Module 1 - COPD
1. Relate assessment and diagnostic findings to the underlying pathophysiology of COPD.
a. Chronic inflammatory response of airways and lungs primarily caused by
cigarette smoking and other noxious particles or gasses
b. Patho
i.
Loss of elastic recoil and airflow obstruction, attributable to mucus
hypersecretion, mucosal edema, and bronchospasm.
ii.
Defined as airflow limitation not fully reversible during forced exhalation
c. Symptoms - dyspnea (worse with exercise), chronic cough (can be intermittent
and non productive), chronic sputum production
d. Other signs - easily fatigued, frequent respiratory infections, use of accessory
muscles, orthopneic, cor pulmonale (later in disease), thin in appearance,
wheezing, pursed lip breathing, chronic cough, barrel chest, prolonged expiratory
time, digital clubbing
e. Problem is in expiring air; V/Q mismatch - hypoxemia
f. Diagnostics
i.
H&P
ii.
Spirometry - best way to diagnose
iii.
CAT or mMRC
1. CAT - “I never cough” vs “i cough all the time”
2. mMRC - dyspnea on a range (i can’t leave my house to im fine)
3.
iv.
Pulmonary function tests - FVC and FEV1; take a short acting
1. Normal FEV1 is about 80% of FVC
2. Diagnosis made when FEV1/FVC is less than 70%
3. Increased residual volume (volume left in lungs)
v.
Serum AAT deficiency
vi.
ABGs, CBC - not a diagnostic but can identify abnormalities; late stages:
low/normal pH, high CO2, low O2 and high-normal bicarb (high if
compensated)
vii.
6 minute walk test - if values of O2 sat are less than 88% at rest, they
qualify for supplemental oxygen
viii.
Chest xray - not diagnosis but shows flat diaphragm from overinflation
ix.
EKG
2. Discuss COPD risk factors and related patient education.
a. Risk factors
i.
Cigarette smoke
ii.
Occupational dusts, vapors, fumes, gasses
iii.
Smoke from home cooking
iv.
Antitrypsin deficiency
v.
Genetics
vi.
Asthma
b. Goals for treatment
i.
Reduce symptoms - relieve symptoms, improve exercise tolerance,
improve health status
ii.
Reduce risk - prevent disease progression, exacerbations, and reduce
mortality
c. Complications
i.
Pulmonary HTN with cor pulmonale
ii.
Hypoxemia and hypercapnia develop later in disease; can lead to
respiratory acidosis
iii.
Bullae - large air spaces in the parenchyma; blebs - air spaces next to
pleurae (on surface); neither can exchange gas
iv.
Acute respiratory failure
v.
Peptic ulcer disease
vi.
Depression/anxiety
vii.
Acute exacerbations
3. Explain the interprofessional management of patients with COPD including medications,
oxygen, and pulmonary rehabilitation.
a. Smoking cessation, avoid environmental irritants, avoid exposure to large
crowds, flu vaccine, Tdap vaccine, treat respiratory infections promptly
i.
5 A’s of tobacco cessation - Ask (do you smoke), advise (to quit), assess
(willingness to quit), assist (plan to quit), arrange (for followup)
b. Meds
i.
Used on a step up basis
ii.
Bronchodilators
1. Beta 2 agonists - relax airway smooth muscle;
a. SABA - short acting, rescue inhaler; albuterol
b. LABA - long acting; salmetrol
2. Muscarinic antagonist - block acetylcholine, bronchodilate,
decrease mucus production
a. SAMA - short acting; ipratropium
b. LAMA - tiotropium
iii.
Inhaled corticosteroids
1. If FEV1 < 60%
2. Flovent
3. Guided by blood eosinophil levels (100-300)
iv.
Combos
1. Short acting combo - ipratropium and albuterol (Combivent)
2. Long acting anticholinergic (LABA) - salmetrol and fluticasone
(Adavir) if add tiotropium (Spiriva) - triple therapy
3. Triple therapy once daily resulted in lower rate of COPD
exacerbations and hospitalizations
v.
Which inhaler when?
1. Early on - only use rescue inhaler (bronchodilator SABA or SAMA)
2. More severe symptoms - add in LAMA or LAMA + LABA
3. More than 2 exacerbations leading to hospitalization, add the ICS
vi.
Other meds
1. Phosphodiesterase inhibitor – for severe COPD and Chronic (end
stage)
2. Bronchitis – rofumilast (Daliresp) is oral anti-inflammatory med
3. Antibiotics – with infection; usually azithromycin (Zithromax)
4. Nonprescription Drugs - mucolytics
c. Oxygen
i.
Increases partial pressure of inspired air
ii.
Indication - Hypoxemia: PaO2 < 55-60 mm Hg or O2 sat < 88%
iii.
Long term effects – increase survival, exercise capacity, cognitive
performance and sleep; may reduce pulmonary hypertension
iv.
Goal: maintain O2 sat>/= 90% during rest, sleep and exertion
v.
Prescriptions: Short term rx – 30 days or less; Long term rx – need > 15
hrs/day
vi.
Reevaluate: every 30-90 days for first year and then annually
vii.
Types of delivery
1. Low flow - nasal cannula and non-rebreather mask
2. High flow - venturi mask and mechanical ventilation
d. Pulmonary rehab
i.
Physical therapy - bronchial hygiene, exercise conditioning, breathing
retraining (8-10xs, 3-4xs a day; pursed lip breathing, diaphragmatic
breathing), energy conservation
ii.
Airway clearing techniques
1. Goal: loosen mucus and secretions so they can be cleared by
coughing
2. Effective cough techniques (Huff) 3. Chest physiotherapy
a. Postural drainage (2-4 x/day)
b. Percussion - No percussion over kidneys, sternum, spinal
cord, bony prominences, tender or painful area.
c. Vibration
4. PEP - uses positive expiratory pressure to clear mucus
iii.
Nutrition
1. Malnutrition
a. Due to:
i.
Increased inflammatory mediators
ii.
Increased metabolic rate
iii.
Lack of appetite
iv.
Altered taste d/t chronic mouth breathing,
excessive sputum, fatigue, anxiety, depression,
infections, and side effects of polypharmacy
2. Keep body weight for height in standard range
3. Rest for at least 30 minutes before eating
4.
5.
6.
7.
Use bronchodilator before meals
Avoid exercises and treatments for an hour before and after meals
Wear oxygen during meals
Diet - high protein and calories, 5-6 small meals, fluids between
meals, restrict fluid and Na PRN, avoid foods that require a lot of
chewing, consider cold and blended foods
iv.
Smoking cessation
v.
Control of environmental factors
vi.
Psychological counseling
vii.
Vocational rehab
e. Surgical therapy
i.
Lung volume reduction surgery
ii.
Bronchoscopic lung volume reduction surgery - absorption atelectasis
4. Identify key points for patient education on oxygen, inhalers, pulmonary hygiene,
physical activity, nutrition, and sleep.
a. Inhalers
i.
Why use a spacer?
1. So there is a chamber and more can get in lungs
ii.
How do you use an inhaler?
iii.
When should they be cleaned?
1. Do not clean the canister, just water on the spacer
iv.
When should inhalers be replaced?
v.
Why should patients rinse their mouths?
1. If steroid it can cause thrush
vi.
How does it differ from a dry powder inhaler?
1. A faster breath
b. Conserve energy as much as possible during ADLs
c. Gradually increase activity with monitoring pulse and respirations
i.
15-20 minutes a day at least 3x a week
ii.
Coordinated walking with PLB
1. Breathe in through nose while taking one step
2. Breathe out through pursed lips while taking 2-4 steps
iii.
SOB expected, RR should return to baseline after 5 minutes
iv.
Keep a diary
v.
Borg scale - level of perceived exertion during exercise
d. Sleep
i.
Meds, postnasal drip, coughing
e. Sexual activity
i.
Permitted when able to climb 2 flights of stairs
ii.
