Presentation on theme: "Unit 10 Nursing Care of the Client: Oxygenation and Perfusion."— Presentation transcript:
Unit 10 Nursing Care of the Client: Oxygenation and Perfusion
Chapter 35 Respiratory System
Anatomy and Physiology Review Primary function: –Delivery of oxygen to and removal of carbon dioxide from lungs
Anatomy and Physiology Review
Assessment Health history Inspection Palpation and percussion Auscultation
pH 7.35 – 7.45 PO2 80 – 100 mm Hg PCO2 35 – 45 mm Hg HCO3 22 – 26 mm Hg
The client has a long history of COPD and is currently experiencing an exacerbation of COPD. The following lab work is done this morning: CBC, ABGs and an electrolyte panel consisting of K+, Na+, Cl, CO2, BUN and FBS. Which lab data requires immediate follow up? A.Increased PaO2 B.Increased RBCs C.Increased PaCO2 D.Hgb Within Normal Limits
A is the answer Hypoxemia provides the stimulus for the respiratory drive in clients with COPD. Increased oxygen levels may depress the respiratory drive. Option B and C are expected findings Option D does not require immediate follow- up.
General Respiratory Medications Anti-tussive –Narcotic –Non-narcotic Expectorant –What is the best one? Mucolytic Antihistamine Decongestant
Infectious/Inflammatory Disorders: Upper Respiratory Common Self-limiting Caused by viruses, bacteria, and allergic reactions (continued)
Pleurisy/Pleural Effusion Pleurisy –Painful condition from inflammation of pleura –Symptoms: Pain on inspiration (continued)
Pleurisy/Pleural Effusion Pleural effusion –Pleural fluid accumulation within pleural space –Symptoms depend on amount of lung tissue compressed and source of effusion (continued)
Treat to eliminate underlying cause, maintain adequate oxygenation to tissues, and prevent complications Treatment: –Oxygen, respiratory therapy, incentive spirometry, thoracentesis, thoracotomy and chest tube drainage, and medications
The nurse is preparing to assist with the insertion of a chest tube that will be attached to a closed-chest drainage system without suction. In monitoring the closed-chest drainage system, the nurse would expect to initially assess for: A.Fluctuation of water in the water-seal chamber during respirations. B.Constant fluid fluctuations in the drainage- collection chamber. C.Continuous bubbling in the suction-control chamber. D.Occasional bubbling in the suction-control chamber.
A is the answer Fluctuations of water during inspiration and expiration in the water-seal chamber indicates normal functioning. Option B should not be seen in the collection chamber. Options C and D should not be seen because suction has not been applied to the suction-control chamber.
The client has a chest tube connected to a closed-chest drainage system attached to suction and is being prepared to transfer to another room on a stretcher. To safely transport the client, it is most important for the nurse to: A.Clamp the chest tube during the transport. B.Get a portable suction before transferring the client. C.Keep the closed-chest drainage system below the level of the chest. D.Place the closed-chest drainage system next to the client on the stretcher.
C is the answer Keeping the closed-chest drainage system below the level of the chest allows for continuous drainage and prevents any back flow pressure. Options A and D should not be done because they will increase pressure in the pleural space. Option B is not the most important.
The physician is preparing to remove the clients chest tube. Just before removing the chest tube, the physician tells the client to take a deep breath and hold it. This intervention is done primarily to: A.Distract the client during the chest tube removal. B.Minimize the negative pressure within the pleural space. C.Decrease the degree of discomfort to the client. D.Increase the intrathoracic pressure temporarily during removal.
D is the answer This is done to decrease the risk of atmospheric air entering the pleural space during removal. Options A and C are not the primary reasons for this intervention. Option B is not correct since negative pressure is desired within the lung.
Severe Acute Respiratory Syndrome (SARS) Viral illness with flu-like symptoms Spread by close personal contact or contact with infectious material Treatment: –Supportive care
Acute Respiratory Tract Disorders: Atelectasis Collapse of lung or portion of lung Signs of respiratory distress proportional to amount of lung tissue involved Treatment: –Respiratory therapy, postural drainage and percussion, suctioning, oxygen, bronchoscopy, thoracentesis, thoracotomy and chest tube drainage, and medications
Pulmonary Embolism Develops when substance (emboli, fat, or amniotic fluid) lodges in branch of pulmonary artery and obstructs flow Symptoms: –Abrupt anxiety, restlessness, inspiratory chest pain, dyspnea, cough, and hemoptysis (continued)
Pulmonary Embolism Treatment: –Medications and embolectomy
Pulmonary Edema Life-threatening condition –Rapid shift of fluid from plasma into alveoli Symptoms: –Hemoptysis, dyspnea, orthopnea, cyanosis, anxiety, significant airway obstruction, and increased HR and respiratory rate (RR) (continued)
Treatment: –Oxygen, medications, and ventilation MAD DOG
Acute Respiratory Distress Syndrome (ARDS) Life-threatening condition –Dyspnea, hypoxemia, and diffuse pulmonary edema Symptoms: –Severe dyspnea, tachypnea, cyanosis, crackles, wheezes, and hemoptysis Treatment is intensive, supportive, and includes many body systems
Acute Respiratory Distress Syndrome (ARDS)
Acute Respiratory Failure Occurs as result of client literally becoming too tired to continue work of breathing Mechanical ventilatory support required during acute phase
Chronic Respiratory Tract Disorders: Asthma Intermittent airway obstruction in response to variety of stimuli Symptoms: –Sudden inspiratory and expiratory wheezing, increasing dyspnea, and chest tightness Treatment: –Taking medications and avoiding known allergens
Chronic Bronchitis Inflammation of bronchial tree with hypersecretion of mucus Symptoms: –History of recurrent respiratory infections, dyspnea, cyanosis, productive cough, and adventitious breath sounds (continued)
Treatment: –Respiratory therapy, medications, and immunizations
Emphysema Complex and destructive lung disease Airflow impeded as it leaves lungs –Results in alveoli distention First symptom: –Morning cough (continued)
Later symptoms: –Dyspnea upon exertion or at rest Treatment: –Smoking cessation, low levels of oxygen, and medications
Bronchiectasis Chronic dilation of bronchi Symptoms: –Chronic productive cough, dyspnea, weight loss, fatigue, thick sputum, crackles, and use of accessory muscles Treatment: –Percussion and postural drainage, respiratory therapy, suctioning, bronchoscopy, and medications
The nurse is caring for a client who was admitted with an exacerbation of COPD. The clients respirations are 28 with dyspnea on exertion. The client is receiving 2L of oxygen per nasal cannula. The morning pulse oximetry is 92%. Which nursing intervention is of priority? A.Monitor the client. B.Notify the physician. C.Get an order to increase the oxygen. D.Place in semi-Fowlers position.
