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Alterations in Respiratory Functioning
Spring 2011
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Anatomy & Physiology Review
Structures of Upper Respiratory Tract Pharynx Larynx Nose Sinuses Structures of Lower Respiratory Tract Airways Trachea Mainstem bronchi Lobar, segmental, and subsegmental bronchi Bronchioles Alveoli
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Anatomy & Physiology Review
Lungs Right Upper lobe Middle lobe Lower lobe Left Pleura Parietal pleura Visceral pleura Pulmonary circulation
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Anatomy & Physiology Review
Accessory Muscles of Respiration Scalene muscles Lift first 2 ribs Sternocleidomastoid Raise sternum Trapezius & Pectoralis muscles Fix shoulders Sometimes abdominal and back muscles
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Aging & Respiratory Changes
Alveolar surface area decreases Efficiency of oxygen and carbon dioxide exchange decreases Elasticity decreases Chest wall elasticity decreases Respiratory muscle strength decreases Diaphragm and intercostals Ability to cough decreases Residual volume increases Vital capacity decreases Pulmonary blood flow decreases Effectiveness of cilia decreases
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Assessment……Patient History
Smoking (pack-years) Childhood illnesses Adult illnesses Vaccinations Medications / herbals Allergies Surgeries upper/lower respiratory system Hospitalizations Diagnostics Chest x-ray, pulmonary function tests, TB test Recent unplanned weight loss / nutritional status Night sweats Sleep disturbances Recent travel Occupation Leisure activities Family history
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Assessment……Current Health Problem
Acute versus chronic Cough Sputum production Chest pain Dyspnea Shortness of Breath (rest/exertion) PND Orthopnea Onset of problem (when)? Frequency of problem? How long it lasts? Worse over time? Symptoms? Interventions / treatments? What makes it better/worse?
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Physical Assessment Nose & Sinuses Pharynx, trachea & Larynx
Lungs & Thorax Inspection Palpation Percussion Auscultation Normal Breath sounds (normal, increased, diminished, absent) Bronchial / tubular Bronchovesicular Vesicular Adventitious breath sounds Crackle Wheeze Rhonchus Pleural friction rub
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Psychosocial Assessment
Anxiety Stress Coping mechanisms / support systems Family role / structure Financial concerns Unemployment Disability / affect on ADL’s Strengths
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Physical Assessment Clubbing Weight loss Unevenly developed muscles
Skin & mucous membrane changes General appearance Endurance
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Diagnostics……Laboratory Tests
RBC Hemoglobin & Hematocrit White Blood Cells Arterial blood gas analysis Sputum specimens
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Diagnostics…..Imaging Chest x-rays Computed tomography (CT)
Ventilation & perfusion scanning (V/Q scan)
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Diagnostics…… noninvasive
Pulse Oximetry Capnometry & Capnography Pulmonary Function Tests Evaluate lung volumes, flow rates, gas exchange, airway resistance Exercise Testing
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Diagnostics…….Invasive
Skin tests Endoscopic Examinations Bronchoscopy Laryngoscopy Mediastinoscopy Thoracentesis Aspirate pleural fluid or air from pleural space Lung Biopsy Obtain tissue for histologic analysis, culture, or cytologic exam
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Health Promotion Lifestyle Behaviors Smoking
Environmental/ocupational exposures Immunizations
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Pharmacologic Management Oxygen Therapy
Goal of oxygen therapy… to use the lowest fraction of inspired oxygen for an acceptable blood oxygen level without causing harmful side effects Hazards & Complications Combusion Oxygen induced hypoventilation Oxygen toxicity Absorption atelectasis Drying of mucous membranes Infection
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Oxygen Therapy Low-flow Systems High-Flow Systems Nasal cannula
Simple facemask Partial rebreather mask Non-rebreather mask High-Flow Systems Venturi mask T-piece Face tent Aerosol mask Tacheostomy collar
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Noninvasive Positive Pressure Ventilation
