on FIO2, flow rate four to ten LPMe. nursing interventions

i. explain procedure to clientii. keep nasal cannula on stand-by for mealsiii. assure venturi device does not become blocked by

beddingiv. assess for dry mucous membranesv. oral carevi. skin care

Non-rebreather mask

a. mask with added reservoir bagb. used at flow rates six to 15 LPM

c. provides highest percentage of O2 available from anymask, from 60-100%d. used for sickest clientse. nursing interventions

i. explain procedure to clientii. client requires close monitoring


6/27

iii. intubation may be needediv. assure reservoir bag does not completely collapse

during peak inspiration1. bag should deflate slightly when patientinhales and expand when client exhales.2. if bag collapses at inspiration, increase liter

flow to bagv. assure pop-off valves on mask are not stuck and

work properly

Home oxygen therapy: three types

a. compressed oxygen comes in tank or cylinder b. liquid oxygen in reservoir c. oxygen concentrator extracts and concentrates oxygenfrom the air

Positive pressure devices

a. CPAP (continuous positive airway pressure)i. compressor provides air flow to clientii. baseline of noninvasive positive pressure is

maintained throughout inspiration and exhalationiii. used primarily to treat sleep apnea at home for

maintenance of patient upper airwayb. BiPAP (bi-level positive airway pressure)

i. provides a baseline of noninvasive positivepressure throughout inspiration and exhalation

ii. provides positive pressure assist during client'sown spontaneous inspiratory effort

iii. used for clients in respiratory failure to rest clientand improve oxygenation to avoid intubation

Ventilators

1. Machines' purpose

a. support and maintain client ventilationb. improve ventilationc. improve oxygenationd. decrease work of breathing

2. Ventilator control modes: assist and synchronizeda. assist-control

i. preset rate at preset tidal volumeii. if client initiates breath, machine delivers the preset

tidal volumeb. synchronized intermittent mandatory ventilation (SIMV)

i. machine set to deliver a given rate at a preset tidalvolume

ii. clients can breathe on their own between machinebreaths but will determine own tidal volume

iii. used to gradually decrease machine support of breathing

3. Ventilator settingsa. tidal volume: amount of air delivered with each machinebreathb. rate: number of breaths delivered by the machine in aminute

c. FIO2: fraction of inspired oxygen

d. %O2: percent of oxygen (e.g., 60%)4. Sighs: deep breaths (higher volume) delivered periodically byventilator


7/27

5. Positive end expiratory pressure (PEEP)

a. normal physiologic PEEP is equal or less than 5cm H2Ob. provides a baseline of positive pressure throughoutexhalationc. used to reduce airway collapse and intrapulmonaryshunting

6. Nursing interventionsa. explain equipment to clientb. monitor client's response to mechanical ventilationc. assure ventilator is working properlyd. monitor artificial airway (as above)e. assess and provide for adequate nutritionf. monitor pulse oximetry and/or arterial blood gases asordered

Chest physiotherapy

1. Consists of coughing, chest wall percussion, vibration, and

postural drainage2. Designed to improve airway clearance3. Used for clients with retained tracheobronchial secretions4. Cough: natural clearing mechanism5. Chest wall percussion, vibration

a. percussion involves clapping chest with cupped handsb. vibration is downward vibrating pressure with flat hand;done during exhalation

6. Postural drainagea. gravitational clearance of airway mucous from variousbronchial segmentsb. uses 10 different body positions

7. Percussion and vibration done in each position; simultaneouslyclient coughs or nurse suctions to remove loosened secretions8. Nursing interventions

a. explain procedure to clientb. place client in desired position according to lobe beingdrainedc. percuss each area for at least three minutesd. encourage client to cough after each area is percussedand vibratede. can cause fatigue

