Respiratory Part 2

1. Respiratory Part 2 Medical Surgical Nursing

2. Nursing Diagnosis- Respiration Airway Clearance, ineffective Breathing Pattern, ineffective Gas Exchange, impaired

3. Ineffective Airway Clearance NANDA Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency

4. Ineffective Airway Clearance R/T Inability to cough effectively Artificial airway Excessive or thick secretions Infection Obstruction Pain

5. Ineffective Airway Clearance AMB (AEB) Ineffective cough Inability to remove airway secretions Abnormal breath sounds crackles Abnormal respiratory rate, rhythm depth

6. Ineffective Airway Clearance Plan / Outcome / Goal Maintain patent airway AEB Clear breath sounds Respiratory easy and unlabored Normal respiratory rate

7. Ineffective Airway ClearanceNursing interventions Assess respiratory Rate Depth Rhythm Effort Breath sounds V/S Lab Values Hgb Hct Sputum cultures ABG’s Dx Tests Pulse Oxygen Sats Monitor respiratory, including patterns, rate, depth, and effort, Breath sounds. Position client to optimize respiration (e.g., head of bed elevated 45 degrees and repositioned at least every 2 hours) If the client has unilateral lung disease, alternate a semi-Fowler's position with a lateral position Teach client to deep breath and perform controlled coughing. Assist with clearing secretions from pharynx by offering tissues and gentle suction of the oral pharynx if necessary. Observe sputum, noting color, odor, and volume Encourage activity and ambulation as tolerated. If unable to ambulate client, turn client from side to side every 2 hours Encourage increased fluid. perform actions to decrease pain if present (e.g. splint/protect painful area during movement, administer prescribed analgesics) in order to increase the client's willingness to move, cough, and deep breathe Administer oxygen as ordered. Administer medications such as bronchodilators or inhaled steroids as ordered. Provide Chest physical therapy: postural drainage, percussion, and vibration as ordered. Refer for physical therapy or respiratory therapy for further treatment. Monitor blood gas values and pulse oxygen saturation levels. If the client has COPD, consider helping the client use the huff cough technique Monitor respiratory, including patterns, rate, depth, and effort, Breath sounds. Position client to optimize respiration (e.g., head of bed elevated 45 degrees and repositioned at least every 2 hours) If the client has unilateral lung disease, alternate a semi-Fowler's position with a lateral position Teach client to deep breath and perform controlled coughing. Assist with clearing secretions from pharynx by offering tissues and gentle suction of the oral pharynx if necessary. Observe sputum, noting color, odor, and volume Encourage activity and ambulation as tolerated. If unable to ambulate client, turn client from side to side every 2 hours Encourage increased fluid. perform actions to decrease pain if present (e.g. splint/protect painful area during movement, administer prescribed analgesics) in order to increase the client's willingness to move, cough, and deep breathe Administer oxygen as ordered. Administer medications such as bronchodilators or inhaled steroids as ordered. Provide Chest physical therapy: postural drainage, percussion, and vibration as ordered. Refer for physical therapy or respiratory therapy for further treatment. Monitor blood gas values and pulse oxygen saturation levels. If the client has COPD, consider helping the client use the huff cough technique

8. Ineffective Airway ClearanceNursing interventions Position: HOB elevated Promote optimum level of activity for best possible lung expansion Ambulate / Chair Turn/reposition Suction prn

9. Ineffective Airway ClearanceNursing interventions O2 per order Admin meds Bronchodilators Steroids Enc to do Respiratory therapy exercises Enc to do Physical therapy exercises

10. Ineffective Airway ClearanceNursing interventions Encourage fluids Facilitate airway clearance Deep breathing Breathing exercises Incentive spirometry Directed cough

11. Ineffective Airway ClearanceNursing interventions Perform actions to decrease pain if present Splint Analgesics per order Perform actions to decrease pain if present splint/protect painful area during movement administer prescribed analgesics) in order to increase the client's willingness to move, cough, and deep breathe Perform actions to decrease pain if present splint/protect painful area during movement administer prescribed analgesics) in order to increase the client's willingness to move, cough, and deep breathe

12. Ineffective Airway ClearanceNursing interventions Discourage smoking Administer central nervous system depressants carefully Increase activity as allowed. discourage smoking (the irritants in smoke increase mucus production, impair ciliary function, and can cause inflammation and damage to the bronchial walls)administer central nervous system depressants judiciouslyincrease activity as allowed. discourage smoking (the irritants in smoke increase mucus production, impair ciliary function, and can cause inflammation and damage to the bronchial walls)administer central nervous system depressants judiciouslyincrease activity as allowed.

13. Ineffective breathing patterns NANDA Definition: Inspiration and/or expiration that does not provide adequate ventilation

14. Ineffective breathing patterns R/T COPD Allergic reactions Aspiration Decreased lung compliance Fatigue History of smoking

15. Ineffective breathing patterns AMB Changes in respiratory pattern from baseline Orthopnea Guarded respirations

16. Ineffective breathing patterns Plan / Outcome / Goal Patient’s breathing pattern is maintained as evidenced by eupnea, normal skin color, and regular respiratory rate/pattern.

