PREOPERATIVE NURSING
● Role of the nurse: Assessing and teaching data
○ Assess patient to make sure they are healthy enough to go into surgery
■ What should you assess the patient for? Risk factors that could put the patient at
a greater risk for complications.
○
Teach patient what they should expect or see when they wake up
■ Lines, drains, splints, etc.
■ Things to do to prevent complications after surgery.
■
Pain
Assessment:
● Risk factors:
● Anxiety – always ask about anxiety
● Allergies:
○ Latex: food: avocado, bananas, chestnuts, eggs, kiwi, potatoes, peaches, Hx of hay fever.
Hx of reactions that suggest a higher risk of having allergies to latex, food, etc.
○ A patient with a hx of any allergic reactions has a greater potential for hypersensitivity
reactions to drugs given during anesthesia.
● Iodine: shellfish allergy; iodine is in IV contrast
● Medications: Assess for herbal supplements, dietary, recreational, otc, etc.
● Patient’s baseline: important to know how they are before they go into surgical procedure.
○ Vital signs
○ Blood sugar
○ Lung sounds
● PMH: (past medical history)
○ Health problems
○ Any issues w/ prior surgeries
○ Personal or family issues w/ anesthesia
Risk factors for surgery:
● Increased age: older age = more complications they have .
● Health status/comorbidities
○ DM: Delayed wound healing could cause infections
■ Stress on the body = increased blood sugar
○ HTN: more at risk for a stroke
■ If risk is very high, NO surgery will happen.
○ A-Fib: Which medications are they on? blood thinners, they have irregular heart beats.
■ Notify doctor if they took their blood thinner, because they will be at risk for
bleeding out. Patient should be off blood thinner 72 hours to week prior to
surgery
○ COPD: Not getting enough oxygen. Poor ventilation/ lung expansion/ oxygenation.
○ Asthma: @ risk for anaphylactic reaction and infections (UTIs)
○ Hx of smoking/Smoking: Causes respiratory problems. Lungs don’t fully expand; you
retain secretions which cause other problems.
○ CKD: May cause fluid volume overload due to isotonic solutions administered.
■
May not be able to filter anesthesia as quickly → delays recovery
○
Anxiety: Fear of death, fear of pain and discomfort.
■ If pt states im going to die → do not send them to surgery.
■ Anxiety can be decreased by giving information about what to expect. Teaching,
address concerns, if they want the procedure explained again call the surgeon to
explain the procedure.
○
Obesity: Increased dosage of anesthetics → takes longer to clear out of the body →
delays recovery.
■ Obese patients metabolize anesthesia differently, they hold onto it and recovery
takes longer.
●
Medications:
○ Recreational drugs - stress that substance use may affect the type and amount of
anesthesia the pt will need.
○ Blood thinners - Causes an increased risk for excessive bleeding. Patients may have a
hard time clotting.
■ Types: Coumadin, ASA, Plavix, Aleve, ibuprofen, Aspirin, warfarin. Must be off
them from 72 hours to 1 week prior to surgery.
○ Insulin: need to know if the patient took insulin prior to surgery
○ Steroids :
■ DO NOT ABRUPTLY STOP STEROID. They are tapered.
■ Work in the adrenals, if abruptly stopped the kidneys can shut down
■ What do steroids do to blood sugar? Increase it.
●
Baseline: to compare results to intraop and post op
○ GI: motility sounds
○ VS (BP,O2, T, RR, HR): What are pt's norms? VS ARE THE KEY TO
EVERYTHING.
■ Which 2 are most important: BP and O2
○ Lung sounds:we want to know how they are before they go into the procedure.
○ Blood sugar:we want to know how they are before they go into the procedure.
○ Physical assessment
○ Labs
Labs - NEED TO KNOW ALL
● WBC: (4.5 - 10)
○ Indicates infection.
■ (at more risk for infection/ immunocompromised if lower than 4.5); (if too high
they have an infection).
● H/H: (9/25)
○
Indicates low fluid volume in body.
■ Hgb – anemic/circulating blood volume, HCT – anemic/circulating blood
volume.
● Plts -> (150 - 400)
○ Assesses if blood will clot fast enough or not/ Indicates risk for bleeding.
■ (plt level too high = risk for clots) (plt levels too low= risk for bleeding)
● BUN/ Creatinine (8-25; 0.6 - 1.3)
○ Assesses kidney function
● Electrolytes:
○ K: 3.5-5.0
○ Na: (135-145)
○ Cl: (98-107)
● PT: (9.6 - 11.8)
- What does this lab assess? At risk for bleeding
● PTT: (20-36)
- What does this lab assess? At risk for bleeding
● INR: (2-3 if on coumadin)
- What does this lab assess? At risk for bleeding
Pt, PTT, INR – If high, they are at risk for bleeding. If low,they are at risks for clots. Opposite of
platelets.
