The Air We Breath

1. By: Diana Blum MSN Metropolitan Community College The Air We Breath

2. Respiratory System • Focuses on the energy required to carry out ADL. When lung tissue is damage and 02 at cellular level is severely decreased the client may not be able to perform any of these functions. Energy conservation tech are most important!

3. Nursing Diagnosis • Pain r/t inflammation, tissue damage • Ineffective breathing pattern r/t surgical incision, pleural effusion, decreased lung expansion • Impaired gas exchange r/t alveolar destruction, bronchospasm, air trapping • Ineffective airway clearance r/t weak cough • Anxiety r/t hypoxemia • Activity intolerance r/t inability to meet 02 needs • Decreased cardiac output r/t pump failure (r-sided) • Imbalance nutrition: less than body require r/t anorexia, dyspnea

4. Anatomy

5. Apnea • Temporary interruption in the normal breathing pattern in which NO air movement occurs • May occur during sleep and at end of life • http://abcnews.go.com/Video/playerIndex?id=2927688

6. ~pnea • Dyspnea} difficulty breathing or shortness of breath • Orthopnea} difficulty with breathing while in a lying position • Tachypnea} respiratory rate >20 • Bradypnea} respiratory rate <12 • Other breathing types located in table 30-1

7. Data Collection • Past history/Family history: colds, TB, Chronic bronchitis, asthma, cancer, sinus infections, ear infections, pneumonia, COPD, emphysema, allergies, immunizations, diabetes, CAD, TB tine, Smoking history (pack per year history) • Chief complaint: obtain details on subjective complaints r/t respiratory system • Cough: • Dyspnea: • Pain: (chest) : • Look at what meds were taken to attempt relief

8. Examination • Ask for subjective info about fatigue, weakness, fever, chills, nasal obstruction, sinus pain, hoarseness, edema, sore throats • Functional assess: • General:

9. Lung sounds • Normal Breath Sounds • Normal Air Flow through the Lungs • Adventitious sounds • Wheezing: musical, whistling sound • http://www.ed4nurses.com/breathsnds.htm • Rales: crackling sound • Expectorate • Rhonchi: bubbling • The sound will be heard throughout inspiration and expiration. • Louder than rales due to larger secretions • Results from air bubbling past secretions in the airways • Interventions: • Deep breathing • Coughing • Hydration (encourage fluids, if no restriction) • Humidify air • Mobilize • Friction rub: creaking, leathery sound • End of inspiration and beginning of expiration • Caused by rubbing of inflamed pleural surfaces against lung tissue. • Interventions: • Chest x-ray • Anti-inflammatory medications

10. Lungs sounds continued Cheyenne Stokes Kussmal’s • Cause: severe brain pathology • Causes: metabolic acidosis, renal failure, diabetic ketoacidosis

11. http://micunursing.com/ • http://www.med.ucla.edu/wilkes/lungintro.htm • http://www.rnceus.com/resp/respabn.html • http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/pd/step29e.htm

12. Age related changes • Muscle atrophy in pharynx and larynx and change in vocal cords • Loss of lung elasticity • Decreased number of alveoli • Weaker chest muscles • Diminished chest movement • Less effective cough • Work harder to breath • Enlargement of bronchioles • More suseptible to lung infections r/t decreased defense mechanisms • Rib cage becomes more rigid and diaphragm flattens

13. Diagnostics • Chest xray • Fluoroscopy: • Looks at speed and degree of lung expansion and looks for structural defects • No jewelry on neck or chest, no clothes from waist up except hospital gown • Ventilation/Perfusion Scan: • IV or inhaled radioactive med given • NPO for 4 hours prior to. • Monitor for anaphylaxis • Radioactive material is excreted in urine • Inform importance of hand washing and if anyone else handles urine they should glove as well

14. Diagnostics continued • Cat scan: • Needs to be still • With or without contrast • Check for iodine allergy • IV access • MRI:. • Lie flat, mechanical noises • NO metal allowed • Pulse oximetry: • May be continuous or intermittent • Small censor on finger or ear • Indicate level of oxygen with result

