Linda Winn, RN, MSN Ed., BA Ed.

Linda Winn, RN, MSN Ed., BA Ed.
Respiratory N415 Linda Winn, RN, MSN Ed., BA Ed.

Respiratory Assessment

Resp Assessment Breathing Pattern Dyspnea Cough and Sputum I:E ratio
Kussmaul Rate Dyspnea Orthopnea PND – Paroxysmal nocturnal dyspnea Cough and Sputum Frequency Dry / moist Amount Color Thickness Odor Kussmaul – regular, rapid, deep

Assessment (Cont.) Inspection Auscultation Chest pain History
Symmetry Skin color – lip color / finger clubbing WOB – accessory muscles Auscultation Adventitious sounds Chest pain History Diagnoses Smoking Quick, Focused Assessment History Smoking, ETOH, Drugs, Toxic exposure

Breath Sounds Link Normal and Adventitious breath sounds

Diagnostics & Labs

Labs H/H Sputum Analysis ABG’s O2 Sats C&S Gram Stain
Acid-Fast smear (AFB) Cytology ABG’s O2 Sats Arterial blood gas (ABG) Obtained from either radial or femoral artery Need a syringe with Heparin Recent temperature Needs to go on ice Allen’s test Need to hold pressure! O2 Sat ) Fake nails Warm extremities No hypotension Atrial fibrillation will give an inaccurate reading Pleth tracing

Diagnostic Tests CXR CT Chest MRI V/Q Scan Bronchoscopy Thoracentesis
Thoracentesis PFTs – Pulmonary Function Tests Spirometry CXR Diagnosis Evaluate treatment effectiveness Evaluate proper placement of tubes and catheters PA & Lateral Chest CT CAT scan Cross section of lung tissue Evaluate tumors and abscesses V/Q Scan Nuclear medicine scan No prep Not NPO Diagnostic for a PE Reported as high or low probability Bronchoscopy Diagnostic or therapeutic NPO and no teeth Consent CXR post procedure Watch for dyspnea Small amount of bleeding is normal Decreased gag Thoracentisis Removal of pleural fluid Patient positioning Support patient and medicate for pain PFTs Total Lung capacity (TLC) - Total amount of air in lungs after a maximal inspiration Tidal volume –(normal 500ml) --Volume of gas expired with a normal breath FVC (Forced vital capacity) --Maximal amount of air that can be expelled after a maximal inspiration FEV1 Amount of air expelled in the first second of a vital capacity maneuver PEFR (Peak expiratory flow rate) -- maximum flow rate achieved during a FVC correlates with FEV1

Chronic Obstructive Pulmonary Disease
Obstruction to expiratory air flow 15 million Americans have COPD 4th leading cause of death Women approaching men in incidence and surpassed men in number of deaths

COPD 2 Types of COPD Asthma no longer considered a type of COPD
Emphysema Chronic Bronchitis (most common) can have either or both Asthma no longer considered a type of COPD

COPD Etiology Common Signs and Symptoms Video Clip
smoking: 90% of people with COPD only15% of smokers get COPD smokers 10 x more likely to die from COPD environmental: Pollution Toxins second hand smoke develops slowly Common Signs and Symptoms Dyspnea and Wheezing Video Clip

Impact of Smoking

COPD video clips http://video.about.com/copd/COPD.htm
(skip through the ads  )

Emphysema - Pathophysiology
Abnormal permanent enlargement of the gas exchange airways with destruction of alveolar walls bronchioles too narrow or collapse slows air movement during exhalation & traps air in lungs increases work of breathing  surface area for gas exchange Blebs, Bulla Hyperinflation of alveoli Destruction of alveolar walls

Chronic Bronchitis Definition Pathophysiology
chronic productive cough for 3 months in each of the last 2 years Pathophysiology hypertrophy of mucous secreting glands & chronic inflammation of small airways  excessive sputum production impaired ciliary movement & excessive sputum can increase risk of infection bronchial walls can become narrowed or obstructed Thicker mucus Goblet cells – mucous secreting glands

Assessment Findings Early Later SOB Dyspnea Activity intolerance
Hypoxemia Chronic cough with sputum Prolonged expiration Wheezing on forced expiration Altered Breathing Techniques Pursed-lip breathing Tripod breathing position Later Hyperinflation of lungs  barrel chest Diminished lung & heart sounds Central cyanosis (chronic hypoxemia) CO2 retention