Technique uses positive pressure to keep alveoli open and improve gas exchange without intubation BiPAP (bi-level positive airway pressure) CPAP (continuous positive airway pressure) Transtracheal oxygen therapy
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Home Oxygen Therapy Patient education Methods Safety
Compressed gas in tank or cylinder Liquid oxygen in a reservoir Concentrator
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Bronchodilators Used for short-term prophylaxis, relief of acute attacks, and long term control (except salmeterol has delayed onset) Beta2 –adrenergic agonists Inhaled, short-acting Albuterol (Proventil, Ventolin) Inhaled, long-acting Formoteraol (foradil aerolizer, salmeterol (Serevent) Oral, long-acting Albuterol (Proventil, Volmax) terbutaline(Brethine) Anticholinergics Ipratropium, inhaled (Atrovent) Methylxanthines Theophylline (Theolair SR) PO or IV Aminophylline Theophylline
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Beta 2 Adrenergic Agonists
ACTION: Activate receptors in bronchial smooth muscle resulting in bronchodilation USE: Prevention & treatment of bronchospasm related to asthma, bronchitis, emphysema ADVERSE nervousness, restlessness, tremor, palpitations, EFFECTS: arrhythmias, hypertension, hyperglycemia Nursing Actions: Assess blood pressure, pulse, respiration, lung sounds Contraindications: cautiously in clients with diabetes, hyperthyroidism, heart disease, hypertension, angina, & on beta-adrenergic blockers. Pregnancy Category C (animal studies have shown adverse effect)
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Inhaled Anticholinergics
ACTION: Inhibits cholinergic receptors in bronchial smooth muscle resulting in decreased cnoncentrations of cyclic guanosine monophosphate (cGMP) producing local bronchodilation USE: Maintenance therapy of reversible airway obstruction due to COPD. Unlabeled use: adjunctive management of bronchospasm caused by asthma. ADVERSE nervousness, headache, blurred vision, palpitations, EFFECTS: nausea, dry mouth, hoarseness. Nursing Actions: assess respiratory status. Not for use in acute attacks of bronchospasm (too slow onset). Rinse mouth after to decrease unpleasant taste. Contraindications: peanut or soy allergy. Avoid during acute bronchospasm. Cautiously with prostatic hypertrophy, glaucoma, urinary retention Pregnancy Category B.
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Methylxanthines ACTION: Mild bronchodilator resulting in relaxation of bronchial smooth muscle. USE: Used as maintenance therapy in long term control of chronic asthma/acute exacerbation of asthma or bronchitis (Aminophylline) ADVERSE anxiety, tachycardia, N&V, tremor EFFECTS: seizures, arrhythmias Nursing Actions: Monitor serum levels and adverse effects Use infusion pump to administer. Caffeine increases CNS and cardiac adverse effects. Many potential interactions. Assess BP, pulse, respiratory status. Contraindications: Heart disease, hypertension, liver/renal dysfunction, diabetes Children & older adults. Pregnancy Category C
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Anti-Inflammatory Agents
Used for long-term prophylaxis, not for aborting ongoing asthmatic attacks Glucocorticoids Inhaled beclomethasone dipropionate (AVAR), budesonide (Pulmicort Turbuhaler), fluticasone propionate (Flovent), triamcinolone acetonide (Azmacort) Oral Prednisone (Deltasone), prednisolone Mast cell stabilizers Cromolyn (inhaled- Intal) and nedocromil (Tilade) Leukotriene modifiers Oral: montelukast (Singulair), zafirlukast (Accolate), zileuton (Zyflo)
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Glucocorticoids ACTION: Prevent inflammation, suppress airway mucous production, promote responsiveness of beta2 receptors in bronchial tree. USE: Inhaled: long term prophylaxis. Oral: short term symptoms of asthma after acute attacks or long term chronic asthma bronchitis maintenance. ADVERSE headache, hoarseness, oropharyngeal EFFECTS: fungal infections, flu-like syndrome, adrenal suppression Nursing Actions: Do not abruptly discontinue; Assess blood sugar levels, respiratory status. If used with beta2 agonist use that first then use glucocorticoid(beta2 agonist promotes bronchodilation & enhances absorption of glucocorticoid. Contraindications: acute attack of asthma, infections, diabetes, glaucoma, immunosuppression, clients who have rece4ived live virus vaccine, on NSAID’s. Pregnancy Category B (budesonide) C-all others
