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Alteration in Gas Transport:

Alteration in Gas Transport:. Care of the Patient with Respiratory Tract Problems. The Nursing Process and Respiration. Assessment Client History Why are you here? General overall health Any ‘colds’ or congestion or allergy problems? Smoking history

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Alteration in Gas Transport:

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  1. Alteration in Gas Transport: Care of the Patient with Respiratory Tract Problems

  2. The Nursing Process and Respiration • Assessment • Client History • Why are you here? • General overall health • Any ‘colds’ or congestion or allergy problems? • Smoking history • Pack years: number of packs per day times number of years • How much time away from work or school have you missed because of this?

  3. Assessment • Client History • Subjective symptoms • Dyspnea with ADLs? • Childhood diseases • Asthma, pneumonia, allergies, croup • Adult illnesses • Pneumonia, sinusitis, TB, HIV, emphysema, DM, HTN, cardiac disease • Vaccine history • Flu, pneumonia, BCG

  4. Assessment • Client History • Surgeries of upper or lower respiratory tract • Injuries to upper or lower respiratory tract • Hospitalizations • Date of last • CXR, PPD, PFT • Recent weight loss • Night sweats

  5. Assessment • Client History • Sleep disturbances • How many pillows? • Family history • Recent travel • Occupation • Leisure activities

  6. Assessment • Client History • Drug use • Recreational (marijuana, cocaine, crack) • Prescription • ACE inhibitors • Antihistamines • Bronchodilators • Chemotherapy • OTC • Allergy medications • Home remedies • Herbals: Elecampane, Hyssop, Mullein, Licorice

  7. Assessment • Client History • Allergies • Foods, drugs, substances • Allergic response? • Treatment? • Diet history • BMI • Obese? Malnourished? • Body weight in pounds times 703 divided by height in inches squared • Food intake related to breathing issues?

  8. Assessment • Client History • Occupation and Home Life • Environmental factors and exposure • Type of heat used in the home • Animals or pets in home • Hobbies involving chemicals • Pest infestation at home or work • Tie to asthma, wheezing related to roaches

  9. Assessment • Major signs and symptoms • Cough • Type, duration, length • Sputum production • Color, consistency, amount • Dyspnea • Rate of perception • ADLs • Paroxysmal nocturnal dyspnea • Orthopnea

  10. Assessment • Major signs and symptoms • Chest pain • Wheezing • Clubbing of fingers / nails • Hemoptysis • Cyanosis

  11. Gerontologic Considerations • Vital capacity and respiratory muscle strength peak between 20-25 and then decrease • Age 40 and older – surface area in alveoli is reduced • Age 50 – alveoli loses elasticity • Loss of chest wall mobility>decrease in vital capacity

  12. Gerontologic Considerations • Amount of respiratory dead space increases with age • Decreased diffusion capacity with age – lower oxygen level in arterial circulation

  13. Risk Factors for Respiratory Disease • Smoking • Personal / family history • Occupation • Allergens • Recreational exposure

  14. Physical Assessment • Nose and Sinuses • External nose • Deformities, tumors • Nostrils: symmetry of size, shape • Nasal flaring • Inspect for color, swelling, drainage, bleeding • Mucous membranes • Nasal septum • Bleeding, perforation, deviation

  15. Physical Assessment • Air movement • Occlude one nare • Sinuses • Via palpation • Tenderness, swelling • Tapping • Penlight • Frontal, maxillary

  16. Physical Assessment • Pharnyx, Trachea, and Larynx • Posterior pharynx • Tongue depressor • One side at a time • Observe rise and fall of palate and uvula (ah) • Inspect for color, symmetry, discharge, edema, ulceration, tonsillar enlargement • Neck • Inspect for symmetry, alignment, masses, swelling, bruises, use of accessory neck muscles in breathing

  17. Physical Assessment • Neck • Lymph nodes • Tender, movable – inflammation • Hard, fixed – suggest malignancy • Trachea • Palpate for position, mobility, tenderness, masses • Larynx • laryngoscope