Low PT and PTT → means blood will clot faster; you will have more clots
If PT is 40 > your blood will clot slowly, like in 40 seconds.
Patient education:
● Expectations: PCA pump, tubes, dsrg, catheters, NGT drains, sutures
○ Tell patient where they will be.
○ Start teaching about post op exercises
○ Teach them about pain, sutures, etc.
● Pain medication: CNS depressant = respiratory depression
- Monitor O2 saturations
●
Post-op exercises:
- Ambulation, lovenox, SCD’s, compression socks, IS
Prevention of complications:
● Atelectasis: IS, TCDB
● DVT/PE: leg exercises, SCDs, TED hose
● Mobility: turning (prevent skin breakdown), walking (incr. GI motility)
○ Better outcomes and faster recovery, reduce anxiety and decrease post – op
complications.
Pre-op checklist:
Informed consent
● Surgeon: Responsible for explaining the procedure, complications, and teaching risk and benefits
●
●
Nurse is responsible for obtaining signature
○ Make sure patient understands what the doctor told them
Contraindications to patient signing informed consent:
- On sedation meds
- Deficient knowledge
- minor
Pre-op checklist: Making sure the patient is safe enough to go to the operating room. Identify risk
factors.
- Id bracelet
- Allergy band
- Baseline VS
- Labs
- H&P
- Signed informed consent
- Blood type and crossmatch
- NPO status
- Valuables, dentures, glasses, contacts
INTRAOPERATIVE NURSING
Role of nurse:
● Safety and comfort of patient:
○ Proper padding: (elbows, heels, bony prominences) - take in account of how long the
procedure will be.
■ They could have skin breakdown if adequate/proper padding is not supplied.
○ Proper alignment and positioning of the patient
○ Strapped in safely: to prevent nerve damage. We don’t want patients to fall off the
operative table during surgery.
Time out: The most important thing we do in surgery
● The final time to make sure everything is correct
● You know everything you can about the patient’s health - last time to catch an error
● MD makes site in pre-op phase, but we (the nurse) need to ensure the right site is marked prior to
procedure
● Informed consent should be reviewed, H&P, allergies need to be there
● Done prior to procedure and right before beginning the procedure
Anesthesia:
● Stage 1: DROWSY to UNCONSCIOUS
○ Difficult to arouse
○ Inhalation agents (I.e. succinylcholine)
●
Stage 2: Known as excitement phase - think of muscle excitement
○ Muscles get tense
○
○
○
Shallow to irregular breathing: Getting ready to begin the intubation process
Pt may vomit so ...
■ Place them on lateral side so they do not choke on their vomit
Ketamine – you must have a quiet environment for this agent to be administered, if
not the pt can have horrible hallucinations.
●
Stage 3 –reflexes lost - paralysis
○ Muscles loosen
○ breathing regular again - b/c patient is intubated
○ usually dlt adjuncts
○ vitals are depressed
●
Stage 4: all reflexes lost
- complete respiratory depression. Tubed and vented.
- Completely ventilated - dependent on us
- neuromuscular blockers
Classifications of Anesthesia:
● General: inhalation; of choice for surgeries of significant duration
● Adjuncts to general:
○ Opioids- sedation and analgesia; pain management; resp depression
○ Benzodiazepines- premedication for amnesia, induction of anesthesia, monitored
anesthesia care
○ Neuromuscular agents- facilitate endotracheal intubation, relaxation of skeletal muscles
● Epidural: manage pain up to 72 hours post op; injected; have emergency equipment available
● Local and regional: rapid recovery, little residual hangover, possible discomfort, hypotension,
seizures
Intraoperative Complications:
● Hypothermia: What can we do for the pt? assess temp, warming blankets and warm fluids as
needed
● Hypoxia: we would look for their 02 sats – constantly
● Anaphylaxis:
○ S/S: hypotension (1st signs), tachycardia(1st signs), elevated respiration rate(1st signs),
Bronchospasms, wheezing, pulmonary edema, crackles.
○ Typically found on the end of inspiration and beginning of expiration.
○ Manifestation may be masked by anesthesia; rapid intervention
● Aspiration: Put patient in lateral position
● Fluid and electrolyte imbalances:
- Caused by getting fluid too quickly (fluid pouring).
- Know what fluid they are getting and what it does to the body.