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Mast Cell Stabilizers ACTION: Prevent release of histamine and substance of anaphylaxis. USE: Prophylaxis of allergic disorders (rhinitis & asthma) Prevention of exercise induced bronchospasm. ADVERSE nasal irritation, irritation of throat & trachea, EFFECTS: hoarseness, unpleasant taste, anaphylaxis Nursing Actions: Advise to take 15 minutes before exercise or exposure to allergen. Prophylaxis may take several weeks for full therapeutic effects. Not for acute attacks. Rinse mouth after use to minimize irritation/hoarseness Contraindications: Cautiously in children, CAD, dysrhytmias, liver/kidney impairment. Pregnancy Category B
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Leukotriene Modifiers
ACTION: Antagonizes effects of leukotrienes resulting in suppression of inflammation, bronchoconstriction, airway edema, & mucus production. USE: Prevention & chronic treatment of asthma; manage seasonal allergic rhinitis ADVERSE headache, fatigue, cough, nausea, increased EFFECTS: liver enzymes Nursing Action: Assess respiratory function, allergy symptoms, monitor liver enzymess: Contraindications: Acute attacks of asthma, liver impairment; Use carefully with warfarin & Theophylline; do not give with food Pregnancy Category B
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Antitussives…opioids vs. nonopioid
codeine and hydrocodone suppress cough reflex center in CNS (medulla) Contraindicated with alcohol use, CNS depression, impaired renal/liver function, BPH, Addison’s disease, COPD Adverse Effects include sedation, nausea, constipation, potential for abuse Nonopioid less effective than opioids Dextromethorphan works in same way as opioids Contraindications: hyperthyroidism, cardiac/vessel disease, hypertension, glaucoma, MAOIs in past 14 days Adverse Effects include dizziness, drowsiness, & nausea Benzonatate (Tessalon Perles) suppresses cough reflex by anesthetizing stretch receptor cells in respiratory tract preventing reflex stimulation of medullary cough center Contraindications: None Adverse Effects include headache, sedation, nausea, constipation, pruritus
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Decongestants Indications: nasal congestion associated with acute/chronic rhinitis, common cold, sinusitis, hay fever Contraindications: narrow angle glaucoma, hypertension, diabetes, prostatitis, hyperthyroidism, CAD Adverse Effects: nervousness, insomnia, palpitations, tremor, rebound congestion. Nasal steroids may cause localized mucosal irritation/dryness. Adrenergics (sympathomimetics) Constrict small arterioles in upper respiratory tract (esp. sinuses) to relieve nasal stuffiness Ephedrine, oxymetazoline (Afrin), xylometazoline (Nasolin, Sudafed), naphazoline (Privine) Anticholinergics (parasympatholytics) Corticosteroids (intranasal steroids) Beclomethasone dipropionate (Beconase), budesonide (Rhinocort), fluticasone (Flonase), triamcinolone (Nasacort)
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Antihistamines Indications: nasal allergies, seasonal hay fever, symptoms of common cold such as sneezing/runny nose. Action: Bind to histamine receptors; prevent action of histamine. Contraindications: narrow angle glaucoma, cardiac / kidney disease, hypertension, asthma, COPD, PUD, seizure disorders, BPH Adverse Effects: drowsiness, dry mouth, changes in vision, difficulty urinating, constipation. Non-sedating antihistamines Loratadine (Claritin) , fexofenadine (Allegra) Traditional antihistamines Diphenhydramine (Benadryl), chlorpheniramine (Chlor-trimeton), brompheniramine (Dimetapp) Hydroxyzine (Vistaril), promethazine (Phenergan), dimenhydrinate (Dramamine)
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Expectorants / Mucolytics
Enhance flow of secretions in respiratory passages Used for pulmonary disorders with large amounts of secretions Antidote for acetaminophen poisoning Acetylcysteine (Mucomyst) Smells like rotten eggs Dilute with fruit juice Expectorants Break down and thin secretions Guaifenesin (Mucinex)
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Influenza Medications
Antiviral Agents Most effective if started with hours of first symptoms Treatment of influenza A Amantadine (Dymmetrel), rimantadine (Flumadine), Treatment of influenza B Ribavirin (Virazole) Treatment of both A & B Zanamivir (Relenza), oseltamivir (Tamiflu) Adverse Effects: bronchospasm; vary significantly by drug Contraindications: COPD, asthma Pregnancy Category C
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Thoracic Surgery Segmental resection (segmentectomy) Wedge resection
Lung resection that includes bronchus, pulmonary artery & vein, tissue of involved lung Wedge resection Remove peripheral portion of small localized areas of tissue Lobectomy Removal of entire lung lobe Pneumonectomy Removal of entire lung (cancer, absceses, TB) No chest tube required