Usually best during the day - not after meals, alcohol or exercise
iii.
Choose less stressful positions, used pursed lip breathing, use oxygen if
prescribed, bronchodilator before
f. EOL
i.
Symptoms can be managed, but COPD cannot be cured
5. Evaluate outcomes of care for the patient with COPD.
Module 2
Obstructive Sleep Apnea
1. Describe healthy sleep habits
a. 7-8 hours per 24 hours
2. Describe the etiology and clinical manifestations of obstructive sleep apnea.
a. Most diagnosed sleep-disordered breathing problem
b. Repeated episodes of partial or complete upper airway obstruction during sleep
c. Apnea is cessation of breathing for longer than 10 seconds
i.
Brain will wake you up because of hypoxia
d. Hypopnea is decrease amount of airflow due to a partial airway obstruction
i.
Snoring will make them up
Apnea
Hypopnea
decrease in airflow >80%
decrease in airflow 3050%
decrease O2 saturation
decrease O2 saturation 34%
> 10 seconds
≥ 10 seconds
Ends in arousal
Ending with arousal
e. Etiology
i.
Tongue & soft palate fall backward and partially obstruct or totally occlude
the pharynx/narrowing of air passages
ii.
Can last from 10-90 seconds
iii.
Hypoxemia and hypercapnia stimulate respirations to return
iv.
Generalized startle response, snorts and gasps cause tongue and soft
palate to move forward and the airway to open
f. Manifestations
i.
3 major signs - sleepiness, sleep apnea, snoring
1. Hypercapnia causes morning headache
3. Relate assessment and diagnostic findings to the underlying pathophysiology of
obstructive sleep apnea.
a. Risk factors - obesity, male gender, >65 years, craniofacial or upper airway soft
tissue abnormalities, neck circumference >17 inches, acromegaly, smoking
b. Complications
i.
HTN, cardiac dysrhythmias, heart failure
1. SNS over-activation, increased vascular resistance, reduced
myocardial muscle oxygenation
ii.
Poor concentration/memory
iii.
Impotence
iv.
Depression
c. Diagnosis
i.
Defined as more than 5 apnea/hypopnea events per hour with a 3% to
4% decrease in oxygen saturation
ii.
Sleep and medical history
iii.
Berlin questionnaire
1. Snoring severity, excessive daytime sleepiness, history of high
blood pressure or obesity
iv.
STOP-BANG questionnaire
1. It consists of eight dichotomous (yes/no) items related to the
clinical features of sleep apnea. The total score ranges from 0 to 8
v.
PSG
1. Monitors chest and abdominal movement, oral and nasal airflow,
SpO2, eye movement, and heart rate and rhythm
4. Explain the interprofessional and nursing management of patients with OSA.
a. Mild apnea: 5-15 events/hour
i.
Conversative treatment
ii.
Changing sleep position
iii.
Sleep hygiene
iv.
Avoid sedatives
v.
Avoid alcohol 3-4 before sleep
vi.
Weight management - diet, exercise, bariatric surgery
vii.
Use of mouth guard
b. Moderate to severe: 15-30/>30 events/hour
i.
Noninvasive Positive Pressure Ventilation (CPAP & BiPAP)
ii.
CPAP mask
1. Continuous pressure of 5-15cm on inspiration and expiration
2. Nasal or facial mask
3. Use for a minimum of 4 hours per night
4. Side effects - nasal congestion, poor fit, facial discomfort, sore
throat, dry eyes, loud, spousal support
iii.
BiPAP
1. Better tolerated than CPAP
2. IPAP - 5-10cm enhances oxygenation
3. EPAP - 3-5cm lower pressure
c. Nursing management
i.
Ensure mask fits correctly
ii.
Monitor patient for: dyspnea, respiratory distress, respiratory rate, vital
signs, oxygen saturation, and hypercarbia/hypoxia
iii.
Humidified circuit
iv.
Start at lower pressure and increase
v.
Education
1. Include patient in choosing mask/machine
2. Recommend support groups
3. Bring machine along if hospitalized
5. Discuss medical and surgical interventions for a patient with OSA.
a. UPPP - remove tonsils, uvula and posterior soft palate to get rid of obstruction
b. GAHM - attaching muscular part of tongue to mandible; UPPP is usually done
with this as well
c. RFA (radiofrequency ablation) - least invasive
d. About 80% experience relief
e. Post op
i.
1-day surgery
ii.
Postop – sore throat, foul breath odor, earache, snoring may continue d/t
edema
iii.
Mouthwash – dilute NSS; okay to brush teeth but not tongue or back of
mouth
iv.
Pain control – consider liquid med
v.
Soft diet – stay hydrated, possible constipation - stool softeners,
laxatives, ambulation, hydration
vi.
Repeat PSG in 3-4 months
f. Inspire Upper Airway Stimulation (UAS) - implantable nerve stimulator
Pulmonary HTN
1. Distinguish between the different classifications of pulmonary hypertension
a. Characterized by elevated pulmonary artery pressure from an increase in
resistance to blood flow through the pulmonary circulation
b. Normal pressure is 12-16mmHg; usually likes low resistance and pressure
c.
d.
e.
f.
2.
3.
4.
5.
HTN is >25 at rest or >30 with exercise
Moderate if 46-60mmHg
Severe if >60mmHg
Groups
i.
Group 1: attributed to medications, specific
diseases, genetic, or idiopathic
ii.
Group 2: related to left-sided heart failure
iii.
Group 3: related to lungs and hypoxemia
iv.
Group 4: related to cardiovascular system and
thromboembolic occlusion
v.
Group 5: multifactorial
Describe the pathophysiology of pulmonary hypertension
a. Risk factors
i.
30-60 years of age
ii.
Women > Men
iii.
Family History
iv.
Certain conditions:
1. Blood clots
2. Chronic kidney disease
3. Diseases that change the structure of the chest wall, such as
scoliosis
4. Hepatitis B or C
5. Liver disease
6. Splenectomy
7. Thyroid disease
b. Idiopathic pulmonary arterial hypertension (IPAH)
i.
Related to connective tissue diseases, cirrhosis and HIV
ii.
Unclear cause
c. SPAH
i.
Chronic increase in pulmonary artery pressures from another disease
ii.
Parenchymal lung disease, LV dysfunction, intracardiac shunts, chronic
PE, or systemic connective tissue disease
iii.
Occurs 5-10% of cases
Identify causative factors that contribute to pulmonary hypertension
Discuss clinical manifestations of IPAH
a. Dyspnea on exertion andd fatigue
b. Exertional chest pain, dizziness and syncope may occur
i.
Related to inabaility of CO to increase in response to increased O2
demand
c. Late disease - dyspnea at rest, S3 sound (ventricular gallop when mitral valve
opens)
Clinical manisfestations of SPAH
a. Dyspnea
b. Fatigue
c.
d.
e.
f.
Lethargy
Chest pain
RV hypertrophy
Right-sided heart failure symptoms
i.
S4 - heard right before 1st heart sound due to overcoming high resistance
ii.
Peripheral edema
iii.
Hepatomegaly - backup in liver
iv.
JVD
v.
Fatigue, ascites
6. Explain the nursing and interprofessional management of pulmonary hypertension
a. Diagnosis
i.
Right sided cardiac catheterization - definitive test
1. Provides accurate measures of right atrial pressure (2-6 mmHg),
pulmonary artery pressures (15-25mmHg), cardiac output (4.0-8.0
l/min), and pulmonary vascular resistance (<250 dynes sec/cm5)
2. Uses a catheter that is placed in the femoral, internal jugular, or
subclavian veins. The catheter advances into the vena cava into
the right atrium. It measures pressures in the right atrium and right
ventricle.
3. A balloon is inflated on the tip of the catheter and “wedges” into
the pulmonary artery. The “wedge” allows for indirect
measurements of the left-side of the heart.
4.
ii.
Want to diagnose very early
iii.