● Environmental: complications that can happen in the environment: Fire → b/c inhalation agents
(oxygen) are HIGHLY FLAMMABLE
Malignant hyperthermia: Rare metabolic disorder, Usually while under general anesthesia
❏ Often occurs with exposure to succinylcholine
❏ They can change the inhalation agent if it is genetic.
❏ Autosomal dominant trait
❏ MH is genetic in nature and has a genetic component.
❏ Can result in cardiac arrest and death - Can cause organ failure, it is deadly.
❏ Rigidity of skeletal muscles: Can’t regulate calcium
● Causes:
- inhalation agents; Happens from anesthesia agent -> succinylcholine
- Genetics; Has a genetic component- why we ask if family/patient has had reaction to
anesthesia
● S/S: Tachycardia (> 150) (earliest sign), tachypnea (earliest sign), increased CO2, rigid muscles,
fever (latest sign)
- Early sign is tachycardia and tachypnea
increased temp is a late sign.
● Tx: Anything that cools the pt: lower thermostat, ice, cooling blanket.
○ Antidote is Dantrolene, causes the muscles to relax.
○ Stop surgery, stop agent responsible for hyperthermia, give 100% O2
○ Lidocaine is used to relax the heart down to make the tachycardia go away.
POSTOPERATIVE NURSING
Entry of client into recovery until discharge home or onto unit. PACU - immediately after surgery
● Role:
○ Assessment of complications
■ Important to maintain vitals and maintain an open airway
○ Prevent complications.
○ Ask the OR nurse how the patient tolerated the surgery.
■ Bleeding, how was their BP?
■ What anesthesia was used?
○ What can you do for the pt in this phase? (EVERY 5 min and when they get to the floor it
is every 15 min)
■ VS, lung sounds, give patient O2, pain meds, raise head of bed to 30 degrees,
Assessing complications
● Airway: Assess if artificial airway patent. Interventions: raise HOB, suction
● Breathing: Assess RR, quality, assess SaO. Intervention: give O2, TCDB, IS, Splinting
● Circulation: Assess: ECG, BP, pulse, cap refill, skin color (pallor), temp (cool). Interventions:
Ambulate, SCDs, TEDs, anticoags
● Neuro: Assess: LOC/ neuro state. Interventions: Reorient, explain procedures
● Gi/Gu: Assess: for N/V, I/Os, wt, fluid volume overload (How much fluids did the pt receive?),
must have no less than 30ml output every hour. Interventions: ambulate,
● S/S(surgical site): assess for s/s of infection (WBCs, drainage color, etc). Interventions: sterile
technique, wash hands, dressing, antibiotics.
CKD (Chronic kidney patients) Patients Post-op period:
● What do you need to ask the OR nurse regarding a CKD patient?
○ Ask OR nurse how much fluid pt had? What type of fluid?
● Important assessments
○ I&O
○ Listen to lung sounds - crackles - signs of fluid in lungs
Day 1:Atelectasis: collapse of the alveoli
● Most common complication that occurs 24 hours after surgery
● Can cause pneumonia if fluid just sits in the lungs
● S/S: crackles, decreased breath sounds, incr RR, restlessness
● What can we do to prevent this? IS, TCDB, ambulation, Huff cough, splinting, more fluids in
order to increase IV fluids.
● Treatment:Oxygen, high fowlers, use pulse ox, IS, turn cough deep breath, ...do interventions.
Up to 24 hrs: Hypovolemic shock: aka - bleeding
● Most common complication 0-24 hrs after surgery; within the first day
● Causes: Loss of fluids/ bleeding, dehydration
● S/S: low bp, high HR, high RR
● Interventions if the patient is actively bleeding:
1. Put pressure to the wound
2. Put the patient in trendelenburg position - (gives blood to vital organs)
3. Administer fluid or blood
4. Notify the doctor
Day 2: Clot formation or DVT:
● S/S: calf pain, swelling
● Cause: Due to lack of movement
●
●
Prevention: SCD, ambulation, blood thinners (Plt level must be greater than 150 for lovenox to be
administered)
Teach: walking prevents clots
Day 3: Infection.
● Occurs day 3 and on... after surgery. Does not happen overnight
● Can be ...
○ atelectasis progressing to pneumonia, UTI, respiratory infection
● S/S: Red, swollen, yellow drainage, fever, tachycardia
● Prevention: Hand washing, antibiotics, wound care, dressing changes, aseptic technique, keep
patient clean
● Prevention of UTI: Really good peri care (front to back); Remove catheter or change the
catheter/Catheter care; Hydration to get infection out; Urine culture and antibiotics if they have an
infection.