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Preoperative Care Relieve anxiety Promote patient participation
Encourage expression of fears / concerns Reinforce surgeon’s explanation Educate what to expect after surgery
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Post Operative Care Maintain patent airway Ensure adequate ventilation
Prevent complications Assess for adequacy of ventilation & gas exchange Maintain closed chest drainage system / chest tube(s) Manage pain (pain causes guarding & hypoventilation) Encourage IS q hour W/A, cough, & DB with splinting Incision care
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Laryngectomy / Radical Neck Disection
Partial Hemilaryngectomy or supraglottic laryngectomy Partial voice conservation laryngectomies Tracheostomy usually temporary Total Tracheostomy permanent Total voice loss Cord stripping, cordectomy, Nodal Neck resection Removal of lymph nodes, sternocleidomastoid muscle, jugular vein, 11th cranial nerve (shoulder drop), & surrounding soft tissue Post Operative Priorities Airway maintenance and ventilation Provide alternate form of communication
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Nasal & Sinus Surgery Rhinoplasty (cosmetic, fractures)
Nasoseptoplasty (nasal septum deviation) Post Operative Care Observe for edema or bleeding Assess vital signs Assess frequency of swallowing Semi-Fowlers position and move slowly Cool compresses on nose, eyes, or face Limit valsalva maneuvers No blowing nose
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Tonsillectomy & Adenoidectomy
For recurrent acute infections, chronic infections, peritonsillar abscess, or enlarged tonsils or adenoids that obstruct airway Postoperatively Assess for airway clearance Provide pain relief Monitor for bleeding
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Respiratory Interventions
Chest Physiotherapy Nebulizer/Updrafts Humidification Incentive Spirometry Cough & deep breathe
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Principles of Mechanical Ventilation
To support & maintain gas exchange and decrease the work of breathing Be concerned with patient first and ventilator second Nursing priorities Monitoring and evaluating patient responses Managing ventilator system safely Preventing complication
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Tracheostomy / Trach Care
Tracheotomy Surgical incision into trachea Tracheostomy Stoma or opening resulting from tracheotomy Temporary or permanent Tube is secured in place with sutures and ties/velcro Postop care Assess respiratory system for Patent airway Bilateral breath sounds Complications
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Complications of Tracheostomy
Tube obstruction Tube dislodgment Pneumothorax Subcutaneous emphysema Bleeding Infection Tracheomalacia Tracheal stenosis Tracheoesophageal fistula
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Types of Tracheostomy Tubes
Plastic or metal Multiple sizes Inner cannula may be disposable or reusable Cuffed tube vs. noncuffed tube Fenestrated tube
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Caring for Patients with Trach
Prevent tissue damage Cuff pressing against tracheal mucosa Check cuff pressure per policy for appropriate inflation Stabilize the tube to minimize movement Suction only when needed Prevent and treat malnutrition, dehydration Warm and humidify air keep secretions thinned and moist
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Tracheostomy Care Keeps tube free of secretions
Maintains patent airway Provides wound care First assess patient (chart 30-5) See Best Practice for Tracheostomy Care (chart 30-4)
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Suctioning Maintains patent airway / promotes gas exchange
Assess need for suctioning Audible or noisy secretions, crackles, or wheezes Patient request for suctioning Hyperoxygenate patient for 30 seconds to 3 minutes to prevent hypoxemia Lubricate with sterile water or saline and insert a 12–14 fr catheter for adults (without suction) Withdraw catheter 1-2cm and begin to apply suction intermittently with a twirling motion Never suction longer than seconds Hyperoxygenate for 1-5 minutes until HR and O2 sat WNL
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Chest Tubes A drain place in pleural space to restore intrapleural pressure and allows re-expansion of the lung Prevents air and fluid from returning to the chest Nursing Priorities Ensure integrity of the system Promote comfort Ensure chest tube patency Prevent complications