Asthma

Asthma Videos http://www.mayoclinic.com/health/asthma/MM00001

Asthma

Exaggerated bronchoconstriction response to stimuli
Airways overreact to triggers causing narrowing Chronic inflammatory disorder of airways 1 in 20 Americans; 5000 deaths/year Common triggers: allergies: dust, mold, sulfites, dander cold, dry air exercise stress Airway narrowing – prominent feature

Common Triggers Allergens: dust, mold, sulfites, dander Cold, dry air
Exercise Stress Environmental

Assessment Findings Wheezing after exposure to triggers, coughing, chest tightness Rapid, shallow respirations, dyspnea,  or absent breath sounds, accessory muscle use Postural changes to aid breathing Activity intolerance Anxiety Severity of symptoms vary Changes in peak expiratory flow rate Sudden onset Increased mucous production Resp. alkalosis Decreased vital capacity Wheezing (expiratory wheeze) Prolonged expiratory phase Accessory muscle use SOB Cyanosis Dyspnea Chest tightness Prolonged attack will lead to respiratory acidosis

In the Zone Green Zone Yellow Zone Red Zone PEFR  80% of baseline
no sx; meds may be  by MD Yellow Zone PEFR 50-80% baseline may have Ø to mod sx having attack or meds adjusted Red Zone  50% baseline severe sx medical alert; call MD

Potential Nursing Diagnoses
Ineffective Airway Clearance Impaired Gas Exchange Ineffective Breathing Pattern Activity Intolerance Altered Nutrition Aspiration, risk for Pain Anxiety Fear High risk for infection Pneumonia Alt breathing pattern – pain Barrel chest due to hyperinflation, prob related to airway clearance O2 sat decreased --- Imp gas exch

Nursing Management Monitor Maintain airway VS LOC lung sounds
sputum amount and character Maintain airway Pursed-lip breathing cough routines positioning for max lung expansion Suctioning avoid cough suppressants unless cough frequent & non-productive Pursed Lip breathing prolongs exhalation, preventing alveolar collapse and air trapping. Does not loosen secretions. Promotes effective exhalatio, not inhalation RN: teach pursed lip breathing – lengthens exh, teach use abd muschles increases sm airway pressure, prevents airway collapse Example PT: COPD c PNA pt admitted – fatigued, sleeping soundly, need VS – what to do? let sleep? No Wake up, enc C&DB

Nursing Management Good oral hygiene Monitor activity tolerance
help pt conserve energy plan rest periods O2 prn Good oral hygiene Decrease anxiety remain with patient during anxious episodes, relaxation techniques, O2 prn Nutrition Hydration Nutrition high calorie, high protein – 6 or more small meals/day Liquids between meals, rather than with meals, so pt doesn’t get full prior to feeling full (satiety) Bronchodilators before meals Easy to chew foods

Collaborative Treatment
Immunizations flu & pneumonia vaccinations Bronchodilators Inhaled steroids Antibiotics Oxygen therapy Pulmonary Rehabilitation Smoking Cessation Asthma meds: Review types and order Acute Attack meds Inh. Steroids: don’t stop, life long, don’t run out PO steroids diff – wean off, anticpate inc. emotionals MDI’s – review hold breath for a few sec Keep back-up inhaler, ie. Purse, car Oxygenation – need adequate H/H COPD – caution c inc conc. Of O2

Patient Education Monitor color, amount, thickness of sputum
Self care: at-home meds & treatments; avoid triggers Prevention Pneumococcal vaccine, flu shot Frequent oral hygiene Encourage fluids Environmental hazards altitude, smog, allergies, smoke Follow up medical care American Lung Association

COPD – Cor Pulmonale Long-term complication
COPD non-curable –cor pulmonale poss

Respiratory RN Diagnoses
Impaired Gas Exchange Ineffective Airway Clearance Others

Pulmonary Tuberculosis

Tuberculosis Incidence Risk Factors Mode of Transmission
Mycobacterium tuberculosis Development of TB Text copy: The world ~ 1/3 of the world’s population infected 80% in developing countries U.S. Medically underserved Immigrants Urban and rural poor IVDA HIV Causitive agent is mycobacterium bacillus Preventable and curable Reportable illness TB infection TB exposure Positive (PPD) TB disease Tuberculosis Active TB