17. Ineffective breathing patternsInterventions: Assess Color Resp Rate Depth Effort rhythm breath sounds Assess respiratory rate and depth by listening to lung sounds. Respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties.* Assess for dyspnea and quantify (e.g., note how many words per breath patient can say); relate dyspnea to precipitating factors.o Assess for dyspnea at rest versus activity and note changes. Dyspnea that occurs with activity may indicate activity intolerance.* Monitor breathing patterns:o Bradypnea (slow respirations)o Tachypnea (increase in respiratory rate)o Hyperventilation (increase in respiratory rate or tidal volume, or both)o Kussmaul’s respirations (deep respirations with fast, normal, or slow rate)o Cheyne-Stokes respiration (waxing and waning with periods of apnea between a repetitive pattern)o Apneusis (sustained maximal inhalation with pause)o Biot’s respiration (irregular periods of apnea alternating with periods in which four or five breaths of identical depth are taken)o Ataxic patterns (irregular and unpredictable pattern with periods of apnea)Specific breathing patterns may indicate an underlying disease process or dysfunction. Cheyne-Stokes respiration represents bilateral dysfunction in the deep cerebral or diencephalon associated with brain injury or metabolic abnormalities. Apneusis and ataxic breathing are associated with failure of the respiratory centers in the pons and medulla.* Note muscles used for breathing (e.g., sternocleido-mastoid, abdominal, diaphragmatic). The accessory muscles of inspiration are not usually involved in quiet breathing. These include the scalenes (attach to the first two ribs) and the sternocleidomastoid (elevates the sternum).* Monitor for diaphragmatic muscle fatigue (paradoxical motion). Paradoxical movement of the diaphragm indicates a reversal of the normal pattern and is indicative of ventilatory muscle fatigue and/or respiratory failure. The diaphragm is the most important muscle of ventilation, normally responsible for 80% to 85% of ventilation during restful breathing.* Note retractions or flaring of nostrils. These signify an increase in work of breathing.* Assess position patient assumes for normal or easy breathing.* Use pulse oximetry to monitor oxygen saturation and pulse rate. Pulse oximetry is a useful tool to detect changes in oxygenation early on; however, for CO2 levels, end tidal CO2 monitoring or arterial blood gases (ABGs) would need to be obtained.* Monitor ABGs as appropriate; note changes. Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. As the patient begins to fail, the respiratory rate decreases and PaCO2 begins to rise.* Monitor for changes in orientation, increased restlessness, anxiety, and air hunger. Restlessness is an early sign of hypoxia.* Avoid high concentration of oxygen in patients with chronic obstructive pulmonary disease (COPD). Hypoxia stimulates the drive to breathe in the chronic CO2 retainer patient. When applying oxygen, close monitoring is imperative to prevent unsafe increases in the patient’s PaO2 , which could result in apnea.* Assess skin color, temperature, capillary refill; note central versus peripheral cyanosis.* Monitor vital capacity in patients with neuromuscular weakness and observe trends. Monitoring detects changes early.* Assess presence of sputum for quantity, color, consistency.* If the sputum is discolored (no longer clear or white), send sputum specimen for culture and sensitivity, as appropriate. An infection may be present. Respiratory infections increase the work of breathing; antibiotic treatment may be indicated.* Assess ability to clear secretions. The inability to clear secretions may add to a change in breathing pattern.* Assess for pain. Postoperative pain can result in shallow breathing.Assess respiratory rate and depth by listening to lung sounds. Respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties.* Assess for dyspnea and quantify (e.g., note how many words per breath patient can say); relate dyspnea to precipitating factors.o Assess for dyspnea at rest versus activity and note changes. Dyspnea that occurs with activity may indicate activity intolerance.* Monitor breathing patterns:o Bradypnea (slow respirations)o Tachypnea (increase in respiratory rate)o Hyperventilation (increase in respiratory rate or tidal volume, or both)o Kussmaul’s respirations (deep respirations with fast, normal, or slow rate)o Cheyne-Stokes respiration (waxing and waning with periods of apnea between a repetitive pattern)o Apneusis (sustained maximal inhalation with pause)o Biot’s respiration (irregular periods of apnea alternating with periods in which four or five breaths of identical depth are taken)o Ataxic patterns (irregular and unpredictable pattern with periods of apnea)Specific breathing patterns may indicate an underlying disease process or dysfunction. Cheyne-Stokes respiration represents bilateral dysfunction in the deep cerebral or diencephalon associated with brain injury or metabolic abnormalities. Apneusis and ataxic breathing are associated with failure of the respiratory centers in the pons and medulla.* Note muscles used for breathing (e.g., sternocleido-mastoid, abdominal, diaphragmatic). The accessory muscles of inspiration are not usually involved in quiet breathing. These include the scalenes (attach to the first two ribs) and the sternocleidomastoid (elevates the sternum).* Monitor for diaphragmatic muscle fatigue (paradoxical motion). Paradoxical movement of the diaphragm indicates a reversal of the normal pattern and is indicative of ventilatory muscle fatigue and/or respiratory failure. The diaphragm is the most important muscle of ventilation, normally responsible for 80% to 85% of ventilation during restful breathing.* Note retractions or flaring of nostrils. These signify an increase in work of breathing.* Assess position patient assumes for normal or easy breathing.* Use pulse oximetry to monitor oxygen saturation and pulse rate. Pulse oximetry is a useful tool to detect changes in oxygenation early on; however, for CO2 levels, end tidal CO2 monitoring or arterial blood gases (ABGs) would need to be obtained.* Monitor ABGs as appropriate; note changes. Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. As the patient begins to fail, the respiratory rate decreases and PaCO2 begins to rise.* Monitor for changes in orientation, increased restlessness, anxiety, and air hunger. Restlessness is an early sign of hypoxia.* Avoid high concentration of oxygen in patients with chronic obstructive pulmonary disease (COPD). Hypoxia stimulates the drive to breathe in the chronic CO2 retainer patient. When applying oxygen, close monitoring is imperative to prevent unsafe increases in the patient’s PaO2 , which could result in apnea.* Assess skin color, temperature, capillary refill; note central versus peripheral cyanosis.* Monitor vital capacity in patients with neuromuscular weakness and observe trends. Monitoring detects changes early.* Assess presence of sputum for quantity, color, consistency.* If the sputum is discolored (no longer clear or white), send sputum specimen for culture and sensitivity, as appropriate. An infection may be present. Respiratory infections increase the work of breathing; antibiotic treatment may be indicated.* Assess ability to clear secretions. The inability to clear secretions may add to a change in breathing pattern.* Assess for pain. Postoperative pain can result in shallow breathing.