Day 4: Dehiscence and evisceration: normally from patients who have had GI surgery and are larger in
weight.
● Dehiscence: stitches pop
● Evisceration? Organs protrude
● What do you do if this happens?
1. Cover with moist sterile dressing w/ saline→ keeps organs moist/alive and increases
circulation. It prevents organs from rotting, if organs are dry they die.
- Sterile dressing: prevents infection
2. Position: Low fowler's @ 30 degree angle with knees bent → relieves tension and
pressure on the abdomen; prevents further evisceration.
3. Lastly we call the MD .
★ Prevention from these occurring: abdominal binder, (best), can also splint.
5. Pulmonary embolism: Day 2 complication.
S/S: chest pain, dyspnea (Early Finding), increased respiratory rate, disoriented, lethargic, restless(Late
Finding).
- Now we need to know early vs late assessment findings. Know when these complications are
most likely to occur…
Postop: Pain control:
● Assess anesthesia used and pre op med client received
● If opioid prescribed, assess client every 30 minutes for RR and pain relief; If on PCA, ensure
client with PCA understands use
● Try using noninvasive measures to relieve post op pain
● GI: Absent bowel sounds – normal b/c they just got out of anesthesia and it puts their gut to sleep,
BUT not good if they are absent after postop day 1.
● Observe the drain and fluid, but NEVER take off the first dressing; Only the surgeon takes off the
first dressing on the patient. You just get a new dressing to reinforce.
● Urinary – MUST have at least 30 ml.
LECTURE 2:
DIABETES MELLITUS
Pancreas:
● Function:
○ Influence carbohydrate metabolism
○ Produces insulin and glucagon
○ Protein metabolism
INSULIN CARRIES GLUCOSE OUT OF THE VASCULAR PLACE!!
Diabetes Mellitus :
● What is Diabetes Mellitus?
○ Chronic disorder of impaired carbohydrate, protein and lipid metabolism caused by a
deficiency of insulin resulting in hyperglycemia.
● What does insulin do?
○ Carries glucose out of the vascular space and into the cells.
● No insulin means increased glucose levels, why?
○ Insulin breaks glucose down. No insulin → glucose can’t be broken down causing
increased glucose levels.
● When cells starve they begin to break down protein/fat for energy.
○ Because their body can't break down proteins. Proteins are huge molecules, the kidneys
work harder and make a lot of urine to try and get rid of protein.
■ Proteins will bust through the kidney filters → pts have blood and
protein/ketones in their urine
■ Breakdown of fat=Metabolic ACIDOSIS
Diabetes and circulation:
● Maintaining perfusion in diabetes is key!!
○ Issues with perfusion b/c of the fat buildup and scarring of arteries causing them to
harden and stiff.
● Due to the poor circulation, diabetics are at higher risk for increased risk for infection b/c poor
wound healing.
● Lower extremities are mainly affected
Diabetes Pathophysiology:
● Type 1
● Autoimmune.
● They make NO insulin – These pts only get insulin – no pills
○ Will always need insulin - Insulin dependent diabetes mellitus (IDDM)
● Rapid onset - all of a sudden
● Occurs in childhood or early adulthood.
● Ketoacidosis - usually in DKA state
●
Type 2
○
○
○
Pancreas still makes SOME insulin but not enough.
■ Can take pills and insulin b/c the pancreas still makes some insulin
Slow onset – insidious
Occurs in adulthood
■ Usually not aware that they are diabetic
Risk factors:
● Type 1:
○ Genetics
● Type 2:
○ Obesity, family history, older age, unhealthy lifestyle
Assessment findings:
● Type 1: relate to volume loss and cellular "starvation".
○ 3Ps – Hallmark clinical manifestations:
■ Polyuria: peeing a lot b/c the kidneys are trying to get rid of the ketones.
● We try to keep pt from going into hypovolemic shock b/c they are peeing
too much and not concentrating the urine. They are pouring out dilute
urine and making themselves dehydrated.
■ Polyphagia: always hungry
■ Polydipsia: increased thirst
● They are not able to concentrate the urine and their body needs the fluids
b/c they are dehydrated.
○ Fatigue and weakness
○ Unexplained weight loss; decreased wt(Because of the fat breakdown)
○ Hot, dry skin; Dry mucous membranes
○ Blurred vision
●
Type 2:
○ 2 Ps: Polyuria and polydipsia
○ Fatigue
○ Prolonged wound healing - Poor circulation/perfusion
○ Changes in vision
○ Weight gain or loss
○ Recurrent more frequent infections
■ UTIs, yeast infections
○ Large amounts of ketones, protein and sugar in urine.