15. Diagnostics continued • PFTs: used to diagnose disease, monitor progression, assesses medications • Measures lung volumes and capacities • Total lung capacity, forced expiratory volume, functional residual capacity, inspiratory capacity, vital capacity, forced vital capacity, minute volume, and thoracic gas volume (table 30-2) • A clip is placed on the nose that the patient breathes through a mouth piece to determine mechanics (flow rates of gas in and out of lungs) and diffusion (movement of gas across aveoli/capillary membrane) • ABGs: measures the concentrations of oxygen and carbon dioxide in the arterial blood to determine if exchange is adequate across the alveolar membrane • pH: 7.35-7.45 • PaCo2: 35-45 • PaO2: 80-100 • HCO3: 22-26 • Sats: 96-100 • http://www.youtube.com/watch?v=IBJtQtzN7O8&feature=related • http://www.youtube.com/watch?v=Xsr5wF-WDrw&feature=related • http://www.youtube.com/watch?v=7s6OGhMfUqI&feature=related • http://www.youtube.com/watch?v=LcmjGMWDbXw&feature=related • http://www.youtube.com/watch?v=t9x4tB9GOi8&feature=related

16. Diagnostics Continued • Bronchoscopy: • It allows direct visualization of structures • Explain procedure and assess allergies • Consent needs to be obtained • NPO 6-8 hours prior • No smoking days prior • dentures removed and document loose teeth • Administer sedatives as prescribed (cetacaine) • Atropine may also be given to decrease secretions • post procedure: • NPO until gag reflex returns • Semi fowler’s position • Monitor vitals • Monitor for edema, hemoptysis, stridor, asymmetric movement of chest • Report abnormal findings to doctor! http://www.youtube.com/watch?v=DS6MHZCGlJk

17. thoracentesis • Removal of pleural fluid for examination or to allow for lung re-expansion • Obtain consent • Post : • Assess respiratory status • Document amount, color of fluid • Monitor dressing for bleeding • Label specimen bottle and send to lab http://www.youtube.com/watch?v=noDxydboLrA&feature=related

18. Diagnostics continued • Tuberculin test (A.K.A. TB Tine) • Determines past or present exposure to tuberculosis • Pre: • Inform the client about intradermal need stick • Cleanse skin and inject intradermally into lower anterior forearm • Mark and record site • Instruct pt that skin reaction can last 1 week and not to scratch it. • Inform patient they need to return in 48-72 hours for interpretation of positive or negative response • ***Reddness, swelling of 5mm or more is considered positive • A pt with a history of BCG vaccination (foreign born) will always test positive regardless of exposure. • Post: follow up depends on response. • If positive pt will be sent for chest x-ray to confirm active tuberculosis

19. Diagnostics Continued • Sputum analysis} the mucous membrane lining in the lower respiratory tract responds to acute inflammation by producing an increase in secretions • Specimens are examined for volume, consistency, color, odor • Sputum that is thick, foul smelling, and yellow, green, or rust colored may indicate bacterial infection • Pt needs to expectorate the specimen into a sterile container after coughing deeply if unable induction may need to be done to obtain • C & S} determines presence of bacteria, id’s specific organism, and appropriate treatment • Acid fast} done to determine the presence of acid fast bacilli including TB. Collection is 3 samples • Cytologic} used to determine the presence of carcinoma or infection. Special collection chamber is needed. Ask facility laboratory. • CBC: • Hemoglobin-assess 02 carrying capacity • WBCs- assess increase r/t infection

20. Breathing exercises • Cough and deep breath (pg. 553) • Incentive Spirometry: instruct the pt to use 10 times every hour awake or with every commercial break if watching t.v. • Purse lip breathing: pucker lips like you are going to blow a kiss, whistle, or blow out a candle. Inhale through the nose and exhale through the pursed lips. Exhalation should last longer than inhalation. • Percussion and vibration • Percussion} clapping of cupped palms against chest wall to dislodge secretions ( only in areas protected by the rib cage) lasts 20-30 secs • Vibration} as pt exhales the therapist creates a shaking movement with the palms • Contraindications for both include: lung ca, bronchospasm, hemorrhage, hemoptysis, increased ICP, chest trauma, PE, pulmonary edema, GERD, anxiety, rib fractures http://www.youtube.com/watch?v=8rI5y2hyC2c&feature=related • Postural Drainage ( page 555)