18. Ineffective breathing patternsInterventions: Position to facilitate optimum breathing patterns HOB up High fowlers Turn q2hr Cough & Deep breath Incentive spirometer q2hrs Increase activities as tolerated Encourage pt to Yawn Oxygen per MD order Therapeutic InterventionsAssess for signs and symptoms of an ineffective breathing pattern (e.g. shallow or slow respirations). Implement measures to improve breathing pattern: place client in a semi- to high Fowler's position unless contraindicated; position client with pillows to prevent slumping if client must remain flat in bed, assist with position change at least every 2 hours unless contraindicated instruct client to deep breathe or use incentive spirometer every 1 - 2 hours perform actions to reduce chest or abdominal pain if present (e.g. splint chest/abdomen with a pillow when positioning, coughing, and deep breathing; administer prescribed analgesics) in order to increase the client's willingness to move and breathe more deeply perform actions to decrease fear and anxiety (see Diagnosis 13, action b) in order to prevent the shallow and/or rapid breathing that can occur with fear and anxiety assist with positive airway pressure techniques (e.g. IPPB, continuous positive airway pressure [CPAP], bilevel positive airway pressure [BiPAP], expiratory positive airway pressure [EPAP]) if ordered instruct client to avoid intake of gas-forming foods (e.g. beans, cauliflower, cabbage, onions), carbonated beverages, and large meals in order to prevent gastric distention and additional pressure on the diaphragm increase activity as allowed administer central nervous system depressants judiciously; hold medication and consult physician if respiratory rate is less than 12/minute. Consult appropriate health care provider (e.g. physician, respiratory therapist) if: ineffective breathing pattern continues signs and symptoms of impaired gas exchange (e.g. restlessness, irritability, confusion, significant decrease in oximetry results, decreased PaO2 and increased PaCO2 levels) are present. * Position patient with proper body alignment for optimal breathing pattern. If not contraindicated, a sitting position allows for good lung excursion and chest expansion.* Ensure that oxygen delivery system is applied to the patient. The appropriate amount of oxygen is continuously delivered so that the patient does not desaturate.An oxygen saturation of 90% or greater should be maintained. This provides for adequate oxygenation.* Encourage sustained deep breaths by:o Using demonstration (emphasizing slow inhalation, holding end inspiration for a few seconds, and passive exhalation)o Using incentive spirometer (place close for convenient patient use)o Asking patient to yawn This simple technique promotes deep inspiration.* Evaluate appropriateness of inspiratory muscle training. This improves conscious control of respiratory muscles.* Maintain a clear airway by encouraging patient to clear own secretions with effective coughing. If secretions cannot be cleared, suction as needed to clear secretions.* Use universal precautions (e.g., gloves, goggles, and mask) as appropriate. If secretions are purulent, precautions should be instituted before receiving the culture and sensitivity final report. Institute appropriate isolation procedures for positive cultures (e.g., methicillin-resistant Staphylococcus aureus, tuberculosis [TB]).* Pace and schedule activities providing adequate rest periods. This prevents dyspnea resulting from fatigue.* Provide reassurance and allay anxiety by staying with patient during acute episodes of respiratory distress. Air hunger can produce an extremely anxious state.* Provide relaxation training as appropriate (e.g., biofeedback, imagery, progressive muscle relaxation).* Encourage diaphragmatic breathing for patient with chronic disease.* Use pain management as appropriate. This allows for pain relief and the ability to deep breathe.* Anticipate the need for intubation and mechanical ventilation if patient is unable to maintain adequate gas exchange with the present breathing pattern.Therapeutic InterventionsAssess for signs and symptoms of an ineffective breathing pattern (e.g. shallow or slow respirations). Implement measures to improve breathing pattern: place client in a semi- to high Fowler's position unless contraindicated; position client with pillows to prevent slumping if client must remain flat in bed, assist with position change at least every 2 hours unless contraindicated instruct client to deep breathe or use incentive spirometer every 1 - 2 hours perform actions to reduce chest or abdominal pain if present (e.g. splint chest/abdomen with a pillow when positioning, coughing, and deep breathing; administer prescribed analgesics) in order to increase the client's willingness to move and breathe more deeply perform actions to decrease fear and anxiety (see Diagnosis 13, action b) in order to prevent the shallow and/or rapid breathing that can occur with fear and anxiety assist with positive airway pressure techniques (e.g. IPPB, continuous positive airway pressure [CPAP], bilevel positive airway pressure [BiPAP], expiratory positive airway pressure [EPAP]) if ordered instruct client to avoid intake of gas-forming foods (e.g. beans, cauliflower, cabbage, onions), carbonated beverages, and large meals in order to prevent gastric distention and additional pressure on the diaphragm increase activity as allowed administer central nervous system depressants judiciously; hold medication and consult physician if respiratory rate is less than 12/minute. Consult appropriate health care provider (e.g. physician, respiratory therapist) if: ineffective breathing pattern continues signs and symptoms of impaired gas exchange (e.g. restlessness, irritability, confusion, significant decrease in oximetry results, decreased PaO2 and increased PaCO2 levels) are present.