Initial testing
1. Chest x-ray - enlarged heart
2. Laboratory test
a. Liver function test (LFT)
b. BMP (BUN/Creatinine)
c. BNP (brain natriuretic peptide) - released when ventricles
are working
i.
0-99 pg/mL is normal
3. Electrocardiogram (ECG)
iv.
Preliminary diagnosis
1. Transthoracic Echo
a. Ultrasound
b. Looks at blood flow and measures pressure in the heart
c. Will report an ejection fraction (EF) - how much left
ventricle pumps out during systole
d. Normal 55-70%
v.
Pulmonary function test (PFTs)
1. Looking for other underlying conditions
2. COPD, pulmonary fibrosis
vi.
CT scan of chest
b. Management
i.
No cure but can decrease symptoms
ii.
Give oxygen to keep sat >90%; low flow oxygen - nasal cannula
iii.
Drugs
1. Calcium channel blocker
a. Causes dilation and lowers pulmonary artery pressures causes low BP and HR
b. Avoid in patients with Right sided heart failure
c. Diltiazem (Cardizem)
d. Nifedipine
2. Endothelin Receptor Antagonists
a. Blocks the constriction of pulmonary arteries, relaxes
pulmonary arteries and decrease PA pressures
b. Given orally
c. Need to monitor LFTs
d. bosentan (Tracleer)
3. Phosphodiesterase (Type 5) Enzyme Inhibitors
a. Promotes smooth muscle relaxation in lung vasculature
b. Given orally
c. sildenafil (Revatio)
d. Very similar to viagra
4. Vasodilators (inhaled)
a. Analog of prostacyclin and dilate systematic and
pulmonary arterial vasculature
b. Given via a nebulizer 6-9 times/day - short half life (4
hours)
c. Need to check BP, do not give if SBP < 85 mmHg
d. Iloprost (Ventavis)
e. Treprostinil (Tyvaso)
f. Side effects - headache, GI symptoms, fluid retention
(edema)
5. Vasodilators (Parenteral) - may need to be hospitalized
a. Analog of prostacyclin and promotes pulmonary
vasodilation/ reduces pulmonary vascular resistance
b. Reserved for patient who do not respond to other therapies
c. Continuous IV infusion or subcutaneous route
d. Extremely short half-life - 1 minute
e. Epoprostenol (Flolan, Veletri) (need cold pouches)
f. Treprostinil (Remodulin)
iv.
Other treatment
1. Diuretics
a. Used to manage peripheral edema
b. Furosemide (Lasix) - monitor I&O (want O positive),
monitor potassium
2. Anticoagulants - Heparin
a. To prevent thrombus formation
3. Surgical intervention
a. Pulmonary thromboendarterectomy (PTE)
i.
Removes clots from the pulmonary arteries
4. Lung transplant
a. Consider if no response to therapies and presence of
severe right-sided heart failure
Head and Neck Cancer
1. Identify the risk factors associated with head and neck cancer.
a. Tobacco causes 85% of head and neck cancers
b. Excess alcohol
c. More common over age of 50
i.
Younger than 50 associated with HPV
d. Twice as common in men than women
e. Sun, asbestos, industrial carcinogens, marijuana, radiation, poor oral hygeine
2. Discuss clinical manifestations in a patient with head and neck cancer.
a. Varies with location of tumor
b. Oral cavity:
i.
White or red patch in the mouth;
ii.
Swelling of the jaw that causes dentures to fit poorly or become
uncomfortable
iii.
Unusual bleeding or pain in the mouth.
c. Pharynx:
i.
Trouble breathing or speaking
ii.
Pain when swallowing
iii.
Pain in the neck
iv.
Sore throat that does not go away
v.
Frequent headaches, pain, or ringing in the ears or trouble hearing.
d. Laryngeal
i.
Hoarseness that last more than 2 weeks
ii.
Pain when swallowing
e. Paranasal sinuses and nasal cavity
i.
Chronic sinus infections that do not respond to treatment with antibiotics
ii.
Nose bleeds
iii.
Frequent headaches
iv.
Swelling or other trouble with the eyes
f. Salivary glands:
i.
Swelling under the chin or around the jawbone
ii.
Numbness or paralysis of the muscles in the face
iii.
Pain in the face, the chin, or the neck that does not go away
g. Late signs - require nursing intervention
i.
Unintentional weight loss
ii.
Difficulty swallowing
iii.
Difficulty moving the tongue
iv.
Difficulty breathing
v.
Partial or fully obstructed airway - ALWAYS PRIORITY
3. Identify diagnostic tests for patients with head and neck cancer.
a. Early detection key to survival
b. Focused assessment of head and neck
i.
Leukoplakia - thickened white patches mainly on gums, insides of cheek,
bottom of mouth, and sometimes on tongue - cannot be scraped off
ii.
Erythroplakia - mucosal membranes; dont always mean cancer, can be a
precursor (50% develop into squamos cell carcinoma
iii.
Palpate lymph nodes
c. If lesions suspected - may have pharyngoscopy or laryngoscopy; may take
biopsy
d. CT scan or MRI
e. PET scan - helpful to find mestastasis and diagnose
4. Summarize the role of speech therapy and identify different approaches to restore
speech in a patient with head and neck cancer.
a. 3 major approaches - ALWAYS ASSESS FOR ASPIRATION OR DYSPHAGIA
i.
Electrolarynx
1. Uses a hand-held battery-powered device that creates speach
with sound waves
2. Little maintanence and easy to learn
3. Con is the bad sound quality
ii.
Transesophageal puncture (TEP)
1. Opening between the trachea and esophagus (fistula) then a oneway prosthetic valve is placed in the tract
2. To speak the patient plugs the stoma with the finger
3. Speech is made by the air vibrating against the esophagus and
formed into words when the lips and tongue move
4. Offers best speech quality with highest satisfaction
iii.
Esophageal speech
1. Depends on the amount of air introduces in the esophagus and
then expelled
2. Must learn the technique
5. Describe the nursing and interprofessional management of a patient with head and neck
cancer.
a. Surgery
i.
Vocal cord stripping
1. Removes the outer layers of tissue on vocal cord
2. Will not affect speech
ii.
Laser surgery
1. An endoscope with a high-intensity laser down the throat
2. The tumor is vaporized or cut out
iii.
Cordectomy
1. Removal of some or all of the vocal cords
2. Speech is impacted dependent upon how much is removed
iv.
Partial or total laryngectomy
1. Partial: portion of the larynx that is affected by the cancer is
removed
2. Total: the entire larynx is removed; changes airflow and normal
voice production not possible
3. Patient will have a tracheostomy in place
v.
Pharyngectomy
1. Removal of part or all the throat
vi.
Neck dissection surgery
1. Radical neck dissection
a. Removal of all the tissue on the side of the neck from the
mandible to the clavicle. Muscle, nerve, salivary gland and
major blood vessels.
2. Modified radical neck dissection
a. Most common
b. All lymph nodes are removed
c. Nerves, blood vessels and muscles may be spared
3. Selective neck dissection
a. Depends on how far the cancer has spread
b. Fewer lymph nodes are removed
c. Muscles, nerves, and blood vessels may remain intact
b. Radiation therapy
i.
Preferred with early disease detection
ii.
Can preserve voice function
iii.
Can be used in combination with other therapies
iv.
External beam therapy
1. A machine is used to the delivery of radiation to the exact location
2. Three-dimensional conformal radiation therapy (3D-CRT)
3. Image guided radiation therapy (IGRT)
v.
Brachytherapy
1. Places a radioactive source near or into the tumor
2. Uses thin, hollow, plastic needles with radioactive seeds
c. Chemotherapy and Targeted Therapy
i.
Stage 3 or 4 cancer
ii.
Must be a chemotherapy certified nurse to administer IV infusions
iii.
If oral, need two nurses to check 7 routes of medication administration
iv.
Cetuximab (Erbitux)
1. Used with chemo for late-stage
2. Targets epidermal growth factor receptor (EGFR) and stops the
cells from growing
3. IV infusion
4. Need to monitor patient during and after infusion for side effects
d. Nutrition
i.