21. Suctioning • Goal} improve to improve oxygen and CO2 exchange by removing excess mucus with a suction catheter…Follow facility guidelines! • Procedure: • Use sterile technique for tracheal and clean technique for oral. • Administer O2 before inserting catheter WHY? • Moisten cath in sterile water and insert through nose or mouth before applying suction • Apply suction as the catheter is withdrawn from the airway • Maintain pressure gauge b/w 80-100 mmHg • Limit EACH pass to 10 seconds • Allow the patient to rest briefly, encourage deep breathing and rinse catheter with sterile water before each pass. • Monitor for patient’s response • If tachycardia or increased respiratory distress develops, stop the procedure immediately and give the patient oxygen as ordered • Document the amount, color, odor, and consistency of the secretions as well as pt status before and after procedure.

22. Nasal Cannula: 1-6 liter flow Simple mask: 6-10 liters/FiO2 35-55% Partial rebreather: has reservoir bag so patient can rebreath part of inhaled gas: 6-10 liters/ FiO2 35-60% Non rebreather: non of exhaled gas rebreathed. FiO2 70-100% (venturi mask)

23. Monitor O2 • Monitor liter flow to make sure it is as prescribed. Assess pt response to therapy (ABGs as ordered) • Maintain sterile water in the humidity reservoir • Clean and replace equipment according to agency policy • NO SMOKING signs need to be posted if not a smoke free facility

24. Artificial Airways • Oral: • Nasal: • Endotracheal • Tracheostomy

29. Care after thoracic surgery • Manage pain with attention to resp status HOB elevated!! • VS as per post-op protocol & relate to client’s norms • Assess resp closely: rate, rhythm, effort • Lung sounds, chest rising and falling with each resp • Note absence of cyanosis or dyspnea • Maintain patent airway, TCDB, IS q 1 hour while wake, suction prn • Care to chest tube and drainage system • 02 responsibilities based on ABGs-02sats • IV responsibilities • Provide for a safe environment r/t: pain meds • Wound assessment and care as ordered • Activity progression as ordered and tolerated • I&0 q 8 hours to include chest tube • Assess lab: h&h, lytes, bun and cr, PT/INR, PTT, CBC

30. Chest Tubes • Chest tubes are inserted to drain blood, fluid, or air and allow full expansion of the lungs. • The chest tube usually remains in place until the X-rays show that all the blood, fluid, or air has drained from the chest and the lung has fully re-expanded. • When the chest tube is no longer needed, it can be easily removed, usually without the need for medications to sedate or numb the patient. Medications may be used to prevent or treat infection (antibiotics). http://www.atriummed.com/PDF/ManagingChestDrainage.ppt#438,37,Remove fluid & air

31. Tidaling: the middle water seal chamber is observed for expected rise in fluid level with expiration. • Air leak: • Suction may be • A gentle bubbling sound is normal to hear with a _____ system • _____ systems have a orange accordion looking object visible when suction is applied • Change the recepticle only when chambers are full using sterile technique • Heimlich Flutter Valve: air and fluid are expelled and not rebreathed in • READ THORACIC SURGERY page 561-562

36. Drug Therapy • Corticosteroids: • May be given parenteral, oral, inhaler • Many SE, masks S/S of infection, cause F&E imbalances • NI: Rinse mouth after each inhaler use, instruct to not to d/c abruptly, takes up to 10 days to obtain a blood level • Decongestants: • NI: monitor pulse, BP, mental status • Avoid if HTN, DM or hyperthyroid clients

37. Drug Therapy Continued • Bronchodilators: • Used for asthma and COPD • May be given oral, IV, by Inhalation • Does stimulate CNS and cardiac activity • Aminophyline, Isuprel, Brethine, Atrovent, Albuterol NI: Monitor HR, oral hygiene, avoid caffeine • Antitussives: • Codeine popular but is a narcotic • Dextromethorphan is non-narcotic • NI: force fluids