19. Ineffective breathing patternsInterventions: Perform actions to reduce chest or abd pain Splint Perform actions to decrease fear & anxiety Instruct to avoid gas forming foods Maintain a clean airway Pace schedule / activities Stay with pt. during episodes of resp. distress

20. Ineffective breathing patternsInterventions: Education Explain all procedures before performing Effects of wearing restrictive clothing Oxygen therapy, safety About medications Environmental factors that may worsen resp status S&S of a “cold” Appropriate breathing, coughing techniques How to count respirations Education/Continuity of Care* Explain all procedures before performing. This decreases patient’s anxiety.* Explain effects of wearing restrictive clothing. Respiratory excursion is not compromised.* Explain use of oxygen therapy, including the type and use of equipment and why its maintenance is important. ratioIssues related to home oxygen use, storage, and precautions need to be addressed.* Instruct about medications: indications, dosage, frequency, and potential side effects. Include review of metered-dose inhaler and nebulizer treatments, as appropriate.* Review the use of at-home monitoring capabilities and refer to home health nursing, oxygen vendors, and other resources for rental equipment as appropriate.* Explain environmental factors that may worsen patient’s pulmonary condition (e.g., pollen, second-hand smoke) and discuss possible precipitating factors (e.g., allergens and emotional stress).* Explain symptoms of a "cold" and impending problems. A respiratory infection would increase the work of breathing.* Teach patient or caregivers appropriate breathing, coughing, and splinting techniques. These facilitate adequate clearance of secretions.* Teach patient how to count own respirations and relate respiratory rate to activity tolerance. Patient will then know when to limit activities in terms of his or her own limitations.* Teach patient when to inhale and exhale while doing strenuous activities. Appropriate breathing techniques during exercise are important in maintaining adequate gas exchange.* Assist patient or caregiver in learning signs of respiratory compromise. Refer significant other/caregiver to participate in basic life support class for CPR, as appropriate.* Refer to social services for further counseling related to patient’s condition and give list of support groups or a contact person from the support group for the patient to talk with. Education/Continuity of Care

21. Impaired Gas Exchange NANDA Definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane

22. Impaired Gas Exchange R/T Decreased pulmonary perfusion Aspiration Anesthesia(_) Allergic response(_) Altered level of consciousness(_) Anxiety(_) Aspiration(_) Decreased lung compliance(_) Edema of tonsils, adenoids, sinuses(_) Excessive or thick secretions(_) Fear(_) Immobility(_) Improper positioningrelated to:decreased pulmonary perfusion associated with obstruction of pulmonary arterial blood flow by the embolus and vasoconstriction resulting from the local release of vasoactive substances (e.g. serotonin, endothelin, some prostaglandins); decreased bronchial airflow associated with bronchoconstriction resulting from: the local release of substances such as serotonin and some prostaglandins a compensatory response to an increase in the amount of dead space in the underperfused lung area (the compensatory bronchoconstriction also affects airways in perfused lung areas); loss of effective lung surface associated with atelectasis if it occurs. Anesthesia(_) Allergic response(_) Altered level of consciousness(_) Anxiety(_) Aspiration(_) Decreased lung compliance(_) Edema of tonsils, adenoids, sinuses(_) Excessive or thick secretions(_) Fear(_) Immobility(_) Improper positioningrelated to:decreased pulmonary perfusion associated with obstruction of pulmonary arterial blood flow by the embolus and vasoconstriction resulting from the local release of vasoactive substances (e.g. serotonin, endothelin, some prostaglandins); decreased bronchial airflow associated with bronchoconstriction resulting from: the local release of substances such as serotonin and some prostaglandins a compensatory response to an increase in the amount of dead space in the underperfused lung area (the compensatory bronchoconstriction also affects airways in perfused lung areas); loss of effective lung surface associated with atelectasis if it occurs.

23. Impaired Gas Exchange AMB Dyspnea on exertion Bending forward Increased anterior-posterior chest diameter Fatigue Decreased Oxygen sats Tendency to assume a three-point position (bending forward while supporting self by placing one hand on each knee).(_) Pursed lip breathing with prolonged expiratory phase.(_) Increased anteroposterior chest diameter, if chronic.(_) Lethargy and fatigue.(_) Increased pulmonary vascular resistance (increased pulmonary artery/right ventricular pressure).(_) Decreased oxygen content, decreased oxygen saturation, increased PCO2.(_) Cyanosis.Tendency to assume a three-point position (bending forward while supporting self by placing one hand on each knee).(_) Pursed lip breathing with prolonged expiratory phase.(_) Increased anteroposterior chest diameter, if chronic.(_) Lethargy and fatigue.(_) Increased pulmonary vascular resistance (increased pulmonary artery/right ventricular pressure).(_) Decreased oxygen content, decreased oxygen saturation, increased PCO2.(_) Cyanosis.