Drainage Systems

1. Chest tubea. tube placed in the pleural space to remove air, fluid, or

bothb. tube placed anterior and superior to remove air c. tube placed posterior and inferior to remove fluid

d. mediastinal tubei. drains blood or fluid from around heart

ii. no tidaling in mediastinal drainage because tube isnot placed in lung cavity

2. Chest drainage devicesa. collection chamber

i. collects fluidii. monitor rate and nature of drainage

b. water seal chamber i. provides a one-way valve: air leaves chest, cannotreenter it

ii. check for bubbling in this chamber: indicates air leak

iii. if no bubbling, check water level in this chamber


8/27

iv. check for tidalingc. suction control chamber

i. negative pressure transmitted to pleural space isdetermined by this chamber, not by the setting on the wallvacuum

ii. wet chamber - suction level determined by water

leveliii. dry chamber - suction level determined by

mechanical settingd. nursing interventions

i. explain procedure to clientii. do not allow dependent loops to form in the tubing;

position the tubing on the bed so that there is straight gravitydrainage to the collection device

iii. do not routinely strip or milk the tubing; allow forgravity drainage

iv. do not routinely clamp the chest tubev. if the tube becomes dislodged and patient has air

leak,I. apply non-occlusive dressing to allow air to

leave the chest and prevent tensionpneumothorax

II. reinsert tube immediatelyvi. tube dislodged, but patient has no air leak

I. apply occlusive dressingII. monitor carefully for respiratory distressIII. depending on client's condition, tube may or

may not need to be replaced

Tuberculin skin testing

a. PPD (Purified protein derivative) is injected intradermallyb. indicates whether client has been infected withMycobacterium tuberculosis or has been in contact with infectedindividualc. site checked at 48 to 72 hours after administration

d. contraindicated in clients with active tuberculosis, orprevious BCG vaccinee. positive reaction: induration (elevated, red, and hard) of 10mm or greaterf. negative reaction: no change at site or some response, yetless than 10 mm and only elevated or red

g. if positive reaction requires a chest x-ray

I. General Respiratory Anatomy and Physiology

A. The respiratory system is comprised of the upper airway and lower airwaystructures.

B. The upper respiratory system filters, moistens and warms air duringinspiration.

C. The lower respiratory system enables the exchange of gases to regulateserum PaO2, PaCO2 and Ph.


9/27

II. Upper Respiratory

A. Nose and sinuses

1. Filters, warms and humidifies air2. First defense against foreign particles3. Inhalation for deep breathing is to be done via nose4. Exhalation is done through the mouth


10/27

B. Pharynx1. Behind oral and nasal cavities2. Nasopharynx

a. behind noseb. soft palate, adenoids and eustachian tube

3. Oropharynxa. from soft palate to base of tongueb. palatine tonsils

4. Laryngopharynxa. base of tongue to esophagusb. where food and fluids are separated from airc. bifurcation of larynx and esophagus

C. Larynx1. Between trachea and pharynx2. Commonly called the voice box3. Thyroid cartilage - Adam's apple4. Cricoid cartilage

a. contains vocal cordsb. the only complete ring in the airway

5. Glottis - opening between vocal cords


11/27

6. Epiglottis - covers airway during swallowing

III. Lower Respiratory and Other StructuresA. Trachea

1. Anterior neck in front of esophagus2. Carries air to lungs

B. Mainstem bronchi

1. Right and left2. Right is more vertical, so right middle lobe is more likely to receiveaspirate into it with the result of aspiraton pneumonia, which ismore commonly found in elderly populations

C. Conducting airways1. Lobar bronchi

a. surrounded by blood vessels, lymphatics, nervesb. lined with ciliated, columnar epithelial cell (


12/27

c. cilia move mucus or foreign substances up to largerairways

2. Bronchiolesa. no cartilage; collapse more easily

b. no ciliac. do not participate in gas exchange

D. Alveolar ducts and alveoli1. Lungs contain approximately 300 million alveoli2. 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

E. Accessory muscles of respiration - use indicates additional effort neededto breathe

1. Scalene muscles - elevate first two ribs2. Sternocleidomastoid - raise sternum3. Trapezius and pectoralis - stabilize shoulders4. Abdominal muscles - puts power into cough and used most often

with chronic respiratory problems and acute severe respiratorydistress


13/27

IV. PhysiologyA. Basic gas-exchange unit of the respiratory system is the aveoli.B. Alveolar stretch receptors respond to inspiration by sending signals to

inhibit inspiratory neurons in the brain stem to prevent lung overdistention.

