Nursing Care of the Client: Oxygenation and Perfusion 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

Anatomy and Physiology Review

Assessment Health history Inspection Palpation and percussion Auscultation

Assessment

Assessment

Assessment

Assessment

Assessment

Assessment

Assessment

Assessment

Diagnostics

Diagnostics

Diagnostics

Diagnostics

Diagnostics

Diagnostics

Diagnostics pH 7.35 – 7.45 PO2 80 – 100 mm Hg PCO2 35 – 45 mm Hg HCO3 22 – 26 mm Hg

Hgb Within Normal Limits 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, ABG’s and an electrolyte panel consisting of K+, Na+, Cl, CO2, BUN and FBS. Which lab data requires immediate follow up? Increased PaO2 Increased RBC’s Increased PaCO2 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.

Nursing Interventions

Nursing Interventions

Nursing Interventions

Nursing Interventions

Nursing Interventions

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)

Infectious/Inflammatory Disorders: Upper Respiratory

Infectious/Inflammatory Disorders: Upper Respiratory Symptoms: Malaise, fever, edema of affected tissues, nasal or sinus congestion, headache, sore throat, and cough Treatment Symptomatic

Pneumonia Inflammation of bronchioles and alveoli accompanied by consolidation in lungs Can result from bacteria, viruses, mycoplasms, fungi, chemicals, or parasite invasions (continued)

Pneumonia

Pneumonia Symptoms: Sudden or high fever, productive cough with thick sputum, dyspnea, coarse crackles, diminished breath sounds, and pleuritic chest pain (continued)

Pneumonia

Pneumonia Treat to clear airways and maintain adequate oxygenation (postural drainage and percussion) Treatment: Respiratory therapy, hydration medications, and turn, cough, deep breathe (TCDB)

Nursing Responsibilities? Pneumonia Antibiotics: Penicillins Tetracyclines Aminoglycosides Cephalosporins “Other” Side Effects: Allergy/Hypersensitivity Anaphylaxis Indirect toxicity Direct toxicity Nursing Responsibilities?

Tuberculosis Caused by inhalation of Mycobacterium tuberculosis Symptoms: Low-grade fever, persistent cough, hemoptysis, hoarseness, dyspnea, night sweats, fatigue, and weight loss (continued)

Tuberculosis

Tuberculosis

Tuberculosis

Tuberculosis Treatment: Airborne precautions and long-term multi-drug regimen

Tuberculosis Medications Nursing Responsibilities

Pleurisy/Pleural Effusion Painful condition from inflammation of pleura Symptoms: Pain on inspiration (continued)

Pleurisy/Pleural Effusion Pleural fluid accumulation within pleural space Symptoms depend on amount of lung tissue compressed and source of effusion (continued)

Pleurisy/Pleural Effusion

Pleurisy/Pleural Effusion

Pleurisy/Pleural Effusion 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

Pleurisy/Pleural Effusion

Pleurisy/Pleural Effusion

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: Fluctuation of water in the water-seal chamber during respirations. Constant fluid fluctuations in the drainage-collection chamber. Continuous bubbling in the suction-control chamber. 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: Clamp the chest tube during the transport. Get a portable suction before transferring the client. Keep the closed-chest drainage system below the level of the chest. 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.

Pleurisy/Pleural Effusion

The physician is preparing to remove the client’s chest tube The physician is preparing to remove the client’s 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: Distract the client during the chest tube removal. Minimize the negative pressure within the pleural space. Decrease the degree of discomfort to the client. 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

Atelectasis

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 Symptoms: 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)

Pulmonary Edema

Pulmonary Edema

MAD DOG Pulmonary Edema 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 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

Asthma

Asthma

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)

Chronic Bronchitis

Chronic Bronchitis 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)

Emphysema

Emphysema

Emphysema

Emphysema

Emphysema

Emphysema

Emphysema Later symptoms: Treatment: Dyspnea upon exertion or at rest Smoking cessation, low levels of oxygen, and medications

Bronchiectasis Chronic dilation of bronchi Symptoms: Treatment: 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

Bronchiectasis

Medications Bronchodilators: Corticosteroids Adrenergic Xanthine Anticholinergic Corticosteroids

Get an order to increase the oxygen. Place in semi-Fowler’s position. The nurse is caring for a client who was admitted with an exacerbation of COPD. The client’s 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? Monitor the client. Notify the physician. Get an order to increase the oxygen. Place in semi-Fowler’s 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 The client is admitted with an acute exacerbation of COPD. Which assessment finding is most indicative of a potential complication? Respirations 32, increasingly anxious and restless. Using accessory muscles during respiration. Pulse oximetry 92%, pursed-lip breathing. 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.

It’s 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-Fowler’s position.

Pneumothorax/Hemothorax 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)

Pneumothorax/Hemothorax

Pneumothorax/Hemothorax 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

It’s 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 shift’s 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

Lung Cancer

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

Infants with Special Needs: Birth to 12 Months Chapter 60 Infants with Special Needs: Birth to 12 Months 105

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)

Pneumonia Treatment: Oxygen, cool mist hydration, respiratory therapy, and medications

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)

Cystic Fibrosis

Cystic Fibrosis 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

Common Problems: 1–18 Years Chapter 61 Common Problems: 1–18 Years

Respiratory System Upper-respiratory infections Allergic rhinitis Tonsillitis Asthma Foreign-body aspiration

Tonsillitis

Epiglottitis

Epiglottitis

Bronchiolitis