May have difficulty swallowing - malnutrition
ii.
Side effects like radiation burns or oral mucositis can cause difficulty
chewing - give soft or liquid foods
iii.
May need to use enteral nutrition - monitor for tolerance (N/V/D, residual)
iv.
Give analgesics before meals
e. Physical therapy to improve ROM
6. Discuss pre and post operative interventions with surgical management.
a. Airway is number priority
b. Body image and effective communcation are important too
c. Find other ways to communicate for right after surgery
d. Post-operative
i.
Airway management, assess for swelling - stridor, monitor tracheostomy
site, suction as needed, monitor drainage, drainage will be bloody at first,
use humidification, encourage cough and deep breathing, keep HOB
elevated, monitoring vital signs, pain management
e. Radiation interventions
i.
Patient may experience the following:
1. Dry mouth
a. Occurs within a few weeks of treatment
b. Can be temporary or permanent
c. Things that may help are:
i.
Encouraging fluids or food or chewing gum
ii.
Using nonalcoholic mouth rinses or artificial saliva
2. Oral mucositis
3. Teach the patient about oral hygiene - soft tooth brushes, mouth
rinses 4-6 times a day
4. Irritation of skin
5. Fatigue
a. Common with chemotherapy as well
b. Encourage light exercise
c. Rest during periods of low energy
7. Articulate essential components of discharge teaching to a patient with a total
laryngectomy.
a. Stoma care
i.
Wash around the area daily
ii.
Remove dried secretions
iii.
Once stoma is healed the tracheostomy will be removed, patients may
have a laryngectomy tube placed
1. Patients should remove tube daily and clean as one would clean a
tracheostomy tube
iv.
Stoma can be covered with a scarf or other loose material
v.
Teach respiratory etiquette
1. Cover stoma when coughing
2. Cover during activity when foreign substance could be inhaled
Tracheostomy
1. Discuss the indications for a tracheostomy.
a. To establish a patent airway
i.
Airway edema
b. Bypass an airway obstruction
i.
Tumor
ii.
Vocal cord paralysis - need trach always
c. Facilitate removal of secretions
i.
Stroke
d. Long-term mechanical ventilation
i.
Acute respiratory distress syndrome (ARDS)
ii.
Stroke
iii.
Brain injury
2. Differentiate between the different tracheostomy
tubes
a. General
i.
Face plate rests against patient neck
1. Need to know trach size
ii.
Outer cannula keeps airway patent
iii.
Inner cannula is inserted into outer
cannula and can be disposable or
nondisposable
b. Fenestrated versus non-fenestrated
i.
Fenestrated
1. Need to know if inner
cannula is fenestrated - cannot suction with a fenestrated tube!
2. Promotes spontaneous respirations
c. Cuffed versus uncuffed
i.
Cuffed
1. Most common
2. Mechanical ventilation
3. Cuff inflated via balloon port on tube - makes sure they recieve all
the air and decreases risk of aspiration
4. Cannot talk when balloon is inflated
ii.
Uncuffed
1. Used with long term trachs
2. Mechanical ventilation not required and risk of aspiration has
decreased
3. Talking and eating are easier
3. Discuss nursing management of the patient with a tracheostomy.
a. Insertion can be done at bedside or in OR
b. Need chest xray to check placement
c. Monitor vitals
d. Ensure bedside suction is working properly
e. Make sure you have ambubag and mouth care supplies as well
4. Discuss interprofessional management of the patient with a tracheostomy.
a. Oxygen management
i.
Administered through a trach collar
ii.
May recieve humidified air only (yellow spout) - no oxygen
5. Identify the steps involved in performing tracheostomy care and suction.
a. Patient monitoring
i.
Assess trach at minimum every shift
ii.
Observe for redness, inflammation, edema, skin breakdown, or any other
signs of infection
iii.
Suction as needed using a sterile technique
iv.
Clean around stoma with normal saline and apply a sterile pre-cut gauze
or Allevyn foam dressing(depends on institution)
1. Do not cut regular gauze
2. Never use hydrogen peroxide on skin - only ever use to clean non
disposable trach once a shift
v.
Cuff inflation should not exceed 20-25cm H20 - use least amount of
volume possible
b. Suction as needed to remove mucus, if the patient has a low pulse ox, tachypnea
or respiratory distress, or they are unable to clear their own secretions
i.
If fenestrated, need to place a nonfenestrated before suctioning
ii.
Sterile technique
iii.
Suction only when going out never when advancing suction catheter
iv.
Do not suction for longer than 10 seconds and allow breaks in between
v.
Always keep a suction kit at bedside
c. Care
i.
Explain procedure to patient
ii.
Put patient in semi-fowlers
iii.
Gather equipment:
1. Tracheostomy kit is usually available
2. Gloves, gauze, trach ties, basin for sterile water
3. Typically, a clean technique unless non-disposable cannula then
sterile gloves needed
iv.
Wash hands and apply PPE
v.
Unlock and remove inner cannula
vi.
Clean around stoma with sterile water dampened gauze and pipe
cleaners; clean around faceplate with cotton swabs
vii.
Gently dry around stoma with new gauze - assess skin
viii.
Place pre cut gauze
ix.
Change once per shift
x.
Change trach ties 24 hours after insertion and then per institution
protocol; should be able to place 2 fingers in between
6. Discuss speech therapy protocols for a patient with a tracheostomy.
a. Swallowing dysfunction
i.
Assessed for risk of aspiration
ii.
Speech therapy completes evaluation - if not aspirating when cuff is
deflated, can keep it deflated or switch to uncuffed
1. Must make sure patient is receiving correct diet, bed is >30
degrees, takes small bites of food, deflate cuff
b. Passy-Muir valve
i.
Allows speech by moving air through the vocal cords - patient exhales
through nose and mouth instead of trach
ii.
May only be able to tolerate short periods at first
iii.
Remove immediately if signs of respiratory distress
7. Identify the steps if decannulation of tracheostomy.
a. Dislodgment
i.
Immediately call for help
ii.
If in respiratory distress, cover stoma with sterile dressing and ventilate
through nose and mouth - if total laryngectomy must ventilate through
stoma
b. Decannulation
i.
Patient needs to meet criteria:
1. Hemodynamically stable
2. Stable respiratory drive
3. Able to protect airway
4. Able to ventilate
ii.
Usually is a multi-step process consisting of downsizing tracheostomy,
Passy-Muir trials, and weaning protocols
iii.
Completed by RT, physician, or advance practice
iv.
Stoma should be covered with sterile occlusive dressing and monitor for
bleeding.
v.
Epithelial tissue will start developing after 24-48 hours and will close in 45 days
Module 3
Noninvasive Positive Pressure Ventilation
1. Define noninvasive positive pressure ventilation.
a. Ventilatory support without using an invasive artificial airway
b. Uses a mask to ventilate the patient
c. Reduces intubation rates
d. Uses:
i.
Reducing respiratory rate
ii.
Reducing CO2 levels - BiPAP is go to for this
iii.
Increasing oxygen levels
iv.
Correcting pH
v.
Increasing the volume of each breath.
2. Explain the indications and contraindications for noninvasive positive pressure
ventilation (NPPV).
a. Indications
i.
Acute respiratory failure
ii.
Heart failure
iii.
COPD exacerbations
iv.
Obstructive sleep apnea
v.
Hypoventilatory syndrome
vi.
Acidosis (moderate) or hypercapnia
b. Contraindications
i.
Agitation
ii.
Cardiac/respiratory arrest
iii.
Excessive oral secretions
iv.
Inability to maintain a patent airway
3. Differentiate between continuous positive pressure ventilation (CPAP) and bilevel
positive pressure ventilation (BiPAP).
a. CPAP
i.
Used for OSA
ii.
It delivers a continuous positive airway pressure above atmospheric
pressure which keeps the airway patent
iii.