  18. Physical Assessment • Lungs and Thorax • Inspection • Palpation • Fremitus • 99 • Crepitus • Bubble wrap • Chest expansion • Movement

  19. Physical Assessment • Lungs and Thorax • Percussion • Pulmonary resonance • Air, fluid, solid masses • Intercostal spaces only • Diagphragmatic excursion • Normal 1 -2 inches • Deep breath / percuss • No breath / percuss • Normally higher on the right (liver)

  20. Physical Assessment • Auscultation • Upright first • Bare chest • Open mouth breathing • Full respiratory cycle • Observe for dizziness

  21. Physical Assessment • Normal breath sounds • Bronchial, bronchovesicular, vesicular • Not heard peripherally • Adventitious breath sounds • Additional sounds superimposed on normal sounds • Indicate pathology • Crackles, wheezes, rhonchi, pleural friction rub

  22. Physical Assessment • Voice sounds • Assessed when abnormalities noted • Increased when sound travels through solid or liquid • Consolidation of lung, pneumonia, atelectasis, pleural effusion, tumor, abscess • Bronchophony: 99 – loud and clear • Whispered Pectriloquy: 1, 2, 3 – loud • Egophony – ‘E’ – heard as an ‘A’

  23. Physical Assessment • Skin and Mucous Membranes • Pallor, cyanosis, nail beds • General Appearance • Muscle development, general body build • Muscles of neck, chest • Endurance • How does the client move in 10 – 20 steps? • Speaking exertion

  24. Diagnostic Assessment • Need to know: • Normal / abnormal for: • RBC • Hgb / Hct • WBC / leukocytes / neutrophils • Eosinophils • Basophils • Lymphocytes • Monocytes • ABGs • Sputum studies • Skin (PPD) testing

  25. Diagnostic Testing • Chest xrays • Digital Chest Radiography • CT • V/Q Scan • Pulse Oximetry • PFTs

  26. Diagnostic Testing • Pulmonary Function Tests (PFTs) • Used generally in chronic conditions • Assesses respiratory function • Determine extent of dysfunction • Measures lung volumes, ventilatory function, and mechanics of breathing, diffusion, and gas exchange • Assesses response to therapy • Screening test in hazardous industries

  27. Diagnostic Testing • Arterial Blood Gases (ABGs) • Measures blood pH and arterial oxygen and carbon dioxide levels • Assesses ability of lungs to provide adequate oxygen and removal of carbon dioxide • Assesses ability of kidneys to maintain normal pH

  28. Diagnostic Testing • Pulse Oximetry • Noninvasive method of monitoring oxygen saturation of hemoglobin • Unreliable in cardiac arrest and shock, dyes or vasoconstictor meds used, severe anemia, or high carbon monoxide level

  29. Diagnostic Testing • Cultures • Throat or sputum • Sputum • Best to obtain early AM • Rinse mouth, takes deep breaths, coughs, and expectorates • Deliver specimen to lab within 2 hours

  30. Diagnostic Examination • Endoscopy • Bronchoscopy, laryngoscopy, mediastinoscopy • Check for patent airway every 15 minutes post procedure for two hours • Thoracentesis • Local anesthetic • Patient must remain still • Usually at bedside • Post procedure: CXR r/o mediastinal shift, monitor VS, auscultate breath sounds • Lung biopsy

  31. Diagnosis • Upper Airway Medical Diagnosis • Rhinitis • Viral rhinitis • Acute sinusitis • Chronic sinusitis • Acute pharyngitis • Chronic pharyngitis • Tonsillitis and adenoiditis

  32. Diagnosis • Upper Airway Medical Diagnosis • Peritonsillar abscess • Laryngitis • Upper Airway Nursing Diagnosis • Ineffective airway clearance • Acute pain • Impaired verbal communication • Fluid volume deficit • Knowledge deficit