24. Impaired Gas Exchange Plan / outcomes / goals Patient maintains optimal gas exchange as evidenced by normal arterial blood gases (ABGs) alert responsive mentation no further reduction in mental status.

25. Impaired Gas ExchangeInterventions Assess for signs and symptoms of impaired gas exchange: restlessness, irritability Confusion somnolence tachypnea, dyspnea Central cyanosis Lab Values decrease in oximetry results Ongoing Assessment* Assess respirations: note quality, rate, pattern, depth, and breathing effort. Both rapid, shallow breathing patterns and hypoventilation affect gas exchange. Shallow, "sighless" breathing patterns postsurgery (as a result of effect of anesthesia, pain, and immobility) reduce lung volume and decrease ventilation.* Assess lung sounds, noting areas of decreased ventilation and the presence of adventitious sounds.* Assess for signs and symptoms of hypoxemia: tachycardia, restlessness, diaphoresis, headache, lethargy, and confusion.* Assess for signs and symptoms of atelectasis: diminished chest excursion, limited diaphragm excursion, bronchial or tubular breath sounds, rales, tracheal shift to affected side. Collapse of alveoli increases physiological shunting.* Assess for signs or symptoms of pulmonary infarction: cough, hemoptysis, pleuritic pain, consolidation, pleural effusion, bronchial breathing, pleural friction rub, fever.* Monitor vital signs. With initial hypoxia and hypercapnia, blood pressure (BP), heart rate, and respiratory rate all rise. As the hypoxia and/or hypercapnia becomes more severe, BP may drop, heart rate tends to continue to be rapid with arrhythmias, and respiratory failure may ensue with the patient unable to maintain the rapid respiratory rate.* Assess for changes in orientation and behavior. Restlessness is an early sign of hypoxia. Chronic hypoxemia may result in cognitive changes such as memory changes.* Monitor ABGs and note changes. Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. As the patient begins to fail, the respiratory rate will decrease and PaCO2 will begin to rise. Some patients, such as those with COPD, have a significant decrease in pulmonary reserves, and any physiological stress may result in acute respiratory failure.* Use pulse oximetry to monitor oxygen saturation and pulse rate. Pulse oximetry is a useful tool to detect changes in oxygenation. Oxygen saturation should be maintained at 90% or greater. This tool can be especially helpful in the outpatient or rehabilitation setting where patients at risk for desaturation from chronic pulmonary diseases can monitor the effects of exercise or activity on their oxygen saturation levels. Home oxygen therapy can then be prescribed as indicated. Patients should be assessed for the need for oxygen both at rest and with activity. A higher liter flow of oxygen is generally required for activity versus rest (e.g., 2 L at rest, and 4 L with activity). Medicare guidelines for reimbursement for home oxygen require a PaCO2 less than 58 and/or oxygen saturation of 88% or less on room air. Oxygen delivery is then titrated to maintain an oxygen saturation of 90% or greater.* Assess skin color for development of cyanosis. For cyanosis to be present, 5 g of hemoglobin must desaturate.* Monitor chest x-ray reports. Chest x-rays may guide the etiological factors of the impaired gas exchange. Keep in mind that radiographic studies of lung water lag behind clinical presentation by 24 hours.* Monitor effects of position changes on oxygenation (SaO2, ABGs, SVO2, and end-tidal CO2). Putting the most congested lung areas in the dependent position (where perfusion is greatest) potentiates ventilation and perfusion imbalances.* Assess patient’s ability to cough effectively to clear secretions. Note quantity, color, and consistency of sputum. Retained secretions impair gas exchange.Ongoing Assessment