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Chest Tubes Chamber One Chamber Two Chamber Three
Collects fluid draining from the patient Fluid must never fill to level of tube from patient or tube connecting to chamber two Chamber Two Is the water seal that prevents air from entering the patient’s pleural space; a one way valve Bubbling indicates air drainage from patient when patient exhales, coughs or sneezes Excessive bubbling may indicate air leak (notify MD if bubbling occurs continuously in water seal chamber) Rise of 2-4 inches during inhalation and fall during exhalation are normal; absence of tidaling may indicate tube obstruction, no more air is leaking into pleural space Chamber Three Suction control
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Chest Tubes Best Practices
Ensure sterility and patency of system Tape tubing junctions to prevent accidental disconnects Keep occlusive dressing at chest tube insertion site Keep sterile gauze at bedside to cover insertion site immediately if tube becomes dislodged Keep padded clamps at bedside Position tubing to prevent kinks and loops which can block drainage Keep manipulation of tube to minimum (gentle milking) Assess respiratory status and document amount and type of drainage hourly first 24 hours then at least every 8 hours or per policy (notify MD if exceeds 100mL/hr/
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Epistaxis Patho: Anterior vs. Posterior
Dryness – crust removal with nose blowing / picking / rubbing Trauma – direct blows, nasogastric suctioning Systemic – (less common); HTN, bleeding disorders, cocaine use, tumor Anterior vs. Posterior Anterior more common Posterior bleeds more difficult to control and need emergency intervention
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Epistaxis Assessment History Inspection and documentation
Number, causes and duration or prior nosebleeds Inspection and documentation Amount & color of blood V.S. Interventions- Anterior nose bleeds Upright position / leaning forward Keep calm & quiet Compress nose with index finger & thumb for 5-10 min ice / cool compresses to nose & face Pack loosely with gauze or nasal tampons Not blowing nose! Interventions- Posterior nose bleeds (usually at hospital) Cautery (silver nitrite, electrocautery) Packing Balloon or tampon Assess for respiratory distress and tolerance of packing Bedrest , pain management Humidity / oxygen Packing usually removed 1-5 days later
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Epistaxis Patient / Family Teaching Petroleum jelly to nares
Nasal saline sprays and humidifiers Avoid vigorous nose blowing / picking Avoid ASA, NSAIDs, strenuous exercise / lifting
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Facial Trauma Dx: CT head, face & cervical spine
Patho: Described by specific bones involved (mandibular, maxillary, orbital, nasal) Assess: #1 Airway For obstruction (stridor, SOB, dyspnea, hypoxia, hypercarbia, cyanosis, loss of consciousness) #2 Site of trauma Edema, facial asymmetry, pain, leakage of spinal fluid from ears/nose, vision & eye movement, extensive bruising behind ears “battle sign” Dx: CT head, face & cervical spine
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Facial Trauma Interventions: Establish & maintain airway
Prepare for possible intubation / trach Control bleeding Assess for extent of injury May require surgical repair / fixation of fracture Jaw wiring Teach patient to keep wire cutter available at all times Titaneum plates BoneSource Teach oral care with Water Pik, soft / liquid diet restrictions (collaborate with nutritionist) , f/u with dentist
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Laryngeal Trauma Patho: crushing / direct blow, fracture,
prolonged ET tube S&S: dyspnea, aphonia, hoarseness, subcutaneous emphysema, hemoptysis DX: MD visualize with laryngoscopy Interventions: Assess airway (be prepared for intubation) Monitor VS Humidified oxygen Watch for respiratory distress Tachypnea, nasal flaring, anxiety, sternal retraction, SOB, dyspnea, low O2 sat, stridor Surgery may be necessary for some
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Neck Trauma Patho: knife, gunshot, accident, traumatic blow Priority:
Assess and maintain airway Assess for involvement of multiple systems Neuro – mental status, sensory & motor function Cervical spine injury – neck precautions Esophagus injury – chest pain, oral bleeding Carotid artery injury – obvious bleeding, Sx of stroke, VS’s.