C. During expiration stretch receptors stop sending signals to inspiratory

neurons and inspiration is ready to start again.D. Oxygen and carbon dioxide are exchanged across the alveolar capillary

membrane by process of diffusion.E. Neural control of respirations is located in the medulla. The respiratory

center in the medulla is stimulated by the concentration of carbon dioxidein the blood.

F. Chemoreceptors, a secondary feedback system, located in the carotidarteries and aortic arch respond to hypoxemia. These chemoreceptorsalso stimulate the medulla

G. Ph regulationI. 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 thechemoreceptors 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, andstimulates respiration as described above.

III. Blood PaO2 (partial pressure of oxygen in arterial blood): adecrease in the PaO2 results in a decreased blood Ph, stimulatingrespiration as described above.

IV. When arterial Ph rises or the arterial PaCO2 falls, hypoventilationoccurs.

V. Disorders of the Upper Respiratory SystemA. Allergic rhinitis (hay fever) - sensitivity to allergens with whitish or clear

nasal dischargeI. Management - antihistamines, nasal steroid sprays

B. Sinusitis

I. Medical conditionI. inflammation of mucus membranes in the sinuses

II. may be followed by infection with a yellowish-greendischarge

II. ManagementI. treatment with antibiotics, decongestants, antihistamines

II. surgery to drain and open sinusesIII. antral irrigation (sinus irrigation)


14/27

IV. Caldwell-Luc procedureC. Upper airway obstruction (choking)

I. FindingsI. stridor (harsh, vibrating breath)

II. no sound of air III. both hands of client around the throat

IV. management: emergency treatmentI. Heimlich maneuver

II. cricothyrotomy (cut cricoid cartilage)III. tracheotomy/tracheostomy

D. Pharyngitis1. Inflammation of mucous membranes of pharynx2. Bacterial, viral, environmental causes3. Treat findings; if culture shows bacteria, use antibiotics

E. Tonsillitis1. Inflammation and/or infection of tonsils2. Acute form is usually bacterial


15/27

3. Treat findings; if culture shows bacteria, use antibioticsF. Peritonsillar abscess

1. Complication of acute tonsillitis2. Infection spreads to surrounding tissue3. If swelling is massive, can endanger airway4. Treat findings; if culture shows bacteria, use antibiotics

G. Vocal cord disorders1. Laryngitis

a. inflammation of vocal cords and surrounding mucousmembranes

b. cause: something irritates the larynxc. occurs in viral and bacterial infections

d. in children, called croup (larynx blocked by edema, spasmor both)

e. treat findings, rest voice, remove irritants, gargle with warmsalt water

2. Vocal cord paralysisa. injury, trauma or disease of larynx, laryngeal nerves or

vagus nerveb. may result as a complication after thyroidectomy surgeryc. assess how well client can protect airwayd. can sometimes be surgically treated with Teflon injection

H. Cancer of the larynx1. Etiology

a. most tumors of the larynx are squamous cell carcinomab. more common among men, age 50 to 65c. cigarette smoking and alcohol consumption are related -

especially in combination2. Findings

a. persistent sore throat

b. dyspneac. dysphagiad. increasing persistent hoarsenesse. weight lossf. enlarged cervical lymph nodes

g. neck pain/lump in neck (late)3. Management

a. radiation therapyb. chemotherapyc. surgery: removal of all or part of larynx to treat cancer

I. total laryngectomy: no voice, permanent stoma inneck with no risk of aspiration from oral cavity

II. radical neck dissection: when cancer hasmetastasized to surrounding tissues - totallaryngectomy and radical neck dissection toremove adjacent cancerous tissue

4. Nursing interventionsa. arrange for clients with larnygectomies to meet with

members of support groupsb. establish a method for communication before surgeryc. maintain airway; have suction equipment at bedsided. observe for signs of hemorrhage or infectione. teach about trach and stoma caref. assist with period of grieving

