1. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 25: Patient Management: Respiratory System

2. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Goals of Bronchial Hygiene Therapies Promote removal of secretions Improve ventilation Improve gas exchange Decrease risk for pulmonary infection Decrease risk for atelectasis

3. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Indications for Postural Drainage Difficulty clearing secretions Sputum production > 30 mL/day (cystic fibrosis) Mucous plugs causing atelectasis Indications for Percussion/Vibration Helps to loosen and dislodge secretions

4. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question When the nurse is positioning a client with an abscess in the right lung for chest physiotherapy (CPT), which of the following is correct? A. Position the client with the diseased lung down. B. Position the client with the diseased lung up. C. Position the client in either direction. D. The client should not have CPT.

5. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. Position the client with the diseased lung down. Rationale: When a client has an abscessed lung, the client needs to be positioned with the diseased lung down to keep the abscess from spreading to the opposite lung. If the client had a lung disease other than an abscess, then the client should be positioned with the diseased lung up, because positioning the diseased lung down would lead to increased hypoxemia.

6. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Goals of Oxygen Therapy Stabilize the arterial oxygen saturation (SaO2) Achieve normal respiratory rate and effort Decrease discomfort Improve myocardial oxygenation

7. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessing the Patient Receiving Oxygen Oxygen is administered at ordered rate and method Mentation Airway patency Breathing effort and rate Nail beds Pulse oximetry and ABG results Use of accessory or abdominal muscles

8. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Ways to Prevent Oxygen Complications Change strap position frequently and pad areas to decrease skin breakdown. Provide oral hygiene and apply protective barriers to nares and lips. Enforce no-smoking rule. Check tubing connections. Keep oxygen concentrations as low as possible. Monitor for CO2 narcosis in patients with COPD.

9. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following statements about managing a nasopharyngeal airway is correct? A. Use the airway in an unconscious client only. B. Measure for the correct airway length from the tip of the nose to the earlobe. C. Use the smallest outer diameter that fits the nostril. D. Nasotracheal suctioning is a clean technique and the catheter may be used for multiple sessions.

10. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. Measure for the correct airway length from the tip of the nose to the earlobe. Rationale: The airway should be used in a conscious client because it is more comfortable and does not elicit the gag reflex. Use the largest outer diameter that fits the nostril. Nasotracheal suctioning is a sterile technique, so follow sterile suctioning guidelines.

11. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Comparison of Intubation Approaches Orotracheal Allow direct visualization of cords Quicker approach in apneic patient Nasotracheal Blind intubation Alternative approach in awake, breathing patient

12. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Complications of Intubation Approaches Orotracheal Dental injury Soft tissue trauma Aspiration Esophageal intubation Vocal cord injury Mainstem bronchus intubation Nasotracheal Nasal trauma Posterior pharyngeal wall perforation Aspiration Esophageal intubation Vocal cord injury Mainstem bronchus intubation

13. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Causes of Iatrogenic Pneumothorax Central line placement Placement of internal pacemaker Lung biopsy Cardiopulmonary resuscitation Barotrauma Thoracentesis

14. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Comparison of Chest Tube Drainage System Principles Collection chamber Water chamber –2 cm of water creates negative pressure on pleural space –Vent –Tidaling Suction control chamber –Suction is determined by water level in the chamber and not the amount on the wall suction –Dry suction

15. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Preventing Complications of Chest Tube Drainage System Management Avoid dependent loops. Never raise a drainage system above the patient’s chest. Assess the patient and the integrity of the system and drainage every hour. Secure the system to the floor. Secure all connections with tape. Keep padded hemostats, sterile water, occlusive dressing supplies at bedside.

16. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question What will happen if the nurse fills the water seal in a chest tube drainage system above the 2-cm level? A. The patient will have increased difficulty breathing because there is a longer column of fluid to move when breathing. B. There will be no effect on the client, but it will make drainage more difficult. C. It will have no effect on the client because 2 cm is the minimum. D. It will get rid of an air leak more quickly.

17. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. The client will have increased difficulty breathing because there is a longer column of fluid to move when breathing. Rationale: Increasing the fluid above 2 cm in the water seal exerts an increased negative pressure on the pleural space and can prevent the air leak from getting better. The higher the water column is, the harder it is for the client to breathe because the client has to move the column of water during breathing. The level at 2 cm is recommended because physiologically it is the best level to act as a one-way valve to close the drainage system to outside air.

18. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Role of the Nurse in Determining the Cause of Agitation Consider the effects of medications on the older adult. Consider any new medications added or drug interactions. Consider physiological causes. Consider pain. Consider alcohol or illicit drug withdrawal, if the patient has a history of using illicit drugs or alcohol.

19. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Definition of Respiratory Failure The respiratory system is unable to perform adequate gas exchange, as evidenced by a PaO2 50 mm Hg. Classified as acute or chronic Hypoxemic respiratory failure (type I) Hypercapnic respiratory failure (type II)

20. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Ventilation Negative-Pressure Ventilation Thoracic cage is pulled outward to cause inspiration Exhalation is passive Types of ventilators –Iron lung –Portable external vents worn over the thorax like a turtle shell Positive-Pressure Ventilation Air is forced into the lung at a certain rate, time, and volume or pressure Exhalation is passive Types of ventilators –Volume –Pressure –High-frequency

21. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Volume Ventilators Certain volume of air is delivered with each breath Pressure to deliver breath depends on lung compliance and other issues Pressure Ventilators Certain amount of gas pressure is delivered in early inspiration and is kept until the inspiratory cycle is done Volume of gas not consistent Types of Ventilation (cont.)

22. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Ventilator Modes Assist-control ventilation (A/C) –Patient can initiate (trigger) a breath –Volume and rate are preset by ventilator Used for a client with weak respiratory muscles Watch the patient, because the patient may be breathing too many breaths between the breaths delivered by the ventilator and may hyperventilate.

23. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Ventilator Modes (cont.) Synchronized intermittent mandatory ventilation (SIMV) –Preset volume and rate –Patient can have independent breaths between ventilator-delivered breaths Used for weaning Examine the minute volume to ensure that the client is being adequately ventilated.

24. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Ventilator Modes (cont.) Pressure support ventilation (PSV) Augments a spontaneous inspiration to overcome the work of breathing. Use cautiously in patients with restrictive airways.

25. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Ventilator Modes (cont.) Pressure-controlled ventilation (PCV) Used to control plateau pressures when compliance is decreased and risk for barotrauma exists Patient/ventilator asynchrony results in large decrease in SaO2 Mean airway and intrathoracic pressures increase –Results in decrease in cardiac output and O2 delivery

26. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Effects of PEEP Decreased venous return Decreased cardiac output Increased risk for barotrauma Increased intracranial pressure (ICP)

27. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Advantages and Disadvantages of Tracheostomy Advantages Decreased dead space, quicker weaning Communication Comfort Oral feeding Disadvantages Infection Hemorrhage Risks of operation Pneumothorax