26. Impaired Gas ExchangeInterventions Bed rest / pace activities Discourage smoking Administer anticoagulants per order Thrombolytic agents per order Oxygen per order Position to facilitate ventilation / perfusion Suction prn Implement measures to improve gas exchange: maintain client on bed rest to reduce oxygen demands during acute respiratory distress; increase activity gradually as allowed and tolerated maintain oxygen therapy as ordered perform actions to improve breathing pattern (see Diagnosis 1, action b) discourage smoking (the carbon monoxide in smoke decreases oxygen availability and the nicotine can cause vasoconstriction and further reduce pulmonary blood flow) perform actions to improve pulmonary blood flow: administer anticoagulants (e.g. continuous intravenous heparin, low-molecular-weight heparin, warfarin) as ordered prepare client for the following if planned: injection of a thrombolytic agent (e.g. streptokinase, alteplase [tPA]) embolectomy. Consult appropriate health care provider (e.g. respiratory therapist, physician) if signs and symptoms of impaired gas exchange persist or worsen. Therapeutic Interventions* Maintain oxygen administration device as ordered, attempting to maintain oxygen saturation at 90% or greater. This provides for adequate oxygenation.Avoid high concentration of oxygen in patients with COPD. Hypoxia stimulates the drive to breathe in the chronic CO2 retainer patient. When applying oxygen, close monitoring is imperative to prevent unsafe increases in the patient’s PaO2, which could result in apnea.NOTE: If the patient is allowed to eat, oxygen still must be given to the patient but in a different manner (e.g., changing from mask to a nasal cannula). Eating is an activity and more oxygen will be consumed than when the patient is at rest. Immediately after the meal, the original oxygen delivery system should be returned.* For patients who should be ambulatory, provide extension tubing or portable oxygen apparatus. These promote activity and facilitate more effective ventilation.* Position with proper body alignment for optimal respiratory excursion (if tolerated, head of bed at 45 degrees). This promotes lung expansion and improves air exchange.* Routinely check the patient’s position so that he or she does not slide down in bed. This would cause the abdomen to compress the diaphragm, which would cause respiratory embarrassment.* Position patient to facilitate ventilation/perfusion matching. Use upright, high-Fowler’s position whenever possible. High-Fowler’s position allows for optimal diaphragm excursion. When patient is positioned on side, the good side should be down (e.g., lung with pulmonary embolus or atelectasis should be up).* Pace activities and schedule rest periods to prevent fatigue. Even simple activities such as bathing during bed rest can cause fatigue and increase oxygen consumption.* Change patient’s position every 2 hours. This facilitates secretion movement and drainage.* Suction as needed. Suction clears secretions if the patient is unable to effectively clear the airway.* Encourage deep breathing, using incentive spirometer as indicated. This reduces alveolar collapse.* For postoperative patients, assist with splinting the chest. Splinting optimizes deep breathing and coughing efforts.* Encourage or assist with ambulation as indicated. This promotes lung expansion, facilitates secretion clearance, and stimulates deep breathing.* Provide reassurance and allay anxiety:o Have an agreed-on method for the patient to call for assistance (e.g., call light, bell).o Stay with the patient during episodes of respiratory distress.* Anticipate need for intubation and mechanical ventilation if patient is unable to maintain adequate gas exchange. Early intubation and mechanical ventilation are recommended to prevent full decompensation of the patient. Mechanical ventilation provides supportive care to maintain adequate oxygenation and ventilation to the patient. Treatment also needs to focus on the underlying causal factor leading to respiratory failure.* Administer medications as prescribed. The type depends on the etiological factors of the problem (e.g., antibiotics for pneumonia, bronchodilators for COPD, anticoagulants/thrombolytics for pulmonary embolus, analgesics for thoracic pain).Implement measures to improve gas exchange: maintain client on bed rest to reduce oxygen demands during acute respiratory distress; increase activity gradually as allowed and tolerated maintain oxygen therapy as ordered perform actions to improve breathing pattern (see Diagnosis 1, action b) discourage smoking (the carbon monoxide in smoke decreases oxygen availability and the nicotine can cause vasoconstriction and further reduce pulmonary blood flow) perform actions to improve pulmonary blood flow: administer anticoagulants (e.g. continuous intravenous heparin, low-molecular-weight heparin, warfarin) as ordered prepare client for the following if planned: injection of a thrombolytic agent (e.g. streptokinase, alteplase [tPA]) embolectomy. Consult appropriate health care provider (e.g. respiratory therapist, physician) if signs and symptoms of impaired gas exchange persist or worsen. Therapeutic Interventions

27. Impaired Gas ExchangeInterventions Educate Pace activities Oxygen therapy and safety TCDB Explain nebulizer Refer to home health agency Education/Continuity of Care* Explain the need to restrict and pace activities to decrease oxygen consumption during the acute episode.* Explain the type of oxygen therapy being used and why its maintenance is important. Issues related to home oxygen use, storage, or precautions need to be addressed.* Teach the patient appropriate deep breathing and coughing techniques. These facilitate adequate air exchange and secretion clearance.* Assist patient in obtaining home nebulizer, as appropriate, and instruct in its use in collaboration with respiratory therapist.* Refer to home health services for nursing care or oxygen management as appropriate. Education/Continuity of Care

28. Influenza AKA Flu Highly contagious Pathogen Viral Epidemic Rapid and extensive spreading infection and affecting many individuals in an area or a population at the same time

29. FYI Influenza & its complications (primarily bacterial pneumonia) are the 8th leading cause of death in the US. @60,000 year

30. H1N1 Newly identified stain ? Pandemic (World-wide epidemic)

31. Mode of transmission Airborne droplet Direct contact

32. Influenza Statistics Incubation period Short Onset Rapid Duration Up to a week Cough & fatigue 2-3 weeks

33. Influenza: S&S (local) Runny nose Sore throat Cough Dry Non-productive ? productive Substernal burning

34. Influenza: S&S (systemic) Chills & fever H/A Malaise Muscle aches Fatigue & weakness

35. Older adults Higher risk of Complications Pneumonia Death

36. Why are older adult more susceptible to complications of influenza? Cilia i Chest muscle strength i Chest wall Stiffer Cough Less effective

37. IDT “Most URI’s are self-limiting”

38. IDT Self-care Symptomatic relief Prevent complications Prevent spread

39. Dx test Throat swab R/O streptococci CBC WBC normal or decreased Vial WBC increased Bacterial Chest x-ray R/O pneumonia

40. Flu Vaccine: Is it effective? Polyvalent influenza virus vaccine 85% effective For 1 year 1/3 of people at risk get it

41. Flu Vaccine: Who should get it? Age >50 years Nursing home residents Pg women Chronically ill Immunosuppressed Resp. conditions Healthcare workers Fam. members of those at risk

42. Flu Vaccine: Who should not get it? Allergic to eggs

43. Small Group Questions What pathogen is assoc. with flu? Identify 5 S&S of the flu What type of isolation would you use for a client with the flu Mary asks you if she should get the flu vaccine, how do you respond? What priority nursing diagnosis would you give for a person with the flu?