VI. Disorders of Lower Respiratory System (LRS): ObstructiveA. General facts: process in chronic obstructive pulmonary diseases

1. Block airflow out of lungs2. Trap air, with impairment of gas exchange3. Increase the work of breathing

B. Emphysema1. Destroys alveoli


16/27

2. Narrows and collapses small airways3. Overall lung loses elasticity4. Traps air 5. As alveolar walls die, there is less surface for vital gas exchange

C. Chronic bronchitis1. Definition

a. inflammatory response in the lungb. affects few alveoli, mostly airways

2. Findingsa. lungs chronically produce fluidsb. inflammation and mucus narrow the airways

D. Asthma1. Definition/etiology

a. reversible obstruction of airwaysb. inflammation of airwaysc. airways hypersensitive to variety of stimulid. bronchospasm is a minor componente. disease waxes and wanes, remissions and exacerbations

2. Findingsa. orthopnea, expiratory wheezingb. barrel chest, cyanosis, clubbing of fingersc. distention of neck veinsd. edema of extremities

e. increased PCO2 and decreased PO2f. polycythemiag. use of accessory muscles to breathe

3. Diagnosticsa. physical examination with history of findingsb. arterial blood gasesc. chest x-ray

4. Complications

a. hypoxemiab. hypercapniac. variety of respiratory infections

d. cor pulmonalee. dysrhythmias

E. Management for obstructive disease1. Antibiotics and corticosteroids for infection or chronic inflammation

or actue exacerbation2. Bronchodilators - long acting for control, short acting for

emergency relief

3. Mucolytics4. Expectorants

5. Respiratory program: postural drainage, exercise, nebulizer, highprotein diet. See Postural Drainage

Hyper (over as inhyperactive)

Ca (sounds like carbondioxide)

Hypercapnia = Too muchcarbon dioxidein arterial blood

Hypo (under as inhypodermic, under skin)

Ox (sounds like oxygen) Hypoxemia = Not enoughoxygen in arterial blood

F. Nursing interventions common to obstructive diseases1. Assess client's risk of respiratory failure2. Assess for degree of respiratory effort - an increase in work to

breathe, dyspnea, or use of accessory muscles
http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23


17/27

3. Assess oxygenation with pulse oximeter if hemoglobin level iswithin normal limits

4. Measure arterial blood gases (ABG) to evaluate gas exchange5. Administer oxygen as indicated6. If risk of respiratory failure, anticipate ventilation7. Assist with secretion removal as indicated

8. Pace client activities to reduce oxygen demand9. Teach diaphragmatic breathing, pursed-lip breathing and energy

conservation methods10. Position in a high Fowler's to ease breathing effort11. Provide for nutritional consults as indicated12. Reinforce the plan for small, frequent high carbohydrate meals13. Provide referrals for:

a. depression associated with diseaseb. pulmonary rehabilitationc. smoking cessation support groups

14. For asthma, teach clients that aspirin or exposure to unknownallergens may stimulate an asthma attack

VII. LRS Disorders: RestrictiveA. In general: these disorders prevent full lung expansion via three

mechanisms1. Lung stiffening2. External compression3. Muscle weakness

B. Pulmonary fibrosis- lung stiffening1. Occupational lung diseases

a. coal worker's pneumoconiosis - risk increases with lengthof exposure to coal dust (>15 years), intensity of exposure,and silica content of dust

b. silicosis: workers who will have inhaled silica dust2. Asbestosis

a. inhalation of asbestos fibersb. disease may develop 15 to 20 years after exposure

c. high risk formesothelioma - lung cancer specific toasbestos

C. Pulmonary sarcoidosis - lung stiffening1. Etiology

a. unknown origin

b. characterized by formation oftubercles, most often in thelungs

c. may progress to fibrosis2. Findings

a. dyspneab. anxiety

3. Diagnosticsa. chest x-rayb. biopsy of affected tissue

4. Managementa. antitussivesb. oxygen therapyc. removal of toxic substancesd. proper use of personal protective equipment to decrease