For example, if CPAP is 5 cm H2O, airway pressure during expiration is 5
cm H2O. During inspiration, we generate 1 to 2 cm H2O of negative
pressure. This reduces airway pressure to 3 or 4 cm H2O.
iv.
Usually ordered at 5-15cm H20
v.
Increases work of breathing because you have to forcibly exhale against
CPAP
vi.
Risk of aspiration
b. BiPAP
i.
Set to deliver a set amount of pressure during the inspiratory phase of
each breath (IPAP) and then maintains a low positive pressure at the end
of expiratory phase (EPAP/PEEP)
ii.
The difference between IPAP and EPAP reflects the amount of pressure
support ventilation provided to the patient
iii.
IPAP (supports the breath): 5-20 cm H20
iv.
EPAP (supports oxygenation): 5-15 cm H20
4. Describe the difference between nasal and orofacial airway.
a. Nasal
i.
More common in home setting
ii.
Best suited for patients who are cooperative
iii.
Causes less claustrophobia
iv.
v.
vi.
vii.
Allows for speaking, drinking, coughing, and secretion clearance
Decreased aspiration risk
Generally, better tolerated
Cons
1. Associated with an increased risk of air leaks from the mouth
2. Limited effectiveness in patients with nasal deformities or blocked
nasal passages
b. Orofacial
i.
Best suited for less cooperative patients
ii.
Indicated for patients with a high severity of illness
iii.
Better for patients with mouth-breathing or pursed-lip breathing
iv.
Generally, provides more effective ventilation
v.
Cons
1. Increases claustrophobia
2. Hinders speaking and coughing
3. Increased aspiration risk
5. Discuss nursing management of a patient receiving NPPV.
a. Perform focused respiratory and perfusion assessment
b. Encourage coughing and deep breathing
c. Elevate HOB
d. Assess for air leaks
e. Inspect the skin
Mechanical Ventilation
1. Describe the indications for mechanical ventilation.
a. Apnea
b. Inability to breathe or protect the airway
c. Acute respiratory failure
d. Severe hypoxia
e. Respiratory muscle fatigue - ALS; people with neuromuscular disorders
f. Goals:
i.
Maintain alveolar ventilation appropriate for the patient’s metabolic needs
ii.
Correct hypoxemia and maximize oxygen transport
iii.
Rest respiratory muscles
g. Main method is positive pressure ventilation
h. 2 categories
i.
Volume - predetermined tidal volume is delivered
ii.
Pressure - tidal volume varies based on several factors (pressure,
compliance, resistance)
2. Explain common ventilator settings and alarms for mechanical ventilation.
a. RR - 12-20 breaths per minute
b. TV - 6-8mL/kg
c. FiO2 - 21-100%
d. I/E ratio - normally set at 1:2 to mimic normal breathing; respiratory distress - 2:1;
COPD - 1:3
e. Settings based on - ABGs, ideal body weight, current physiologic state, level of
consciousness, respiratory muscle strength
f. Alarms
i.
High pressure limit
1. Secretions/coughing, excess water in tubing, biting ETT,
bronchospasm, ETT or tubing kinked, decrease compliance (pulm.
edema), patient/ventilator asynchrony - fighting the ventilator; give
them sedation
ii.
Low pressure limit
1. Disconnection, self-extubation, ETT/trach cuff leak
3. Differentiate between the different modes of mechanical ventilation.
a. Assist Control
i.
Every breath is supported by the ventilator
ii.
Delivers a preset tidal volume with a preset rate
iii.
Initial rate 12-14 breath per minute
iv.
Patient can breathe faster but no slower and will receive that preset tidal
volume for every breath
v.
Tidal volume is set between 6-8 ml/kg
vi.
Set PEEP (depends on patient status)
vii.
Can result in hyperventilation
viii.
May lead to deconditioning of respiratory muscles
ix.
Provides maximal amount of support
x.
How to report?
1. Respirations/tidal volume/PEEP/FiO2
b. Pressure Support
i.
Positive pressure only applied during inspiration and is used with the
patient’s spontaneous respirations; patient makes their own rate and TV
ii.
Patient must be able to initiate a breath
iii.
How to report?
1. Pressure/PEEP/FiO2
2. Pressure between 5 and 14
iv.
Used during weaning
v.
Risk of hypoventilation and apnea - not used during respiratory distress
vi.
Advantages
1. Increased patient comfort, decreased WOB (because inspiratory
efforts are augmented), decreased O2 consumption (because
inspiratory work is reduced), and increased endurance
conditioning (because the patient is exercising respiratory
muscles)
c. Synchronized Intermittent Mandatory Ventilation (SIMV)
i.
Delivers a preset tidal volume at a preset frequency in synchrony with the
patient’s spontaneous breaths
ii.
iii.
Can breathe spontaneously and self generate TV and RR in between
Benefits
1. Patient-ventilator synchrony, lower mean airway pressure, and
prevention of muscle atrophy as the patient takes on more of the
WOB (must have respiratory drive)
iv.
Used to wean patients off ventilation
4. Discuss interprofessional management of the mechanically ventilated patient.
a. Complications
i.
Cardiovascular
1. Hypotension - decrease in CO causes decrease in BP
ii.
Pulmonary
1. Barotrauma
a. Increase airway pressure distends the lungs and ruptures
overdistended alveoli
2. Pneumothorax
a. Air escapes into the pleural space from alveoli or
interstitium and become trapped, this increases pleural
pressures and collapses the lung
b. May need immediate intervention
3. Pneumomediastinum
a. Rupture of alveoli into the lung interstitium
4. Alveolar Hypoventilation - insufficient ventilation
a. Caused by inappropriate ventilator settings, leakage of air,
obstruction
b. Caused by a low tidal volume or respiratory rate
c. Can lead to atelectasis (increase PEEP, coughing, move
around), hypoventilation and respiratory acidosis
5. Alveolar Hyperventilation
a. Caused by overventilation
i.
Respiratory rate or tidal volume is too high
b. Leads to respiratory alkalosis - breathing off CO2
c. Common causes: hypoxemia, pain, fear, anxiety
6. Ventilator Associated Pneumonia (VAP)
a. Caused by contaminated respiratory equipment,
inadequate hand hygiene, patients’ inability to cough or
clear secretions
iii.
Neurologic System
1. Increase ICP - causes impairment in venous return
iv.
Gastrointestinal system
1. Highest risk for developing stress ulcers
a. Reduced cardiac output may contribute to ischemia of the
stomach and intestinal mucosa
b. Need stress ulcer prophylaxis
i.
Proton pump inhibitors (Prevacid, Protonix)
5.
6.
7.
8.
2. Decreased peristalsis
a. Risk for constipation
b. May need a bowel regimen - stool softener (Docusate),
Cena, Miralax, enema
Describe the importance of mouth care in a ventilated patient.
a. Brush teeth BID
b. Oral swabs with 1.5% hydrogen peroxide
c. .12% chlorhexidine oral rinse
d. Mouth moisturizer
e. Oropharyngeal suctioning
f. Trach care
Suction when?
a. Visible secretions
b. Respiratory distress
c. Coughing
d. Increase RR
e. Decrease sat
f. Breath sounds, which one? - coarse crackles
Monitoring
a. ABGs, SpO2, respirations (rate, rhythm, use of accessory muscles)
b. Signs of hypoxemia - cyanosis, tachycardia, pallor, restlessness
c. Assess ventilator settings q4h
Analyze the weaning protocol in a patient on mechanical ventilation
a. Process of trying to reduce ventilator support
i.
Varies patient to patient
ii.
Is the underlying cause resolved or improving?
iii.
Adequate oxygenation?
iv.
Are they hemodynamically stable?
v.
Are they able to initiate respirations?
vi.
Any other factors? - secretions, LOC
vii.
Must have own RR and TV
b. Respiratory therapy will complete a Spontaneous Breathing Trial (SBT)
i.