44. COPD - overview COPD? Chronic Obstructive Pulmonary Disease Broad classifications of diseases

45. COPD Characterized by airflow limitation Irreversible Dyspnea on exertion Progressive Abn. inflammatory response of the lungs to noxious particles or gases

46. Pathophysiology Noxious particles of gas ? Inflammatory response ? Narrowing of airway In COPD the airflow limitation is both progressive and assoc. with abnormal inflammatory response of the lungs to noxious gases. The inflammatory response occurs thorugh the airways, parenchyma and pulmonary vasculature. Because of the chronic inflammation and the body’s attempt to repair it, narrowing occurs in the small peripheral airways. In COPD the airflow limitation is both progressive and assoc. with abnormal inflammatory response of the lungs to noxious gases. The inflammatory response occurs thorugh the airways, parenchyma and pulmonary vasculature. Because of the chronic inflammation and the body’s attempt to repair it, narrowing occurs in the small peripheral airways.

47. Pathophysiology Inflammation ? Thickening of the wall of the pulmonary capillaries (Smoke damage & inflammatory process)

48. COPD Includes Emphysema Chronic bronchitis Does not include Asthma

49. COPD - FYI COPD 4th leading cause of death in the US 12th leading cause of disability Death from COPD is on the rise while death from heart disease is going down

50. COPD Risk Factors for COPD Exposure to tobacco smoke 80-90% of COPD Passive smoking Occupational exposure Air pollution

51. COPD risk factors #1 Smoking Why is smoking so bad?? ? phagocytes ? cilia function ? mucus production

52. Chronic Bronchitis Disease of the airway Definition: cough + sputum production > 3 months

53. Chronic Bronchitis Pathophysiology Pollutant irritates airway ? Inflammation h secretion of mucus ? Bronchial walls thicken ? Lumen narrows Mucus plugs airway

54. Chronic Bronchitis Plugs become areas for bacteria to grow and chronic infections which increases mucus secretions and eventually, areas of focal necrosis and fibrosis

55. Chronic Bronchitis Alveoli/bronchioles become damaged ? susceptibility to LRI

56. Emphysema Pathophysiology Affects alveolar membrane Destruction of alveolar wall Loss of elastic recoil Over distended alveoli

57. Emphysema Pathophysiology Over distended alveoli? Damage to adjacent pulmonary capillaries Impaired passive expiration

58. Emphysema Impaired gas exchange impaired expiration Hypoxemia h CO2

59. Emphysema Damaged pulmonary capillary bed h pulmonary pressure ? h work load for right ventricle ? Right side heart failure

60. COPD Compare and contrast Chronic Bronchitis is a disease of the ___________? Airway Emphysema is a disease affecting the ___________? Alveoli

61. C.O.P.D. Risk factors, S&S, treatment, Dx, Rx - same for Chronic Bronchitis & Emphysema

62. C.O.P.D. Clinical Manifestation (primary) Cough Sputum production Dyspnea on exertion (Secondary) Wt. loss Resp. infections Barrel chest Weight loss because: dyspnea interferes with eating, also the work of breathing is energy depleting. Weight loss because: dyspnea interferes with eating, also the work of breathing is energy depleting.

63. C.O.P.D.Nrs. Assessment Risk factors Past Hx / Family Hx Pattern of development Presence of comobidities Current Tx Impact

64. Dx tests ABG’s Baseline PaO2 Rule out other diseases CT scan X-ray

65. C.O.P.D. Medical Management Risk reduction Smoking cessation! (The only thing that slows down the progression of the disease!)

66. C.O.P.D. Rx. therapy Primary Bronchodilators Corticosteriods Secondary Antibiotics Mucolytic agents Anti-tussive agents

67. Bronchodilators Action: Increases the size of the lumen Relieve bronchospasms Reduce airway obstruction ? ventilation

68. Bronchodilators Examples Albuterol (Proventil, Ventolin, Volmax) Metaproterenol (Alupent) Ipratropium bromide (Atrovent) Theophylline (Theo-Dur)*

69. Glucocorticoids Action Potent anti-inflammatory agent

70. Corticsteriods S/E Na+ & H20 retention Never discontinue abruptly

71. Glucocorticoids Examples Prednisone Methyprednisone Beclovent

72. C.O.P.D. Medical Management Treatment O2 2 L/min Pulmonary rehab Breathing exercises Pulmonary hygiene

73. Small Group Questions What 2 diseases are assoc. with COPD? Describe the pathophysiology of COPD. What effect does smoking have on the resp. system? Differentiate between chronic bronchitis and emphysema. What are the 3 main S&S of COPD? What 2 classifications of meds are used to treat clients with COPD (what are their actions)?