lung damage

D. Nursing interventions common to all types of pulmonary fibrosis1. Prevent infection or exposure to infection2. Pace clients' activities to reduce oxygen demands and dyspnea3. Reinforce the need for small, frequent meals4. Encourage daily activities within pulmonary tolerance

a. provide referrals for:I. depression associated with disease

II. smoking cessation support groups
http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23


18/27

III. occupational rehabilitation

E. Disorders of fluid in pleurae1. Pleural fluid disorders - all treated with water seal chest drainage

systems

2. Pneumothorax: air between the pleuraea. open pneumothorax: hole in the chest wall, communicates

with the lungb. closed pneumothorax: hole in lung, chest wall intactc. tension pneumothorax - a nursing and medical emergency

i. closed pneumothoraxii. air is forced into the pleural space with a continued

pressure build upiii. shifts mediastinum away from affected side with

results of a compressed heartiv. treated with chest tube insertionv. cardiac and respiratory arrest if not treated

d. examples of the above

3. Pleural effusiona. fluid (transudate or exudate) in the pleural spaceb. if small, no treatmentc. if larger, treated with chest tube insertion


19/27

d. repeated pleural effusion may be treated with pleurodesisto scar tissue and decreased fluid secretions

4. Hemothoraxa. blood in the pleural spaceb. treated with thoracentesis or chest tube

5. Empyema

a. purulent drainage in the pleural spaceb. often from a chronic condition such as lung cancerc. treated with chest tube inserton

6. Chylothoraxa. lymphatic fluid in pleural spaceb. treated with thoracentesis or chest tube

F. Musculoskeletal diseases associated with difficulty breathing1. Guillain-Barre syndrome - follows a viral infection

a. ascending paralysis that may affect muscles ofrespiration as paralysis ascends

b. muscles so weak that client cannot breathe deeply, a

nursing and medical emergencyc. may progress to respiratory failure

i. may require intubationii. mechanical ventilationiii. course of illness varies from a few months to years

2. Myasthenia gravisa. sporadic, progressive weakness of skeletal muscleb. cause: lack of acetylcholine with results of a myoneural

junction malfunctionc. may not be able to chew and swallow well

i. may aspirateii. may lose protective airway reflexes

d. repeated muscle movements, especially towards daysend, can exacerbate acute respiratory failure

3. Poliomyelitisa. viral infectionb. if disease strikes the respiratory muscles the result may be

respiratory failurec. may not swallow well

i. may aspirateii. may lose protective airway reflexes

4. Amyotrophic lateral sclerosis (ALS; Lou Gehrig's Disease)

a. affects motor neurons; autonomic, sensory and mentalfunction unchanged

b. manifests as a chronic, progressive irreversible disorderc. begins usually in distal ends of upper extremitiesd. often leads to respiratory failure within two to five yearse. results in ethical issue

i. whether clients want mechanical ventilationii. whether nutritional support is desired

All of these musculoskeletal disorders EXCEPT Guillain-Barre featurethe letter M:

-Myasthenia gravis

-Poliomyelitis

-Amyotrophic Lateral Sclerosis

-Muscular dystrophies


20/27

iii. if they would rather die when disease becomes thissevere

f. results in clients' inability to communicate or physicallymove from voluntarily and/or clients lack involuntaryreflexes, such as blinking or gag reflex

5. Muscular dystrophies

a. progressive symmetrical wasting of voluntary muscles withno nerve effect

b. as thoracic muscles weaken, breathing becomes moredifficult

c. may not swallow well; risk for aspiration with loss ofprotective airway reflexes

6. Interventions common to musculoskeletal disorders

a. monitor carefully forchanges in conditionb. assess regularswallowing and ability to protect the upper

airway

c. discuss client preference for mechanical ventilation ornutritional support: does client wish it?