○ When the blood sugar is out of control, what are the s/s?
■ 3Ps: Polyphagia, body is looking for energy; polydipsia; polyuria,
■ Patient may be @ risk for hypovolemic shock b/c they can’t concentrate their
urine and cannot control their urge to urinate.
Diabetes Mellitus Diagnosis tests:
● Fasting blood sugar(FBS)
●
●
●
○ could have diabetes if > 126 - needs to do further testing
○ Cannot eat for period of time (8hrs).
○ Usually 1st test
Casual Blood Sugar - fingerstick
○ > 200 and having symptoms (peeing a lot...etc) will do further testing.
Glucose Tolerance test: > 200
○ Give pt glucose drink, wait 2 hours and then test BS
○ If they BS greater than 200 pt probably have diabetes b/c the body was unable to break
down the sugar.
HgbA1c (AKA: glycosylated Hgb) It tells you the average over 3 month period.
○ Not the 1st test done. Indicates how well the body has been breaking down sugars.
■ 1st time diabetic patients will be high because they haven’t been regulating their
blood sugar very well.
○ Measures of whichren 1% of hgb is coated w/ glucose (glycated). Once glycated, a hgb
molecule will remain for the remainder of the RBCs lifespan - 120 days. The higher the
HgbA1C the higher the blood glucose levels have been over the past 90 days.
○ > 8 is BAD for an established diabetic patient.
■ < 7 is good for established diabetic pt.
■ 5.7 or less is normal.
Treatment for Type 1 diabetes:
● Pt will need insulin forever.
● INSULIN
Treatment for Type 2 diabetes:
- Diet and exercise - 1st interventions then insulin
- Insulins
- Oral antidiabetics
Type 2 Diabetes and diet:
● Diet:
○ Decrease protein and cholesterol: Because diabetics can’t break it down.
● Reduces vascular damage. Will cause less damage to kidneys
○ Increase fiber: Helps with absorption of glucose.
■ If patient is hypoglycemic we give them OJ and Apple juice but apple juice is
preferred. Apples are higher in fiber.
○ 55-60% complex carbs:
■ Brown rice, whole wheat, oat, quinoa, bananas, oatmeal, beats, lentils, yams,
sweet potatoes
○ 20-30% fats: healthy fats: Avocado, nuts, canola oil, olive/coconut oil, almonds
○ 12-20% protein – chicken, fillet mignon, fish (salmon)
○ Decrease alcohol use:Decrease you do not have to eliminate.
■ Alcohol turns into sugars, and interacts with a lot of diabetic meds.
●
Exercise:
○ Need to wait for BS to normalize before they start exercising
○ Exercise the SAME time and routine every day
■ Less fluctuations.
○ Exercise causes bs to go down!
■ Exercise when BS is highest. BS is the highest in the afternoon and is the lowest
in the morning.
○ Slowly increase exercise. 20- 30 minutes a day, 3-4x a week.
○ 60 – 80% of your maximum hr.
○ Snack before exercise → apple (more fiber). Pt should eat the snack around 30 min
before exercising.
○ Exercising can lower your BS for up to 48 hrs.
○ Aerobic exercises:
■ Swimming, walking, resistance training, using bands, normal body weight
exercises
■ We don’t want diabetic pts to do any heavy lifting exercises.
Oral antidiabetic medications: TYPE 1 DIABETICS ONLY GET INSULIN
● Sulfonylureas (includes: glipizide, glyburide, glimepride) → Work in pancreas
○ Stimulate pancreas to release insulin
○ PT CANNOT DRINK ALCOHOL, teach pt
○ Will cause weight gain because excess fluid retention
■ Closely monitor HF and CKD b/c they are already at higher risk for fluid
overload
○ Give with food to decrease symptoms of n/v.
○ Side effects: N/V, upset stomach, hypoglycemia, weight gain
●
●
●
Meglitinides (similar insulin release as sulf.) → work in pancreas
○ Faster acting but shorter duration
○ Take 30 min before meal; DO NOT TAKE IF MEAL WAS SKIPPED
○ Less chance for hypoglycemia with this medication
Biguanides → Work in liver
○ Inhibits the way the liver produces glucose
○ First in line treatment for T2D
○ Take with food because this causes GI upset
○ Contraindicated for CHF, liver failure, CKD pts
○ Hard on kidneys; Can be toxic to lungs, liver, kidneys
○ Metformin: MUST BE OFF 48 HOURS BEFORE IF PATIENT IS GIVEN IV
CONTRAST
■ Iodine is also hard on the kidneys. Iodine is metabolized in the kidneys and can
cause the kidneys to shut down.