A is the answer The client is manifesting signs and symptoms consistent with COPD. Clients with COPD experience some degree of hypoxia. Options B and C are not appropriate at this time. Option D is not the best position for a client with COPD.
The client is admitted with an acute exacerbation of COPD. Which assessment finding is most indicative of a potential complication? A.Respirations 32, increasingly anxious and restless. B.Using accessory muscles during respiration. C.Pulse oximetry 92%, pursed-lip breathing. D.Expectorating copious amounts of white phlegm.
A is the answer Increasing anxiousness and restlessness are signs indicating hypoxemia. Options B, C and D are expected findings for a client with an exacerbation of COPD.
Its time for report…
Prioritize the five nursing interventions as you would do them initially: A – Auscultate lung sounds. B – Assess pulse oximeter, O2 and NC. C – Retake the vital signs. D – Check theophylline level. E – Place in high-Fowlers position.
Pneumothorax/Hemothorax Pneumothorax –Air in pleural space Hemothorax –Blood in pleural space May be traumatic, spontaneous, or tension Symptoms determined by severity of injury and amount of lung tissue affected (continued)
For affected lung to re-expand, air and/or blood must be removed from pleural space Thoracotomy tube inserted to drain fluid and air –Allows lung to re-expand Analgesics given for pain
Its time for report…
Prioritize the five nursing interventions as you would do them initially: A – Check the pulse oximetry. B – Assess for fluctuation in the water-seal chamber and bubbling in the suction-control chamber. C – Check for the previous shifts fluid level marking on the tape. D – Assess chest tube patency and drainage. E – Ask Mr. G to cough and deep breathe.
Lung Cancer May originate in lung or result from metastasis Symptoms develop late –May include cough, dyspnea, hemoptysis, and pain Treatment: –Surgery, chemotherapy, and radiation
Laryngeal Cancer Relatively asymptomatic May include hoarseness, difficulty speaking, difficulty swallowing, and laryngeal pain Treatment determined by extent of tumor growth: –Surgery, chemotherapy, and radiation
Epistaxis Hemorrhage of nares or nostrils May stem from dry nasal mucosa, local irritation, trauma, or hypertension Treat to maintain airway, stop bleeding, identify cause, and prevent recurrence Treatment: –Firm pressure on nares or nasal packing
Chapter 60 Infants with Special Needs: Birth to 12 Months
Laryngotracheobronchitis Viral illness causing welling of upper airway Symptoms: –Stridor, barking cough, and hoarseness Treat to maintain patent airway and improve respiratory effort (continued)
Laryngotracheobronchitis Treatment: –Cool mist and medications E.g., bronchodilators, corticosteroids
Pneumonia Inflammation of bronchioles and alveoli spaces often preceded by upper respiratory infection (URI) Symptoms: –Abrupt onset of fever, flaring nostrils, circumoral cyanosis, chest retractions, cough, and increased pulse and respirations (continued)
Respiratory Distress Syndrome (RDS) Most often found in pre-term infants Symptoms: –Tachypnea, retractions, grunting, crackles, pallor, cyanosis, hypothermia, edema, flaccid muscle tone, GI shutdown, jaundice, and acidosis (continued)
RDS First 96 hours critical to recovery Treatment: –Surfactant and supportive care
Cystic Fibrosis Genetic dysfunction of exocrine glands Affects lungs, pancreas, liver, and reproductive organs Symptoms: –Meconium ileus, intussusception, problems gaining and maintaining weight, pulmonary problems, and salty taste on skin (continued)
Treat pulmonary problems and nutrition
Sudden Infant Death Syndrome (SIDS) Also known as crib death Sudden unexpected death of apparently healthy infant No single cause identified Provide empathic support to family Inform family that autopsy must be done