d. assist with coughing and secretion clearance as indicated

e. prevent infectionf. assess for with appropriate referrals fordepression that is

often associated with these diseases

g. administermedications specific to the disease condition

h. assist/provide occupational or/and physicalrehibilitation as indicated

i. maintain adequate nutritionj. with terminal disorders, provide for referrals for family

VIII. LRS Disorders: Infectious

A. Pneumonia1. Definition/etiology

a. acute infection of lung parenchymab. cause: bacterium, virus, protozoan, mycobacterium,

mycoplasma, or rickettsiac. pneumonia is the leading cause of death from infectious

causesd. may affect only a region of lung: lobar pneumonia,

bronchopneumoniae. may be the result of:

i. primary infectionii. secondary to other lung damage

iii. aspiration2. Risk factors for pneumonia

a. pre-existing pulmonary diseaseb. abdominal and thoracic surgeryc. mechanical ventilationd. advanced agee. decreased ability to protect airway or cough effectivelyf. artificial airway

g. chronic illness and debilitationh. depressed immune functioni. cancer

3. Diagnostics

a. chest radiographb. sputum culture, sensitivity and microscopic analysis, Gram

stain, cytologyc. ABG as indicated by clinical condition

4. Managementa. antimicrobials, depending on pathogenb. antipyreticc. expectorants


21/27

d. antitussivese. supplemental oxygen, as indicatedf. IV fluids to treat dehydration

5. Nursing interventionsa. monitor finger oximeter if hemoglobin levels within normal

limits

b. promote hydration to liquify secretionsc. teach effective coughing techniques to minimize energy

expenditured. suction if necessarye. teach the need to continue entire course of antimicrobial

therapy which is usually seven to ten daysf. teach that findings are expected to be less within 48 to 72

hours of initial therapyg. encourage pneumonia vaccine for high-risk groups

B. Pulmonary tuberculosis (PTB)1. Etiology

a. mycobacterium tuberculosisb. bacilli lodge in alveolic. pulmonary infiltratesd. can spread throughout body via bloode. multi-drug resistant PTB is becoming more

prevalentf. PTB incidence is rising with increasing

homelessness and AIDS2. Findings

a. weakness with fatigueb. anorexia with weight lossc. night sweats

d. chest paine. productive cough

3. Diagnosticsa. sputum and gastric contents, analysis for the

presence of acid-fast bacillib. chest x-ray for presence of active or calcified

lesions, "coin" lesionsc. tuberculin testing

i. tine, mantoux tests checked 48 to 72 hours for

induration positive if >10 mm induration in

healthy persons; positive if >5 mminduration in clients who areimmunosuppressed

d. establishes if there is an antibody response to thetubercle bacillus

e. if positive, indicates prior exposure to bacillus, notan active disease

4. Managementa. 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 isnot effective

d. high carbohydrate, high protein diet with frequentsmall meals

5. Nursing interventionsa. with active infection, client must be isolated with

airborne precautions when in the hospitalb. teach client


22/27

i. proper techniques to prevent spread ofinfection: hand washing, etc.

ii. to report bloody sputumiii. not to use over the counter (OTC)

medications without health care provider'sapproval

iv. importance of taking medications asprescribed

adherence to treatment regimen return at scheduled times for lab

testing of liver enzymes an increase in B6 to minimize

peripheral neuropathies, a commonside effect of drug therapy

v. family and close contacts must be tested fordisease

C. Lung abscess

1. Localized area of lung infection2. Usually follows pneumonia, TB or aspiration3. Treatment consists of draining and culturing abscess and

antimicrobial therapy

IX. LRS Disorders: Miscellaneous

A. Pulmonary embolism1. Definition/etiology

a. clot blocks blood from the "bed" of arteries that feed thelung

b. client is breathing but gases are not exchanged -ventilation without perfusion

c. hypoxemia resultsd. 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

pelvis2. Diagnostics

a. ventilation/perfusion (V/P) scan, also called V/Q scanb. ABG

c. EKG3. Management

a. oxygen via maskb. anticoagulation - heparin in acute and coumadin for

chronic riskc. thrombolyticsd. filter surgically placed in vena cava for long term care


