Ineffective Airway
Clearance
ANATOMY OF THE
RESPIRATORY TRACT
Structures and Functions of
Respiratory System
 Physiology



of Respiration
Arterial blood gases
Mixed venous blood gases
Oximetry
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Assessment of Respiratory System
Auscultation
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Assessment of Respiratory
System
 Abnormal
breath sounds
 Adventitious sounds






Fine crackles
Coarse crackles
Rhonchi
Wheezes
Stridor
Pleural friction rub
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Arterial Blood Gas
Elements
ABG Element
Normal Value
Range
pH
7.4
7.35 to 7.45
Pa02
90mmHg
80 to 100 mmHg
Sa02
93 to 100%
PaC02
40mmHg
35 to 45 mmHg
HC03
24mEq/L
22 to 26mEq/L
UPPER AIRWAY OBSTRUCTION
 As







evidenced by
Increased respiratory rate > 24/min
Change in respiratory character
 ↓depth – shallow
 Snore-like or noisy
Change in breath sounds
 Limited or no air movement
 Stridor-high pitched
C/O “cannot breathe,” SOB, chest pain
↓ SpO2
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↑ Pulse, ↑ BP
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xt=1&list=PLBC00F19576AB
↓ LOC, ↑ restlessness
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GENERAL NURSING
INTERVENTIONS
 Positioning

Open airway, ↑ HOB
 Oxygen/AMBU
 Remove

foreign body
Suctioning/Manual removal
 Decrease


Edema
Meds- steroids
Ice packs to nasal area
THE PATIENT WITH A
TRACHEOSTOMY
NURSING MANAGEMENT
Tracheostomy
 The
stoma that results
from the tracheotomy
Indications
Bypass upper airway
 Facilitate removal of secretions
 Long term ventilation
 Permits oral intake and speech
who require long-term
mechanical ventilation

ADVANTAGES OF A
TRACHEOSTOMY
 Less
risk of long-term
damage to airway
 Increased comfort
 Patient can eat
 Increased mobility because
tube is more secure
TRACHEOSTOMY TUBE
NURSING MANAGEMENT:
TRACH CARE
•
•
•
•
Suctioning
Site Care: cleaning stoma, changing dressing and
ties
Inner cannula care
Bedside equipment
•
•
•
•
•
Obturator
replacement trach tube
suction equipment
Oxygen
AMBU bag
TRACH
MANAGEMENT
 Why
•
•


Inflate cuff
risk of aspiration
mechanical ventilation
Inflate with minimum volume to create an airway
seal
Pressure should not exceed 20 mm Hg or 25 cm
H2 O
CARE OF THE PATIENT WITH A
TRACHEOSTOMY
Nursing
Diagnosis
Ineffective
Airway Clearance
Risk for Infection
Impaired Verbal Communication
Impaired Swallowing
Nursing Management:
Lower Respiratory
Problems
Pneumonia
Pneumonia
An excess of fluid in the lungs
caused by an inflammatory process
 Possible



causes:
Microorganisms (bacterial, viral, or fungal)
Aspiration
Chemical irritants
 Leading
disease
cause of death due to infectious
Hospital-acquired
pneumonia
Occurring 48 hrs or
longer after admission
 Second most common nosocomial
infection

•
Risk factors
 Immunosuppressive
 General
therapy
debility
 Endotracheal intubation
Community-acquired
Pneumonia


Lower respiratory
infection of lung
Onset in
community or
during first 2 days of
hospitalization



4 million U.S. adults
diagnosed yearly
Highest incidence
in midwinter
Smoking important
risk factor
Community Acquired
Pneumonia
Clinical Manifestations

Symptoms
 Sudden
onset of
fever
 Chills
 Cough productive
of purulent, bloodtinged, or rustcolored sputum
 Pleuritic chest pain
 Atypical
symptoms
 Gradual
onset
 Dry cough
 Extrapulmonary
manifestations,
nausea, vomiting, and
diarrhea
Physical Examination
Findings
 Dyspnea
 Tachypnea
 Dullness
to
percussion
 Fremitus
 Bronchial breath
sounds
 Crackles