38. Drug Therapy Continued • Antimicrobials: • Obtain C & S before administration of 1st dose • NI: Assess for allergies • Instruct on importance of taking all of prescription • Mast Cell Stabilizers: • Does not help after onset of S/S • Intal (cromolyn) most common med • NI: instruct to use prior to activity • Expectorants: • Pill or syrup form • Robitussin is a popular OTC • NI: assess effectiveness of cough

39. Drug therapy Continued • Antihistamines: • Can be purchased without prescription • Dry MM • Mild sedation and antiemetic effects • Benadryl (1st generation) • Claritin (2nd generation) • May worsen cough by drying bronchial secretions • Not recommended for clients with asthma • NI: Care with operating machinery, being in a situation where sound judgment is imperative. Avoid alcohol

40. Acute Viral Rhinitis • common cold—lasts 2-14 days • Inflammation and edema of nasal mm • Based on H&P • S/S: nasal stuffiness, sneezing, running nose, ha, sore throat, fatigue, fever • Most contagious first 3 days • NI: Prevent spread of infection-handwashing, proper disposal of tissue • Rest, fluids to exceed 3000ml • Humidifier, antipyretics, analgesics • Call MD if T > 101, severe sore throat with white patches, chest pain, purulent sputum

41. Influenza • Several strains and more common in winter • Is an acute viral respiratory infection with fever and aches, chills, ha, cough • Complications: bronchitis, pneumonia • Spread by droplet/physical contact • Incubation 1-3 days, illness lasts 2-8day • NI: Rest, fluids, balanced diet, antipyretics, analgesics, antiviral agents (which must be started 24-48 hours after S/S) • Use of immunizations to prevents – 70-90% effective • Go to MD office only if chest pain or increase on chest congestion.

43. Pneumonia • Bacteria often pneumococcus which releases toxins=inflammation=damage • Viral, fungal, hypostatic, aspiration, nosocomial, chemical • Classified by location: lobar, bronchial • At risk: smokers, altered LOC, immunosuppressed, chronically ill, tube feeders, trach and ET tube clients

44. Pneumonia Diagnosis • H&P • C&S of sputum • CXR • WBC • Blood cultures

45. S/S • Chills, fever, sweats, chest pain, cough, purulent sputum production, hemoptysis, dyspnea, headache, herpes simplex, leukocytosis (WBC=20,000-30,000), tachycardia, crackles, wheezes, N/V • ****Elderly= • Complications: Pleurisy, Pleural-effusion

46. NI • HOB > 30-45 degrees, keep warm and dry, VS q 4 h, assess lung sounds, skin color and signs of hypoxia • What Is Hypoxia? • FF, I&O q 8 h, freq oral cares, care of expectorations, safety precautions r/t fever, fatigue • TCDB q 2h, measures to mobilize secretions, hi protein diet • Assess fluid and electrolyte balance

47. Pleurisy • Inflammation of the pleura • Causes: pneumonia, TB, injury • S/S abrupt / severe pain. Breathing and coughing aggravates • Tx: analgesics, anti-inflammatory, antitussives, antimicrobials, heat • NI: Assess and Tx pain, Splint with cough, HOB >, meds as appropriate

48. Chest trauma • 2 types • Penetrating: • Non penetrating: • S/S: visible trauma, chest pain, Dyspnea, cough, asymmetric movement, cyanosis, rapid weak pulse decreased blood pressure, tracheal deviation, JVD, bloodshot or bulging eyes • Tx: stablize and prevent further injury, remove clothing to assess injury and observe for other injuries like bleeding. Immediately treat the bleeding cover chest wound and tape on 3 sides

49. Pneumothorax • Accumulation of air in the pleural cavity resulting in complete or partial collapse of the lung. • Spontaneous (smokers, blebs) • Tension pneumothorax-air entering space > causing pressure on heart and great vessels • Diagnosis: CXR, H&P • S/S:dyspnea, tachypnea, tachycardia, restlessness, pain, anxiety, decreased movement in chest wall, < lung sounds, progressive cyanosis, sucking chest wound with open pneumothorax. • TX: Chest tube insertion to remove air or fluid • Closure of open chest wound or tear in structures • NI: Fowlers or semi-Fowlers http://video.google.com/videoplay?docid=1169503917162980359&q=%22chest+tube+%22&total=14&start=0&num=10&so=0&type=search&plindex=1