23/27

B. Acute respiratory distress syndrome (ARDS)1. Definition/etiology

a. alveolar capillary membrane becomes more permeable tofluids

b. increased extravascular lung fluidc. pulmonary compliance decreases

d. intrapulmonary shunt increasese. refractory hypoxemia - does not respond to oxygen therapyf. usually seen after lung injury or massive multi-system

organ disease2. Findings

a. restlessness, anxietyb. dyspneac. tachycardiad. cyanosise. intercostal retractions

3. Diagnosticsa. clinical presentation and history of findings

b. hypoxemia on ABG despite increasing inspired oxygenlevel

c. chest x-ray shows diffuse infiltrates4. Management

a. optimize oxygenationI. mechanical ventilation

II. sedation may be requiredIII. paralytic agents may be necessary

b. antibiotics, as indicatedc. corticosteroids

5. Nursing interventionsa. plan for frequent rest periods

b. monitor trends in oxygenation status, ABGs, respiratoryeffort

c. observe for behavioral changes and vital signs; confusionand hypertension may indicate cerebral hypoxia

C. Lung cancer 1. Definition/etiology

a. types of lung cancer

I. squamous cell carcinoma

II. small-cell (oat cell) carcinoma

SQUAMOUS CELL CARCINOMA

A. Risk factors1. Is most often associated with cigarette smoking2. Exposure to environmental carcinogens e.g. uranium, asbestos

B. Characteristics1. Accounts for 30-35% of lung cancer cases2. Is more common among men3. Findings occur earlier because of bronchial obstructive characteristics (arises

from bronchial epithelium)4. Causes cavitating pulmonary lesions5. Usually metastasizes locally

C. Therapy1. Life expectancy is better than small cell carcinoma

2. Surgical resection is often attempted
http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/unmanaged/ReviewforNCLEXRN/repository/AddInfo/cell_car.htmhttp://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/unmanaged/ReviewforNCLEXRN/repository/AddInfo/sma_cell.htmhttp://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/unmanaged/ReviewforNCLEXRN/repository/AddInfo/cell_car.htmhttp://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/unmanaged/ReviewforNCLEXRN/repository/AddInfo/sma_cell.htm


24/27

III. adenocarcinoma

IV. large cell carcinoma

b. prognosis is generally poor

SMALL CELL CARCINOMA

A. Risk Factors1. Cigarette smoking2. Environmental carcinogens

B. Characteristics1. Accounts for 15% to 25% of lung cancers2. Spreads early3. Very malignant form4. Is often associated with endocrine disturbances

C. Therapy1. Poorest prognosis2. Average survival is less than one year

ADENOCARCINOMA

A. Risk Factors1. Not related to cigarette smoking2. Lung scarring3. Chronic interstitial fibrosis

B. Characteristics1. More common among women2. Accounts for about half of all lung cancers

3. Usually located in peripheral section of lungs4. Often no clinical signs or findings until well advanced

C. Treatment1. Does not respond well to chemotherapy2. Most often, surgical resection is attempted

LARGE CELL CARCINOMA

A. Risk Factors1. Cigarette smoking2. Environmental carcinogens

B. Characteristics1. Occurs in 15-25% of all lung cancers2. Frequently metastases via blood3. Usually peripheral rather than centrally located in the lung lobes

C. Therapy1. Usually client is not a candidate for surgery due to the high frequency of

metastasis2. Tumors often responds to radiation therapy but frequently recurs
http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/unmanaged/ReviewforNCLEXRN/repository/AddInfo/car_noma.htmhttp://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/unmanaged/ReviewforNCLEXRN/repository/AddInfo/lar_cell.htmhttp://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/unmanaged/ReviewforNCLEXRN/repository/AddInfo/car_noma.htmhttp://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/unmanaged/ReviewforNCLEXRN/repository/AddInfo/lar_cell.htm