Diagnostic Tests PPD CXR AFB Bronchoscopy WBC
PPD (purified protein derivative) +PPD = exposed, not dx of active dx CXR Sputum for AFB (acid fast bacillus) Smear Culture A positive sputum culture for AFB confirms the diagnosis of active TB AFB – x3 Teach – 1st thing in am Rinse c H2O, not mouthwash Cough up sputum into sterile cup Don’t touch inside of cup, cap Tell RN ASAP Bronch – Pre-medicated == drowsy f/u care: enc C&DB, wake up

Assessment Findings Classic Sx: Weight Loss Low-grade fever
Night sweats Productive Cough Classic: Weight Loss Low-grade fever Night sweats Productive Cough Morning cough with mucous production Low grade fever, usually in the afternoon Pallor, chills, night sweats, generalized weakness, fatigue, anorexia, weight loss Late symptoms include blood-tinged sputum and chest pain

Treatment Medications Multi-drug approach
INH – Isoniazid Rifampin (Rifadin) Ethambutol (Myambutol) Pyrazinamide (PZA) Multi-drug approach Not transmittable after 2-3 weeks of treatment All meds are hepatotoxic: Monitor (teach) S/S liver tox, poss hepatitis: jaundice, anorexia, malaise, clay stools, inc. AST Notify MD of these sx (teach) May cause orange urine - ok Meds: always 4 drugs or more teach meds concurrent, not sequential Duration: min 6 month, up to 24 mo Promote adherence: DOT, Intermittent dosing (2-3X/week)

Nursing Care In-hospital Care Public Health Nurse
Negative pressure Room Respiratory isolation N-95 mask Fit testing Transporting Patient Public Health Nurse DOT In Hosp Environmental factors that increase risk of transmission include: Exposure in a small enclosed space. Inadequate local or general ventilation that results in insufficient dilution and/or removal of infectious droplet nuclei. Recirculation of air containing infectious droplet nuclei. 888respiratory isolation was often inadequate. For example, isolation rooms were found to have positive rather than negative pressure, air was being recirculated from isolation rooms to other high risk areas, doors to isolation rooms were left open, isolation precautions were discontinued too soon, and healthcare workers did not wear adequate respiratory protection. Resp Iso- -pressure room, until 3 – AFB’s HEPA fit masks – fit tested Teach: cover mouth/nose, all tissues biohazard, hand wash teach: adherance can = cure Teach: take daily vit. Negative airflow room Respirator masks Patient and family education Nutrition Collection of sputum samples PH RN sputum weekly, then monthly to check effectiveness non-comp == multidrug resis f/u visits x12mo for recurrence teach liver sx Development of drug resistant TB MDR-TB (multi drug resistant TB) DOT (directly observed therapy) Incentives Identification of close contacts Unscheduled home visits

O2 Levels Needs O2 <55 <88% May be OK 40 75%
PaO SaO2 Needs O2 <55 <88% May be OK % Short-term With COPD Critical <40 <75%

ABG’s Acid – Base Balance Nursing Considerations in drawing ABG’s
Allen’s Test Ice Pressure Place in ice, call for tansport to lab, pressure 5”, up to 20” c anticoagulation tx

ABG Normal Values pH 7.35-7.45 pCO2 35-45 HCO3 22-26 PaO2 80-100 mm Hg
SaO2 >95% pO2 – dissolved in plasma SaO2 bound to Hbg - transports O2 to cells, large drop in paO2 compensated by SaO2 remaining saturated

ABG Evaluation Step 1 – pO2 Step 2 – pH Step 3 – pCO2 Step 4 – HCO3
Acidotic or Alkalotic? Step 3 – pCO2 Respiratory cause? Step 4 – HCO3 Metabolic cause? Step 5 – Compensated or Uncompensated

ABG examples pH 7.39 pO2 59 pCO2 59 HCO3 31 Diagnosis?
What is this typical of? Respiratory Acidosis with compensation Typical of COPD

Group Activity 1 pH 7.3 pCO2 25 HCO3 16 pO2 85
Interpretation: _______________ Met Acidosis with partial Comp. Normal O2

Group Activity 2 pH 7.33 pCO2 47 HCO3 24 pO2 76
Interpretation: _______________ Resp Acidosis, uncompensated, mild hypoxia

Group Activity 3 Create ABG for pt with Metabolic Acidosis
Metabolic Alkalosis with compensation Met Acidosis ph down, HCO3 down, HA, drowsy, inc. RR

Linda Winn, RN, MSN Ed., BA Ed.

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