74. Pneumonia Pathophysiology An inflammatory process in which there is consolidation In the alveolar spaces. Gas exchange cannot take place in consolidated area

75. Pneumonia Causative agents Viral pneumonia Bacterial Pneumonia Streptococcus pneumoniae Pneumocystis Pneumonia Fungal pneumonia Radiation pneumonia Chemical pneumonitis Aspiration pneumonia Hypostatis pneumonia

76. Pneumonia FYI Most common cause of death from infectious agents 66,000 deaths / year $$$

77. Pneumonia Progression of events Inflammation ? h Exudate ? i movement of O2 and CO2 ? WBC migrate into the alveoli ? Fill air-containing spaces? i ventilation Oxygen saturation? i

78. Pneumonia: Risk factors Immunosuppressant Smoking Prolonged immobility Depressed cough reflex NPO ETOH intoxication Gen. anesthetic or opiod Advanced age

79. Pneumonia: S&S TYPICAL Onset Acute Shaking Chills Fever Cough Productive Sputum Rust-colored Purulent

80. Pneumonia: S&S TYPICAL Chest pain Aching Sharp Localized Breath sounds Diminished Crackles (over effected lung) Respiratory distress

81. Pneumonia: S&S ATYPICAL “Walking pneumonia” Milder symptoms Fever H/A Muscle aches Malaise

82. Pneumonia: S&S ATYPICAL Cough Dry Hacking Non-productive Persistent >6 weeks Worse at night Self limited

83. S&S Elderly General deterioration Weakness Abd. Symptoms Anorexia Confusion Tachycardia Tachypnea Do Not C/O Cough Pain Fever Sputum

84. Pneumonia Dx Sputum C&S CBC / WBC h Bacteria i Viral ABG’s Pulse oximetry Chest x-ray What is a normal WBC count? 4,500 – 10,000 mm3

85. Pneumonia: Medications Primary Antibiotics Bronchodilators Expectorant

86. Antibiotics Action Aids immune system in controlling pathogens Nursing consideration Educate to take all of the meds Not contagious after 24 hours on meds

87. Bronchodilators Dilate bronchi Reduce bronchospasms Improve ventilation

88. Expectorants Break up mucus Decrease its viscosity Liquefies mucus ? Easier to expectorate Take with lots of water!

89. Pneumonia: Medications Secondary Antibiotics Antipyretic Analgesic

90. Pneumonia: Oxygen therapy

91. Pneumonia: Nursing Fluids 2,500 – 3,000 mL/day Humidifier Chest physiotherapy TCDB I.S. Assess respiratory status Position HOB Rest

92. Pneumonia – Nursing Interventions O2 per order Maintaining nutrition Gatorade Ensure Promoting the patients knowledge

93. Pneumonia Prevention Vaccine Pneumonia Flu Treat URI Avoid irritants

94. Pneumonia: Small Group Questions Describe the pathophysiology of pneumonia. What is the difference btw typical and atypical pneumonia? What causes pneumocystis carinii? What lab values are associated with bacterial pneumonia? / viral pneumonia?

95. Pneumonia: Small Group Questions 5. What is Nosocomial pneumonia 6. Identify 5 risk factors for developing pneumonia 7. What medications might be administered to treat a pt. with pneumonia? 8. What nursing education would you give to a patient with pneumonia? 9. What are the gerontological considerations of caring for the elderly in regards to pneumonia?

96. Lung Cancer Pathophysiology Carcinogen binds to the DNA and changes it? Abnormal growth Usually develops on the wall of the bronchial tree

97. FYI Lung Cancer is the number one cancer killer in the US

98. Lung Cancer Etiology/Contributing factors #1 Tobacco Smoke (85%) Second hand smoke Carcinogens Asbestos Uranium Arsenic Nickel Iron oxide Radon Coal dust

99. Lung Cancer Clinical manifestations: early Insidious and asymptomatic until late stages

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101. FYI 70% of lung CA have metastasized by the time of diagnosis

102. Lung Cancer S&S: Early Objective symptoms #1: Cough #2 Repeated respiratory tract infection Wheezing Dyspnea

103. Lung Cancer S&S: Late Hemoptysis Chest pain Wt loss Anemia Anorexia

104. Lung Cancer Dx exams/procedures X-ray CT scan Biopsy via Bronchoscopy cytology

105. Lung Cancer Treatment Surgery Removal Chemotherapy Metastasis Radiation To shrink or reduce symptoms

106. Lung CA Priority Nrs Dx Ineffective breathing Ineffective Airway clearance Ineffective Gas exchange

107. Assessment Resp assessment Smoking hx Lab values S&S of complications

108. Assessment S&S of complications Edema H/A Dizziness Vision changes Difficulty breathing C/O pain

109. Interventions Assess q4hrs HOB Pulmonary hygiene TCDB IS O2 per order Suction PRN Emotional support

110. Secondary Nrs Dx Activity intolerance Pain Grieving

111. Activity intolerance Document response to activity Pulse Resp. status Fatigue Planned rest periods Increase activities gradually Enc to remain as active as possible Allow fam. To provide assist PRN Keep frequently used objects nearby

112. Pain Assess pain Administer analgesics PRN

113. PAIN & CANCER “For cancer pain, maintain a continuous medication schedule using opiates, NSAIDs and other drugs as ordered” Addiction is not a concern for the terminal cancer client; adequate pain relief that does not allow “breakthrough” pain is vital.

114. Pain Assess pain Administer analgesics PRN Alternative pain relief Massage Positioning Distraction Relaxation techniques

115. Pain Provide diversion activities TV Reading Social events Allow family to remain

116. Grieving Spend time with client & family Answer questions honestly Enc. Pt to express feelings (fear, anxiety, concerns) Assist to understand the grief process

117. Grieving Enc other support systems Spiritual Social groups Social services Hospice Discuss advanced directives Living will

118. Lung Cancer Preventative measures Stop smoking