Lasts 30 minutes up to 120 minutes
ii.
Should be completed daily
iii.
Typically placed on PSV with low levels of PEEP and FiO2
iv.
If patient tolerates then place on trach collar/extubation
v.
If unable to tolerate:
1. Place back on initial ventilator settings
2. Reassess the next day
Pneumonia
1. Discuss risk factors for developing pneumonia.
a. Three ways organisms reach lungs:
i.
Aspiration from nasopharynx or oropharynx
ii.
Inhalation of microbes present in the air
iii.
Hematogenous spread from primary infection elsewhere in body
b. Risk factors
i.
Age > 65 years old, bedrest, malnutrition, upper respiratory infection,
tracheal intubation, chest/abdominal surgery, altered level of
consciousness - aspiration, immunosuppression, smoking, IV drug use,
living in long-term care facility
2. Distinguish between the two main types of pneumonia.
a. Community acquired
i.
Occurs in patients who have not been hospitalized or resided in a longterm care facility within 14 days of the onset of symptoms.
ii.
Common pathogens: Legionella pneumophila, MRSA, S. pneumoniae
b. Hospital acquired
i.
Occurring 48 hours or longer after admission and not intubating at time of
hospitalization
ii.
Ventilator Associated Pneumonia (VAP): Occurring more than 48 hours
after endotracheal intubation
iii.
Common pathogens: Pseudomonas aeruginosa, E. coli, Klebsielle
pneumoniae, Acinetobacter
3. Relate assessment and diagnostic findings to the underlying pathophysiology of
pneumonia.
a. Expanded CURB-65
i.
Identify the level of risk
1. 1 point for each of the following
2. C: Confusion
3. U: BUN > 20 mg/dL
4. R: Respiratory rate ≥ 30 breaths/min
5. B: Systolic Blood pressure < 90 mmHg
6. 65: ≥ 65 years old
7. LDH: > 230 µ/L - enzyme in every cell; released into blood during
cell injury or death
8. Albumin: < 3.5 g/dL
9. Platelet count: < 100
ii.
0-2 is low risk: outpatient
iii.
3-4 is intermediate risk: inpatient
iv.
5-8 is high risk: ICU
b. Pneumonia Severity Index - higher class, higher acuity
c. Assessments
i.
Coarse and fine crackles, diminished sounds
ii.
Egophony - say E but it sounds like A
iii.
Fremitus - say 99 and palpate back; they will have consolidation (alveoli
filled with water) so you can’t feel the vibrations
iv.
Accessory muscle usage, tachypneic
4.
5.
6.
7.
d. Diagnostics
i.
ABGs, H&P, chest xray, sputum culture and sensitivity, CBC
(WBCs>15,000 with bands), blood culture and sensitivity, C reactive
protein (differentiate from HF or RF), procalcitonin (bacterial)
ii.
Start antibiotics before results of culture!
Types of pneumonia
a. Aspiration
i.
Abnormal entry of material from the mouth/stomach into the trachea/lungs
ii.
HAP or CAP
b. Necrotizing
i.
Rare complication of bacterial lung infection
ii.
Usually CAP
c. Opportunistic
i.
Caused by microorganisms that do not normally cause disease
ii.
Pneumocystis jiroveci pneumonia (PCP) - HIV or immunosuppression
iii.
Cytomegalovirus (CMV) pneumonia
Manifestations
a. Cough
i.
Non-productive
ii.
Productive
1. Note color, amount, odor
2. Green, white, rust-color, purulent
b. Fever
c. Dyspnea
d. Tachypnea/ Tachycardia
e. Pleuritic chest pain - does pain get worse when you take a deep breath
f. Careful with elderly-may not exhibit typical symptoms; may have anorexia,
stuporous
Explain the importance of antimicrobial stewardship in a patient receiving antibiotic
therapy.
a. A national priority - aims to promote and monitor the judicious use of
antimicrobials, lead to reduced health care costs and most important, better
patient outcomes
b. Steps
i.
Ensure pertinent information about antibiotics is available at the point of
care
ii.
Question the antibiotic administration route
iii.
Reassess antibiotic therapy in 2 to 3 days
iv.
Review antibiotic therapy when your patient develops a new C. difficile
infection
v.
Reconcile antibiotics during all patient-care transitions
Identify appropriate nursing interventions for the individual diagnosed with pneumonia.
a. Drug therapy
i.
Empiric therapy started based on likely pathogen
ii.
b.
c.
d.
e.
f.
CAP (minimum 5 days of treatment)
1. Outpatient tx: macrolide, (e.g., azithromycin, clarithromycin, or
erythromycin) if previously healthy; if co-morbidities and recent hx,
add respiratory fluoroquinolone, (e.g., levofloxacin, moxifloxacin,
gemifloxacin)
2. Inpatient tx: Dependent on if non-severe/ severe; MRSA or
Pseudomonas
a. respiratory fluoroquinolone, macrolide and B-lactam, (e.g.,
cefotaxime, ceftriaxone, and ampicillin)
iii.
Xenleta (lefamulin)-FDA approved 2019
iv.
HAP
1. Dependent on organism
2. If not MDRO then:
a. Ceftriaxone or Levofloxacin or ampicillin/sulbactam or
Ciprofloxacin
3. If MDRO then:
a. Can use a Cephalosporin (Cefepime) or carbapenem
(Meropenem/Imipenem) or Beta-lactam (Piperacillintazobactam)
b. plus a fluroquinolone (Ciprofloxacin) or aminoglycoside
(Amikacin)
Hydration and nutrition
Analgesics and antipyretics
Oxygen as needed
Mobility
Pneumococcal and flu vaccines
i.
Initial Vaccination:
1. Persons ≥ 65 yrs, smokers, or individuals with long-term chronic
health problems aged 2-64 yrs
ii.
2. Persons with lowered immune systems 2-64 yrs
3. Persons living in chronic care facility
Re-vaccination:
1. Persons ≥ 65 yrs who received vaccine ≥ 5 yrs previously and
were < 65 at time.
2. One-time revaccination for persons 2-64 lowered immune systems
if ≥ 5 yrs since last vaccination.
iii.
8. Discuss health promotion in the acute care setting with a patient diagnosed with
pneumonia.
a. Medical asepsis, monitor response to treatment, early mobilization, position
changes (bad lung up), prevent aspiration, airway clearance
b. Preventing pneumonia - VAP specific
i.
Use Positive Pressure Ventilation
ii.
Limit Ventilator Days – assess need daily
iii.
Limit sedation – stop sedation at least one time daily
iv.
HOB elevation 30-45 degrees
v.
Ventilator equipment changes only when soiled
vi.
Continuous removal of subglottic secretions
vii.
Twice-daily oral hygiene with chlorhexidine
c. Evaluation
i.
Clear breath sounds
ii.
Normal breathing patterns
iii.
No signs of hypoxia
iv.
Normal chest x-ray
v.
Normal WBC count 5-10
vi.
Absence of complications related to pneumonia
Acute Respiratory Failure
1. Discuss the etiology and clinical manifestations of hypoxemic and hypercapnic acute
respiratory failure.
a. Occurs when oxygenation, ventilation or both are inadequate
b. Not a disease but aa representation of lung function
c. Causes
i.
ARDS
ii.
COPD
iii.
Pulmonary edema
iv.
Pneumonia
v.
Neuromuscular issues (MS, ALS)
d. Causes of V/Q mismatch
i.
Increased secretions in the airways (COPD) or alveoli (Pneumonia)
ii.
Bronchospasms (asthma)
iii.
Pain
1. Activates the stress response so will increase baseline metabolic
state
iv.
Atelectasis
v.
Pulmonary embolism
1. Ventilation without perfusion
e. Hypoxemic
i.
PaO2 is less than 60 mmHg when receiving O2 concentrations of 60% or
more
ii.
Main problem is oxygenation
iii.
Edema and inflammation present; alveoli may also be filled with exudate
(shunt)
iv.