  33. Planning and Implementation • Upper airway • Maintain patent airway • Promote comfort • Promote communication • Encourage fluid intake • Teach self care • Encourage appropriate hand washing

  34. Planning and Implementation • Managing potential complications • Sepsis • Sepsis • Meningitis • Otitis media

  35. Evaluation • Maintenance of patent airway • Reports feelings of comfort • Demonstrates ability to communicate • Maintains adequate fluid intake • Identifies strategies to prevent infections • Becomes free of s/sx of infection • Demonstrates adequate knowledge

  36. Upper Airway Obstruction and Trauma • Medical Diagnosis • Sleep apnea • Obstructive • Central • Mixed • Epistaxis • Nasal Obstruction • Fractures of the nose • Laryngeal Obstruction • Laryngeal Carcinoma

  37. Upper Airway Obstruction and Trauma • Nursing Diagnosis • Knowledge deficit • Anxiety • Ineffective airway clearance • Impaired verbal communication • Nutritional imbalance • Alteration in body image • Self care deficit • Sleep deprivation • Risk for injury • Fatigue

  38. Planning and Implementation • Sleep apnea • Avoid ETOH • Decrease body mass • CPAP • Uvulopalatopharyngoplasty • Tracheostomy • Pharmacologic Management • Low flow O2 • Triptil • Education

  39. Planning and Implementation • Epistaxis • Dependent on location of site • Generally anterior • Pinch outer portion / sit upright • Silver nitrate / gelfoam / electrocautery • Topical vasoconstrictors • Monitor VS • Estimate amount of blood loss • Don’t forget standard precautions

  40. Planning and Implementation • Nasal Obstruction • Deviation of nasal septum • Submucous resection • Generally outpatient • Promote drainage • Alleviate discomfort • Frequent oral hygiene

  41. Planning and Implementation • Fractures of the nose • Bleeding from site • Bruising • Clear fluid • CSF • Glucose positive • Surgical reduction ~ one week post injury • Ice therapy • Control anxiety • Oral hygiene

  42. Planning and Implementation • Laryngeal Obstruction • Often fatal • Acute laryngitis, urticaria, scarlet fever, anaphylaxis, foreign bodies • Edema: SQ Epi 1:1,000 / corticosteroid • Abdominal thrust (Heimlich) • Emergent tracheotomy

  43. Planning and Implementation • Laryngeal Cancer • Risk factors: chart 22-5 • Dependent upon tumor staging (chart 22-6) • Laryngectomy • Radiation • Speech therapy • Potential complications: respiratory distress, hemorrhage, infection, wound breakdown

  44. Laryngeal Cancer • Educate preoperatively • Reduce anxiety • Maintain patent airway • Encourage speech therapy • Maintain adequate nutrition • Promote positive body image • Teach self care

  45. Evaluation • Adequate level of knowledge • Lessened anxiety • Clear airway • Acquires effective communication • Appropriate intake • Positive self and body image • Complication free • Adheres to home therapy

  46. Chest and Lower Respiratory Tract • Medical Diagnosis • Atelectasis • Patho: figure 23-1 • Acute tracheobronchitis • Pneumonia • MUST know table 23-1 and charts 23-2, 23-3 • Review older adult considerations / risk factors • Assess any older adult with AMS for pneumonia • May not have cough or fever

  47. Nursing Diagnosis • Ineffective airway clearance • Activity intolerance • Fluid volume deficit • Altered nutrition • Knowledge deficit • Impaired gas exchange • Pain • Fatigue

  48. Planning and Implementation • Avoid potential complications: • Continuing symptoms • Shock • Respiratory failure • Atelectasis • Pleural effusion • Confusion • Superinfection

  49. Planning and Implementation • Improve airway patency • Hydration • Humidification • Oxygen therapy • CPT • Promote rest • Long recovery periods • Conserve energy • Promote fluid intake

  50. Planning and Implementation • Maintain adequate nutrition • Determine caloric needs with RD help • Educate client • Teach self care

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