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Head & Neck Cancer Patho: squamous cell of mucosa, salivary glands, thyroid or other structures; curable if treated early Risk Factors: (info to gather in history) Smoking in pack years & alcohol use voice abuse chronic laryngitis industrial chemicals hardwood dust poor oral hygiene GERD
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Head & Neck Cancer Warning signs Pain Lump in mouth, throat or neck
Difficulty swallowing Oral lesions or persistent sore throat Oral bleeding Numbnness of mouth, lips, or face Change in fit of dentrues Burning sensation when drinking acidic / hot fluids Hoarseness or change in voice quality Shortness of breath Anorexia & weight loss Table 31-1
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Head & Neck Cancer Diagnostics Physical exam
CBC, bleeding times, chemistries Xrays, CT, MRI, PET scan, Nuclear Imaging Bone scans Panendoscopy (laryngoscopy, nasopharyngoscopy, esophagoscopy, bronchoscopy) Biopsy & tumor staging Physical exam Inspect & palpate head/neck for tumor, enlarged lymph nodes
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Head & Neck Cancer Treatment Surgery Radiation Chemotherapy
Laryngectomy (total or partial) Tracheotomy Cordectomy Post operative care Assess & maintain airway, VS, comfort, nutrition, speech therapy or alternative forms of communication (artificial larynx) Post operative complications Airway obstruction, hemorrhage, wound breakdown, tumor recurrence Radiation Skin problems, hoarseness, dysphagia, xerostomia, sore throat Chemotherapy
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Asthma Patho: intermittant & reversible airflow obstruction; affects only airways Obstruction due to Inflammation Allergens, irritants, airborne particles / organisms, ASA, NSAID’s Airway hyperresponsiveness (twitchy airways) Exercise, URI, unknown factors May have both
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Asthma Assessment: Step System Family history
History of dyspnea, chest tightness, coughing, wheezing, increased mucous Are symptoms continuous, seasonal, associated with specific activities / exposures Associated symptoms Rhinitis, rash, pruiritis Physical exam Audible wheeze, increased respiratory rate, coughing, accessory muscles, retractions, labored breathing, cyanosis, hypoxemia, tacchycardia Step System Classification of asthma r/t frequency and severity of symptoms and response to drugs (chart 32-2)
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Asthma Diagnostics Intervention goals Drug Therapy
ABG’s (decreased PaO2) Increased eosinophils and IgE (if allergic) PFT’s (decreased FEV1 or PEF) Intervention goals Improve airflow Relieve symptoms Prevent episodes Drug Therapy Preventative therapy drugs Anti-inflammatories Leukotriene antagonist Inhaled corticosteroid Inhaled cromolyn Bronchodilators Rescue drugs – use during acute attack
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Asthma Patient education Drug therapy
Use bronchodilators 30 mins before exercise Sequence of using inhalers Lifestyle management Stop smoking Avoid triggers Self assess respiratory status Peak flow meter BID (green-80% or above, yellow-50-80%, red-50% of personal best) When to seek emergency care Cyanosis Difficulty breathing walking or talking Retractions / nasal flaring Failure of drugs to control symptoms Peak expiratory rate declining or below 50% below baseline
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