25/27

c. largely preventable if smokers stop and nonsmokers avoidsecond hand smoke

2. Findingsa. hoarse voiceb. changes in breathingc. persistent cough or change in cough

d. blood-streaked or bloody sputume. chest pain or tightness in chest wallf. recurring pneumonia, pleural effusion

g. weight loss3. Diagnostics

a. medical imaging examinationsb. cytological sputum analysisc. bronchoscopyd. biopsy - most definitive diagnostic tool for lung cancer

4. Managementa. nonsurgical

i. chemotherapyii. radiation therapyiii. laser therapy to de-bulk tumor

iv. thoracentesis and pleurodesisb. 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 interventionsa. post-operative care

i. chest drainageii. 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 oxygenationiv. provide opportunities for the client to talk about

cancer; as needed, refer to support groupsv. teach information as based on treatment plan and

prognosisvi. optimize nutritional status

D. Cor pulmonale1. Definition/etiology

a. right ventricularhypertrophy and subsequent chronic heartfailure

b. cause: heart must pump against great resistance fromlung's blood vessels: called increased pulmonary vascularresistance (PVR)

c. increased PVR results from chronic lung diseased. may be due to primary pulmonary hypertension as well

2. Diagnosticsa. pulmonary artery pressure readings via a catheterb. echocardiogramc. chest radiographd. ABGe. EKG
http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23http://ncsbn.myncsbnlx.com/data/companies/ncsbn/media/#%23


26/27

3. Managementa. administer oxygen as orderedb. if hemoglobin within normal limits (WNL), monitor

oxygenation with finger or pulse oximeterc. bed rest, as neededd. monitor effects of medications

I. cardiac glycosidesII. pulmonary artery vasodilatorIII. diureticsIV. restricted fluid intake as indicated

e. nursing interventionsI. monitor for changes in oxygenation status

II. pace activities in clients who tire easily

E. Respiratory failure1. Definition: lungs cannot maintain arterial oxygen levels or

eliminate carbon dioxide

a. PaCO2 > 50 mm Hg

b. PaO2 < 50 mm Hgc. clients with chronic lung disease precautions

i. look for drop from baseline functionii. this is a nursing and medical emergencyiii. clients are always hypoxemic

2. Etiology

a. lung diseases that harden the alveolar-capillary membraneto trap O2

b. neuro-muscular or musculoskeletal disordersi. respiratory drive dulled or bluntedii. muscles too weak to breathe

3. Diagnostics: ABG4. Management

a. oxygen per maskb. mechanical ventilationc. 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 easebreathing 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 continuallyrequires more oxygen and more energy.

Nursing interventions for clients with chronic lung disease should include pacingof activities, because these clients have little reserve for exertion.

Quality of life for clients can be significantly improved if clients routinely usediaphragmatic breathing and pursed-lip breathing.

Clients with asthma must understand the different types of inhalers and when touse each type. Some rescue inhalers are for acute dyspnea. Other inhalers arefor maintenance or preventative types of drugs.

A finger or pulse oximeter reading is simply one element of an assessment. It isnot 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.


27/27

The serious public health issue of pulmonary TB requires control and reporting ofany incidence and recent contacts that the client had so prophalactic therapy fortwo to three months can be initiated.

When caring for a client after a chest tube insertion, an occlusive dressing isplaced around the chest tube insertion site and the connections of the chest tubesystem 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. Thisdressing 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 theclient. See if the alarm resets or if the cause is obvious. If the alarm continues tosound and the client develops distress, disconnect the client from the ventilator,use a manual resuscitation bag to ventilate with 100% oxygen and page or callthe 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 thetube by the client, tube slips into right main stem bronchus, or increasedsecretions.

To maximize therapeutic effect ofinhalers, the key is technique. It is critical toteach 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 otherchronic lung diseases.

Best approach to pulmonary embolus is prevention. The use of intermittentcompression stockings prevents clots in the deep veins.

Clients with pulmonary TB need intensive community follow up to ensure thatthey continue with pharmacological treatment once discharged from the hospital.Clients who stop therapy too soon are the source for the more deadly multi-drugresistant forms of pulmonary TB.

8b respiratory finalwithdx

Documents