Thiazolidinedione → works in muscle and fat
○ Can cause liver toxicity
○
○
○
Tests: AST, ALT, total bilirubin → to look at the liver enzymes.
Side effect = wt gain bc they retain fluids – edema b/c they retain fluids.
Caution with CHF pts
●
Alpha-glucose inhibitors → works in small intestine/GI tract to speed up and clear out the food
faster.
○ Side effect = diarrhea (biggest SE)
○ Causes hypoglycemia when not given with food → give with 1st bite of food.
○ Starch blocker (miglitol)
●
Incretin mimetic (Byetta or victoza) NOT INSULIN but given Sub-Q
○ Stimulates insulin release and decreases the secretion of glucose
○ Side effects = N/V, HTN, (Biggest SE, most common) DECREASES gastric emptying(
constipation, feeling of fullness), hypoglycemia
○ Increase pts fiber in diet
○ Only for type 2 pts.
Any diabetic drugs they are at risk for liver toxicity. Know peak, onset and duration. Peak is
most important.
-
Insulin tips:
● SQ – clear then cloudy (which is which?)
○ Air into cloudy, air into clear, draw up clear, draw up cloudy.
○ CANNOT MIX LONG ACTING INSULINS
● IV – Regular insulin can be given IV
- Onset: 30 – 60 min; Peak: 2-4 hr; Duration: 5-8 hr.
Complications of Diabetes Mellitus:
● Hypoglycemia: BS level < 70
● Risk factors:
○ Increased insulin - Giving too much
○ Decreased food intake
○ Increased exercise
○ Alcohol
● S/S: Diaphoretic (Cold and clammy), Sweaty, Shaky, Irritable, hungry, Anxious (late),
Confused (late), Dec LOC(late), Tachycardia(late)
● Onset: sudden may lead to insulin shock
● Tx: Conscious and unconscious
○ Conscious: Rule of 15's
■ 15g carb (ex. fruit juice, 5-8 lifesavers, 4-6 oz of regular soda,
commercial dextrose products).
■ Best is: 4-6 oz Apple, it has fiber in it.
○ Unconscious - Glucagon (thick syrupy consistency that sits in their mouth) or IV
dextrose (50%) [BIG syringe, Hard to push, consistency is very thick]
■ Recheck BS in 15 minutes, if BS < 70 – repeat the process
●
Hyperglycemia: > 110
○ If pt has hyperglycemia > 250, increase risk for infection for more than 2 weeks.
○ S/S: 3Ps (polydipsia, polyuria, polyphagia), blurred vision, nausea, drowsiness,
hot and dry
○ Causes/Risk factors: no treatment, infection, changes in eating, insulin
administration or exercise regimen, malfunction of insulin pump, stress, illness,
skipping meds
○ Treatment: Insulin, medications
●
DKA (metabolic acidosis) → Type 1
○ Glucose BS > 250
○ Ketonuria - large amounts in urine
○ Low pH <7.3
○ CO3 <15
○ Symptoms: N/V, dehydration, Kussmaul’s respirations (hallmark symptom), acetone
odor to breath (hallmark symptom), infection, Low LOC, lethargic, not alert and oriented,
3p’s, tachycardia, hypotension, hypokalemia.
■ Kussmaul RR: Hyperventilating state. It is what pt does to compensate for the
metabolic acidotic state; Deep, labored breathing, rapid breathing,
●
Tx: We are trying to prevent hypovolemic shock b/c they are dehydrated - there is too little fluid.
○ IV fluids: Start with isotonic fluids until blood pressure is stabilized and UO is 30 - 60
ml/hr. Must be given fluids or else they will go into circulatory collapse.
■ Isotonic NS(0.9 Sodium chloride).
○ IV regular insulin until BS 200-300. Slow infusion of regular insulin via pump
■ Rapid infusion can lead to cerebral edema
○ We monitor I & O to determine if their kidneys are still diuresing
■ NS and IV Reg insulin (break down sugars ASAP). @ BS of 200-350 we change
to dextrose ½ NS. (we add dextrose b/c the insulin in the IV is causing BS to
drop and it also decreases risk for Cerebral edema)
○ Monitory and careful replacement of potassium, based off most recent labs
■ K+: 3.5 - 5.0
Long term complications:
1. Diabetics have poor perfusion b/c sugar in blood tears into vessels and hardens/scars them; the
elasticity is no longer good..