Causes - pulmonary embolism, ARDS, pneumonia
v.
Etiology
f.
1. V/Q mismatch - usually 1:1 ratio at middle
a. Apex - higher ratio; more ventilation than perfusion
b. Base - lower ratio; more perfusion than ventilation
2. Shunt - extreme form of V/Q mismatch; blood exits heart without
gas exchange
a. Intrapulmonary - pneumonia
b. Anatomic - VSD
3. Diffusion limitation - gas exchange across the alveolar-capillary
membrane is compromised by a process that damages or
destroys the alveolar membrane or affects blood flow through the
pulmonary capillaries
a. Pulmonary fibrosis, interstitial lung disease, ARDS,
pulmonary edema
b. Classic sign is hypoxemia with exercise
4. Alveolar hypoventilation - obstructed airway
vi.
Treatments
1. V/Q mismatch - oxygen therapy
2. Shunt - mechanical ventilation with PEEP and FiO2
vii.
Can lead to anaerobic metabolism then lactic acid then metabolic
acidosis (not enough bicarb to deal with lactic acid) then cell death
Hypercapnic
i.
Occurs when PaCO2 is greater than 50 mmHg with acidemia
ii.
Main problem: CO2 removal (ventilation)
iii.
Etiology
1. CNS - depressed drive to breathe (opioids)
2. Neuromuscular - respiratory muscle weakness
3. Chest Wall abnormalities - flail chest, kyphoscoliosis
4. Problems of the airway and alveoli - asthma, COPD, cystic fibrosis
iv.
Tolerated better because it takes longer
Hypoxemia
Hypercapnia
Dyspnea
Dyspnea
Tachypnea
Tripod position
Nasal Flaring
Pursed-lip breathing
Use of accessory muscles
Bradypnea
Decreased SpO2 (<90%)
Rapid rate with shallow breathing
Cyanosis (late)
Decreased tidal volume
Change in mental status
2. Analyze and interpret diagnostic findings common in acute respiratory failure.
3. Explain the interprofessional management of the patient with acute respiratory failure.
a. Respiratory therapy
i.
Oxygen therapy
1. Administer at lowest possible FiO2
2. Observe the patient’s response to oxygen
3. Several different modalities available but want to keep PaO2 at 60
mmHg or higher and SaO2 > 90%
a. Want to avoid oxygen toxicity
b. Careful with patient with chronic hypercapnia
4. Start with nasal cannula (2-6L/min)
a. Then may transition to high flow nasal cannula (60L/min),
CPAP, BiPAP or mechanical ventilation
b. Mobilize secretions
i.
Coughing, HOB at 30 degrees, good lung down, chest pt, suctioning as
needed, hydration
c. Drugs
i.
Reduce airway inflammation
1. Corticosteroids
a. IV - Methylprednisolone (Solu-Medrol) IV - fastest
2. Inhaled - Flovent and Pulmicort; takes 4-5 days
ii.
Reduce bronchospasm
1. Short-acting bronchodilator
a. Albuterol
iii.
Relieve pulmonary congestion
1. Diuretic
a. Furosemide (Lasix) - monitor potassium; may need to give
supplement
iv.
Treat the underlying infection
1. IV antibiotics
v.
Reduce anxiety and pain - can cause an increase in O2 consumption;
start at lowest dose possible
1. Benzodiazepines
a. Lorazepam (Ativan)
2. Opioids
a. Morphine
vi.
Reduce restlessness
1. Look for treatable causes of restlessness
a. Hypoxemia
b. Pain
c. Delirium
4. Describe measures to prevent and
manage complications of acute
respiratory failure.
Module 4
Thoracic Surgery/Chest Tubes
1. Discuss indications for thoracic surgery.
a. Removal of empyema, abscess, chronic effusions, tumors/masses
b. Tracheal/esophageal resection
c. Lung reduction (emphysema)
d. Hiatal hernia repair
e. Types
i.
Thoracotomy - incision into chest
1. Median sternotomy - cardiac surgery
2. Lateral thoracotomy
a. Posterolateral incision (most common)
b. Anterolateral incision
ii.
Segmentectomy - biopsy
iii.
Lobectomy
iv.
Pneumonectomy - entire lung
2. Describe appropriate preoperative and postoperative care for patients undergoing
thoracic surgery.
a. Preop
i.
CBC (white count can increase right after surgery without infection) H&H, BUN and creatinine (don’t want dehydration), electrolytes
(potassium, sodium, calcium and magnesium), EKG, chest xray
ii.
Encourage smoking cessation
iii.
Major aspects of teaching:
1. Pulmonary hygiene
2. Pain Control
3. Chest Tubes - temporary; will come out in 2-3 days
4. ROM
Position patient on side with arm extended - watch for pressure points
iv.
b. Intraop
i.
VATS
ii.
Open thoracotomy
c. Postop
i.
Assessment
1. Vital Signs - q15mins for the first hour
2. Pain Control
3. Pulmonary Hygiene
4. OOB
5. Fluid & Electrolytes - 125mL/hour
6. Incision/Dressing
7. Chest Tubes
8. Patient Education
3. Compare and contrast pathophysiology, clinical manifestations, and interprofessional
management of individuals with chest trauma and pleural effusions.
a. Pleural effusion
i.
Fluid buildup between pleura
ii.
Causes - metastatic , traumatic, HF, fluid overload
iii.
Manifestations
1. Dyspnea, SOB, crackles, fever, breath sounds decreased
iv.
Diagnosis - chest xray; CT scan
v.
Treatment - thoracentesis; treat underlying cause
b. Trauma
i.
Rib fractures - ribs 5-9 most common
ii.
Goal is to decrease pain and prevent atelectasis
iii.
Pneumothorax - chest pain, dyspnea, tachycardia, cyanosis
iv.
Hemothorax - won’t really know until chest tube is in
1. 3 sided dressing
2. Chest tube
v.
Flail chest
1. 2 or more ribs broken in 2 spots each; ribs go in opposite direction
of the rest of the rib cage
vi.
Tension pneumothorax
1. Air gets into pleural cavity and can not escape
2. Respiratory and cardiac arrest, hypotension, tachycardia, JVD due
to decreased CO
4. Review the pre- and post-procedure care of patients undergoing a thoracentesis.
a. Orthopneic position - leaning over table
b. Assess for pneumothorax after procedure
c. Breath sounds should increase
5. Describe the purpose, function and nursing responsibilities related to chest tubes and
various drainage systems.
a. Chest Tube placement
i.
5th anterior or midaxillary line - less muscle dissection
ii.
Can also be
1. 2nd ICS, midclavicular line – simple pneumo, post thoracic
surgery
a. Air is lighter than liquid and tends to rise to top
2. 5th-6th ICS, midaxillary line - For hemothorax, empyema, Post
thoracic surgery
a. Fluid heavier and tends to go to lowest level…chest tubes
iii.
Insertion is a clean technique
b. Drainage systems
i.
1st - collection chamber
1. Fluid collection; air vents to 2nd compartment
2. Monitor fluid for amount, color and odor
ii.
2nd - water-seal chamber
1. Contains 2 cm of water; acts as one-way valve; air goes in,
bubbles out, but can’t go back to patient
2. Bubbles at first as air is being released; may also bubble with
coughing/sneezing
3. Tidaling is normal
iii.
3rd - suction control chamber
1. Uses column of water to control suction from regulator
2. Can also be dry suction - not as loud
3. Usual suction order is -20cm H2O
c. Assessment
i.
Assess whether CT is to suction (amount) or simply underwater seal
ii.
Assess fluctuation (aka tidaling), air leak, drainage
iii.
Assess presence of subQ emphysema or crepitus - rice krispies
iv.
Assess dressing – change daily or per hospital protocol
v.
Keep container below insertion site
d. Amount of drainage
i.
Report greater than 200mL/hr in first hour and 100mL/hr after
e. Removal
i.
Criteria: little/no drainage, no air leak, absence of hemo- or pneumothorax
ii.