Tachycardia
Flushing
Cyanosis
Confusion
Delirium
Diagnostic Tests
 Pulse
 History
 Physical
examination
 Chest x-ray
 Gram stain of sputum
 Sputum culture and
sensitivity
oximetry or
ABGs
 CBC, differential,
chemistries
 Blood cultures
Treatment
Based
on
 Known
risk factors
 Severity of illness
 Suspected or identified organism
Antibiotic
10-14 days
 Empiric
 Pathogen
specific
Medications
 Antibiotic
therapy
 Respiratory
Fluroquinolone
 Antivirals
 Aymanadine,
Flumadine
 Mucolytics/expectorants
 Mucinex
 Antipyretics
 Anti-tussive
 Robituusin,
Tessalon pearls
 Analgesics
 morphine,
codeine, Dilaudid
Collaborative Care
 Oxygen
for hypoxemia
 Influenza drugs and influenza vaccine
 Fluid intake at least 3 L per day
 Small frequent meals
 Prevent aspiration
 Position change Q 2 hours
Collaborative Care
 Pneumococcal

vaccine
at risk
 Chronic
illness such as
heart and lung disease,
diabetes mellitus
 Recovering from severe
illness
 65 or older
 Long-term care facility
resident
Nursing Diagnoses
Impaired
gas exchange
Ineffective breathing pattern
Acute pain
Hyperthermia
Imbalanced nutrition: Less than
body requirements
Activity intolerance
Goals
Clear
breath sounds
Normal breathing patterns
No signs of hypoxia
Normal chest x-ray
No complications related to
pneumonia
Evaluation
 Dyspnea
not
present
 SpO2 ≥ 95
 Free of adventitious
breath sounds
 Clears sputum from
airway
 Reports
pain
control
 Verbalizes causal
factors
 Adequate fluid
and caloric intake
 Perform activities
of daily living
Pulmonary
Tuberculosis
Nursing Management
What is Tuberculosis
An infectious disease caused by
Mycobacterium tuberculosis
 Spreads
through airborne droplets
 May also occur in the kidneys, bones,
 adrenal glands, lymph nodes, and
meninges and can be disseminated
throughout the body
Who is at Risk?
Crowded,
poverty stricken settings
Homeless persons
Elderly
Healthcare workers and others such as
prison guards
Residents of long term care facilities
Alcoholics and IV drug users
Low socioeconomic background and
medically underserved
Clinical Findings
Early
stages usually symptom free
 incidental
Systemic
 fatigue,
findings with routine CXRs
symptoms
malaise, anorexia/weight loss,
low-grade fevers (esp. in the late
afternoon), and night sweats
 Cough that becomes frequent and
produces mucopurulent sputum
 May have dull or tight chest pain
Lab & Diagnostic Findings
 Sputum
 To
Culture
examine for acid-fast bacilli
(AFB)
 Cultures positive for
M.Tuberculosis confirm the
diagnosis of TB
 Perform q 2-4wks to determine
effectiveness of medication
therapy
 CXR
Lab & Diagnostic Findings
TB
skin test
 Positive
reaction occurs 3-10 wks
after the initial infection
 Once acquired, test always
positive
 Does not show whether the
infection is dormant or active
 For the immunocompromised,
smaller indurations may be
considered positive
 Determines presence of active or
calcified lesions
Drug Therapy Regimen For TB:
Latent TB Infection Treatment Regimens
Isoniazid
(INH) for 9 months (standard)
Daily or *twice/week
INH for 6 months
Daily or *twice/week
INH and Rifapentine for 3 months
*Once weekly
Rifampin (RI) for 4 months
Daily
* Directly Observe Therapy
Nursing Management: Drug
Therapy
 Patient
 After
considered noninfectious
2-3 weeks of continuous medication
therapy
 Three negative sputum (AFB) smears
Nursing Management:
Medication side effects
Major
side effect of medications is
hepatitis
Rifampin: educate patient that urine,
feces, sputum, tears, and sweat will have
red-orange discoloration
Isoniazid: peripheral neuropathy
Streptomycin: damage to eighth cranial
nerve
Nursing Management
 Encourage
liquids
 Small, frequent meals
 High-carbohydrate, high-protein, high-vitamin
diet
 Vitamin B-6 supplementation
 Reduce elevated temp
 Improve gas exchange
 Provide client & family teaching and referrals
 Avoid smoking, asbestos, secondhand smoke
 Consult social services
Acute Interventions
Respiratory
isolation
Drug therapy
Immediate workup (CXR, sputum
smear, and culture)
Teach client to cover nose & mouth
with tissue when coughing and
sneezing
Teach good hand washing
techniques
Chest Trauma
Thoracic Injuries
Pneumothorax
Air entering the pleural cavity
Types
 Spontaneous-Rupture
of
small blebs
 Iatrogenic-Oops!
 Traumatic-Penetrating
 Tension-Pressure
 Hemothoax-Bleeding
 Chylothorax-Lymphatic
fluid
Treatment
 None
 Chest

tube
Water seal
Nursing Care: Patient
with Chest Tube
 Assessment
of respiratory status
 Assessment of chest tube, drainage & system