2. Can’t break down fat so they are full of fat/ atherosclerosis. Diabetics will have HTN b/c heart
doesn’t pump well and has to work harder and causing more pressure to the muscles = more
vascular damage.
● Peripheral vascular disease: Peripheral vessels get clogged → no blood flow to feet or hands →
possible amputation. Numbness and tingling.
● Retinopathy: Vision loss b/c vessels of the eye get damaged by high sugars that are not broken
down. Leading to potential blindness.
●
●
●
●
●
Neuropathy: Fat fills feet and fingers first → b/c the fat or hardening of vessels happens in
smaller vessels/capillaries.
○ Tingling in fingers = no blood flow to the area. Lack/loss of feeling in the extremities.
Angiopathy: Heart attack, HF, stroke. Arteries filled up to where they have MIs.
Nephropathy: Too many ketones to glomeruli and can no longer repair itself and function →
have to go on dialysis b/c kidneys won’t perfuse the way they should. Can lead to renal failure.
Infections: Delayed wound healing - inorder to heal they need to profuse
Mostly occur because of poor perfusion/circulation
Nursing goals:
❖ Manage diabetes
❖ Maintain fasting BS < 125
❖ Maintain HgA1C < 6.5%
❖ Preventing complications and lifestyle modifications
Nursing interventions:
❖ Monitor BS (blood sugar) as ordered
❖ Monitor for signs of hypo/hyperglycemia
❖ Administer insulin as ordered
Pt education (cont.)
❖ Importance of monitoring Blood Sugar
❖ Teach them how - show them the steps
❖ Diet
❖ Exercise
❖ Stop smoking
Patient education:
● Sick day rules:
○ Blood Sugar rise when you are sick
○ Pts need to monitor BS more frequently. May need more meds or insulin based on their
BS levels.
●
Foot care:
○ Diabetic shoes: Thick leather soles with big toe box. Able to freely move their toes, no
rubbing should occur.
○ NEED TO LOOK AT THEIR FEET DAILY. Wash and dry daily, especially between
the toes.
○ Avoid extreme temperature: hot/cold.
○ Trimming of nails: ONLY podiatrist (foot doctor) can do this - NURSES CANNOT do
this
Lecture 3
Pulmonary disorders:
RESPIRATORY SYSTEM
Nursing diagnoses (3): impaired gas exchange, altered breathing patterns, ineffective airway clearance.
Gas exchange at the alveoli:
● Exchange of gases occurs because of differences in partial pressures.
● Oxygen diffuses from the air into the blood at the alveoli to be transported to the cells of the
body.
● Carbon dioxide diffuses from the blood into the air at the alveoli to be removed from the body.
Assessment:
● Pulse ox
○ Normal > 90%
○ COPD >88%
● ABG’s - measures how well the gas exchange is
● Lung sounds - crackles can indicate fluid in the lungs → atelectasis.
● Pattern of breathing/Rate of breathing
● Looking at my chest. Look at Positioning: tri-pod - indicates air hunger
History:
● Smoking/ Drug use
● Allergies
● Diet: sodium intake, can cause the pt to retain fluid in their lungs.
● Chest pain/Dyspnea (ADLs)
● Kussmaul’s respirations (rapid, labored, deep respirations) is r/t DKA or metabolic acidosis
Respiratory focused assessment:
●
●
●
Inspection:
○ Skin and nails:
■ Cyanosis: Not getting good gas exchange
■ Capillary refill: < 3 Sec
■ Clubbing: In heart and lung diseases that reduce the amount of oxygen in the
blood. (COPD)
○ Head and neck: Hypertrophy (head and neck get large), have a barrel chest - COPD pts.
Palpation:
○ Vocal/tactile fremitus (vibration): Indicates fluid that is there and not supposed to be
there.
■ Vibration when pt speaks.
○ Crepitus: Crackling sensation under finger tips, like bubble wrap
■ Subcutaneous emphysema = air trapping in tissue
Auscultation:
○ Normal breath sounds:
■ Bronchial (on expiration)
■ Bronchovesicular (on expiration and inspiration)
■ Vesicular (on inspiration)
○ Abnormal (adventitious) breath sounds:
■
Crackles (rales): popping, discontinuous sounds.
●
■
Indicate fluid in the lungs. End of inspiration and start of expiration
Wheezes: squeaky, musical, continuous sound. End of inspiration and start of
expiration
●
Specific to asthma pts; due to bronchoconstriction –air can’t get through
the airway.