Premedicate for pain relief
iii.
Patient does valsalva maneuver
iv.
Occlusive 2 sided dressing - seals as they breathe in to avoid
pneumothorax and releases pressure as they breathe out
f. Troubleshooting
i.
ii.
iii.
If unit breaks, place distal end of chest tube in 2cm sterile water until
replaced
Do not clamp chest tubes unless changing drainage unit
Chest tube pulls out of chest - 3 sided dressing
Arthritis
1. Compare and contrast the manifestations and underlying pathophysiology of
osteoarthritis and rheumatoid arthritis.
a.
Parameter
RA
OA
Age at onset
Young to middle age
Usually older than 40
Gender
Female-to-male ratio is
2:1 or 3:1. Less marked
sex difference after age
60.
Females 2:1 after age
60; except for traumatic
arthritis, men less
affected until age 70 or
80.
Weight
Lost or maintained
weight
Often overweight or
obese
Disease
Systemic disease with
exacerbations and
remissions.
Localized disease with
variable, progressive
course.
Pain
Stiffness lasts 1 hr to all
Stiffness occurs on
arising but usually
subsides after 30 min.
Pain gradually worsens
with joint use and
disease progression,
relieved with joint rest
but may disrupt sleep.
day and may ↓ with use.
Pain is variable, may
disrupt sleep.
Effusions
Common
Uncommon
Nodules
Present, especially on
extensor surfaces.
Heberden’s (DIPs) and
Bouchard’s (PIPs)
nodes.
Synovial
WBC count 5000–
WBC count <2000/μL
(mild leukocytosis);
normal viscosity.
60,000/μL with mostly
neutrophils; ↓ viscosity.
Clear
Straw colored
RF
RF positive
RF negative
Labs
↑ In ANA titer likely.
Positive anti-CCP in
60%–80% of patients
(more important than RF
factor)
ANA negative
Anti-CCP negative
Transient elevation in
ESR related to synovitis
↑ ESR, CRP indicative
of active inflammation.
Xray
Joint space narrowing
and erosion with bony
overgrowths, subluxation
with advanced disease.
Osteoporosis related to
decreased activity,
corticosteroid use.
Joint space narrowing,
osteophytes,
subchondral cysts,
sclerosis.
b. Manifestations
i.
OA
1. Mild discomfort to joint pain that worsens with use
2. Early on, pain relieved by rest; later pain with rest/sleep
3. Pain may be worse as barometric pressures fall (before inclement
weather)
4. Pain may be referred (groin, buttock, medial thigh/knee)
5. Crepitation
6. Bow legged appearance
ii.
RA
1. Fatigue, anorexia, weight loss, generalized stiffness that then
becomes more localized
2. ? Precipitating event - stress, after pregnancy
3. Inflamed joints; tender, painful, warm to touch; limitation of motion,
increases with motion
4. Tenosynovitis- inflammation of tendon and its sheath
5. Deformity and disability, atrophy of muscles and destruction of
tendons – Subluxation, ulnar drift, swan neck, boutonniere
deformities
6.
2. Describe the interprofessional management of patients with arthritis focused on joint
protection and alignment, exercise, nutrition, pain management, and medications.
a. OA
i.
Weight loss
ii.
Reduction of occupation hazards
iii.
iv.
v.
vi.
vii.
b. RA
i.
ii.
iii.
iv.
c. Both
i.
ii.
iii.
Good posture and body mechanics
Muscle strengthening
Smoking cessation
Rest during acute inflammation
1. Do not immobilize for more than a week
Drugs
1. Intraarticular corticosteroid injections
2. Hyaluronic acid (HA) – (not supported by professional medical
organizations)
a. Viscosupplementation (does not reverse OA)
b. Injected into joint space (3-4 weekly injections)
3. DMOADs (disease modifying osteoarthritis drugs – research
ongoing on strontium ranelate)
Plan care around morning stiffness
Balance rest and activity
Rest during acute inflammation
1. Do not immobilize for more than a week
Drugs
1. Disease modifying anti-rheumatic drugs (DMARDS)
a. Methotrexate (Rheumotrex), cyclosporine, leflunomide
b. Antimalarials, e.g., Hydroxychloroquine (Plaquenil)
c. Biologic Response Modifiers (BRMs): anti TNF, e.g.,
Remicade (infliximab), Enbrel (etanercept), Humira
(adalimumab), Cimzia (certolizumab pegol) and Simponi
(golimumab).
2. Monotherapy started early, combos later
3. Precautions
a. Risk for GI irritation, rash, bone marrow depression
b. Monitor liver function, bone marrow function, creatinine at
a minimum (esp. Methotrexate)
c. Vision checks and sunscreen (hydroxychloroquine –
Plaquenil)
d. Administer PPD and perform CXR before starting
e. Monitor for infection
f. Avoid live vaccines for those on Biologic Response
Modifiers
g. Report bruising, bleeding, persistent fever, etc.
h. Sub q injections for some drugs – pt education
Joint protection - modify activities
Assistive devices
Prevent deformity
1. Functional positioning - Body alignment while in bed
a. small, flat pillow under head;
b. no pillows under knees; lying prone 30” twice daily
2. Light weight splints
iv.
ROM - limit reps with inflammation
v.
May have weight gain with steroids or secondary to pain-induced
immobility
vi.
Ice for acute inflammation -10-15” for exacerbation
vii.
Heat therapy for stiffness
1. 20” for chronic pain
2. Hot packs, whirlpool baths,
3. Paraffin wax baths
viii.
Environment modifications
ix.
Sexual counseling
x.
Supplements
1. Glucosamine is an amino sugar that the body produces and
distributes in cartilage and other connective tissue.
2. Chondroitin sulfate is a complex carbohydrate that helps cartilage
retain water.
xi.
Drugs
1. Mild to moderate joint pain
a. Acetaminophen (1000 mg every 6 hours)
b. Topical agent (e.g., capsaicin cream [Zostrix])
c. OTC creams (BenGay, ArthriCare)
d. Topical salicylates (e.g., Aspercreme)
2. Moderate to severe
a. More severe pain and/or risk for bleeding concern with
NSAIDS – may use Tramadol, weak opioid
b. Nonsteroidal antiinflammatory drug (NSAID)
i.
Ibuprofen (Motrin-200 mg 4x/day), Misoprostol
(Cytotec), a prostaglandin to decrease GI side
effects
ii.
Arthrotec (combination of misoprostol and NSAID)
iii.
Diclofenac (Volteran) gel
c. COX-2 inhibitors (also NSAIDS) - protects the stomach
more
i.
celecoxib (Celebrex)
ii.
naproxen (Alleve)
3. Discuss the general postoperative care of the patient having joint replacement surgery.
a. Arthroscopic surgery
i.
For patients <55 years of age
ii.
Delay need for knee replacement
iii.
Remove debris
b. Arthroplasty
i.
Total joint replacement
Traditional approach – 20-30 cm incision with staples and sutures
1. Semipermeable dressing rather than tape
2. Drain to prevent hematoma formation and allow for autologous
blood donation within 6 hours
iii.
Minimally invasive approach – 10 cm incision
1. Limited view of joint
2. Shorter recovery with fewer complications
iv.
Outpatient surgery for some pts
v.
Hospital average stay 3 days without complications; protected ambulation
and therapy for 6 weeks; return to full activities may take 6 months.
c. Post op
i.
Vitals
ii.
Pulmonary hygiene
iii.
Short term antibiotics
iv.
Pain management
v.
Anti inflammatories
vi.
Stool softener
vii.
PT consult
viii.
VTE preventions
ix.
Peripheral perfusion
x.
Measure drainage - drain removed post op day 1
d. Hip surgery
i.
Abduction of hip
ii.
Avoid hip flexion - HOB no more than 45 degrees first night
e. Knee surgery
i.
Continuous Passive Motion (CPM)
f. Dislocation is an emergency
i.
Pain, loss of function
ii.