Is it patent?
How much drainage?
Correct suction?
Any air leaks?
 Clamping
 What
happens if it becomes disconnected?
 Patient Transportation
Chest Tube Removal
 Chest
Tube Removal--when lungs are re-expanded
and fluid drainage has ceased
 Sutures
 Apply
removed
sterile petroleum jelly gauze dressing
 Patient
takes a deep breath, exhaling, and
Valsalva’s maneuver
 MD
removes
 Apply
dressing, observe for several days
Pulmonary
Embolism
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Pulmonary Embolism
 Blockage
of pulmonary arteries by
thrombus, fat or air embolus, or tumor
tissue
 Obstructs alveolar perfusion
 Most commonly affects lower lobes
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
49
Pulmonary Embolism
From: Brooks, M.L., Exploring
Medical Language – A Student-Directed
Approach, Mosby Elsevier, 2012
From: Brooks, M.L., Exploring
Medical Language – A Student-Directed
Approach, Mosby Elsevier, 2005
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Risk Factors
 Deep
vein
thrombosis (90%)
 Immobility or
reduced mobility
 Surgery
 History of DVT
 Malignancy
 Obesity
 Oral contraceptives/
hormones
 Smoking
 Heart
failure
 Pregnancy/delivery
 Clotting disorders
 Atrial fibrillation
 Central venous
catheters
 Fractured long
bones
Clinical Manifestations
 Variable
 Dyspnea
most common
 Tachypnea, cough, chest pain,
hemoptysis, crackles, wheezing, fever,
tachycardia, syncope, change in LOC
 Dependent on size and extent of emboli
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Complications
 Pulmonary



Alveolar necrosis and hemorrhage
Abscess
Pleural effusion
 Pulmonary


infarction
hypertension
Results from hypoxemia associated with
massive or recurrent emboli
Right ventricular hypertrophy
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Diagnostic Studies
 Arterial
blood gases
 Chest x-ray
 Electrocardiogram
 Troponin levels
 B-type natriuretic peptide
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Diagnostic Studies
 D-Dimer


Elevated with any clot degradation
False negatives with small PE
 Spiral


(helical) CT scan
Most frequently used dx test
Requires IV contrast media
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Diagnostic Studies
 Ventilation-perfusion


(V/Q) scan
Used if patient cannot have contrast
Two components
 Perfusion
scanning
 Ventilation scanning
 Pulmonary

angiography
Most sensitive but invasive
 Arterial
blood gases (ABGs)
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
When admitting a 45-year-old female with a diagnosis of
pulmonary embolism, the nurse will assess the patient for
which risk factors (select all that apply)?
A. Obesity
Pneumonia
C. Malignancy
D. Cigarette
smoking
E. Prolonged air
travel
20% 20% 20% 20% 20%
on
g
ed
ai
rt
ra
ve
l
ng
sm
ok
i
et
te
ar
M
al
ign
Ci
g
Pr
ol
an
cy
a
on
i
m
Pn
eu
Ob
es
ity
B.
30
Collaborative Care
 Prevention—the



key!
Sequential compression devices
Early ambulation
Prophylactic anticoagulation
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Collaborative Care
 Goals



of treatment
Prevent further thrombi
Prevent further embolization to pulmonary system
Provide cardiopulmonary support
 Supportive



care variable
Oxygen → mechanical ventilation
Pulmonary toilet
Fluids, diuretics, analgesics
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Drug Therapy
 Anticoagulation



Low-molecular-weight heparin (LHWH)
Unfractionated IV heparin
Warfarin (Coumadin)
 Fibrinolytic


agents
Tissue plasminogen activator (tPA)
Alteplase (Activase)
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Surgical Therapy
 Pulmonary
embolectomy for massive PE
 Inferior vena cava (IVC) filter

Prevents migration of clots in pulmonary
system
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Inferior Vena Cava Filters
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Management
 Semi-Fowler’s
position
 IV
access
 Oxygen therapy
 Frequent cardio/pulmonary assessments
 Monitor laboratory results.
 Emotional support and reassurance
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Patient Teaching
 Regarding
long-term anticoagulant
therapy
 Measures to prevent DVT
 Importance of follow-up exams
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Evaluation
•
Expected Outcomes




Adequate tissue perfusion and respiratory
function
Adequate cardiac output
Increased level of comfort
No recurrence of PE
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
The nurse instructs a patient with a pulmonary embolism about
administering enoxaparin (Lovenox) after discharge. Which
statement by the patient indicates understanding about the
instructions?
ed
ic i
ne
of
...
sm
air
tt
hi
th
e
je
c
pe
l
“I
w
ill
in
ex
ill
w
“I
0%
...
0%
ou
t
ed
m
hi
s
et
ta
k
to
ne
ed
“I
0%
i..
.
v.
..
di
ss
ol
ill
w
ne
ici
D.
0%
m
ed
C.
he
B.
“The medicine will
dissolve the clot in my
lung.”
“I need to take this
medicine with meals.”
“I will expel the air out
of the syringe before I
administer.”
“I will inject this
medicine into my
abdomen.”
“T
A.
30