■
Friction rubs: sounds similar to sand-paper
■
Rhonchi: Rumbling, lower-pitched, coarse, continuous snoring sound. Crackles
begin to consolidate, resulting in more fluid in the lung.
■
Diminished lung sounds: If you don’t hear anything, air isn’t moving → lungs are
consolidated.
Diagnostics:
●
●
Abg’s - tests blood gas exchange
Pulse ox: #1 TEST. Fastest and actual indicator of oxygen status of the patient.
○ Good pulse ox number is > 90.
○ COPD: Chronic disease process that doesn’t allow for oxygenation to happen: >88%
●
●
Pulmonary function test: For pneumonia and Tb patients. Tests how good the airway opens up.
Sputum test: #2 TEST. Tell us whether an infectious process is happening (ex. Pneumonia)
○ Done in the morning when there is the most sputum.
○ Broad spectrum antibiotics are used while waiting until the sputum test results come back
to determine how to tx the patient.
●
Chest x-ray: Shows if there is something in the lungs, consolidation.
○ DOES NOT diagnose anything... Sputum test diagnosis.
CT, MRI
Fluoroscopic and Radioisotope procedures
Bronchoscopy: Done when a good sputum culture was not obtained or chest x-ray shows more
than just fluid in the lungs.
○ Lidocaine is sprayed to numb gag reflex, then a large scope is put in the throat. They get
fluid samples to diagnose the issue.
■ It is usually cancer.
○ NPO for bronchoscopy → short-time, 4 hrs minimum.
○ Gag reflux must return before giving the patient any food/beverages. Patient is at risk for
aspiration.
Thoracentesis: Needle put in the chest and fluid is aspirated.
○ Pt sits over the table, causing lungs to expand to the greatest potential. Usually makes
patients feel better to be on the bedside table.
○ High risk for pneumothorax, due to their punctured lung, and tracheal deviation (tracheal
shifts to right or left)
○ What could occur 3 days after the procedure? Pt is at most risk for an infection.
■ S/S of infection: fever, high WBC
○ Nursing considerations after procedure:
●
●
●
●
■
■
Tediously assess: lung sounds, RR, breathing, chest should be rising and falling.
Assess pt every 15 minutes.
Should be even and unlabored.
Blood gas analysis:
● pH → 7.35-7.45
● Carbon dioxide (CO2)→ 45-35. Lungs
● Bicarbonate (HCO3) → 22-26 Kidneys
Respiratory acidosis:
● Pathophysiology → accumulation of CO2; CO2 is filling up in the body causing it to be acidotic.
○ This results in the formation of the carbonic acid.
● Causes:
○ Caused by Hypoventilation
○ Airway obstruction
○ Alveoli dysfunction
Know the Causes side
Respiratory alkalosis:
● Pathophysiology → excess elimination of CO2
● Causes:
○ By hyperventilation
○ Mechanical ventilation
Metabolic acidosis:
● Pathophysiology: excess acid in the stomach consuming HCO3
● Causes:
○ Excess loss of HCO3 by GI tract - diarrhea
○ Renal failure
○ Kussmaul’s respiration (hallmark s/s)
Know the Causes side
Metabolic alkalosis:
● Pathophysiology: Accumulation of the HCO3
●
Causes:
○ Loss of normal body acids - how are these lost? Vomiting, ng suctioning
○ Excess administration of sodium bicarbonate
○ Hypokalemia
○ Vomiting and NG suctioning (biggest cause)
Oxygen delivery:
● Room air: 21%
● Nasal cannula: Most common one we see
○ Delivers 24-44% (1-6L).
○ 4L max for COPD, they are at risk for oxygen toxicity.
● Face mask: 35-50% (6-12L)
● Venturi mask: Prevents O2 toxicity and provides the patient with room air and oxygen
with the small openings in the mask.
○ Has better control of how much oxygen you are breathing. Delivers precise, highflow rates of O2.
○ Good for COPD pts.
● Non-rebreather: up to 100%, 15L
Complications of oxygen therapy:
● Oxygen toxicity: Oxygen concentrations greater than 50% for extended periods of time (longer
than 48 hours) can cause overproduction of free radicals, which can severely damage cells.
○ S/S: Includes non-productive cough, substernal discomfort, paresthesias, dyspnea,
restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia,
alveolar atelectasis, and alveolar infiltrates on x-ray. Respiratory distress, confusion,
hallucinations, sleepy (hard to arouse), anxious, and getting worse when increasing O2
levels.
○ COPD patients are at risk for oxygen toxicity.
○ If they have non-rebreather mask they are at high risk for oxygen toxicity - getting too
much oxygen
● Prevention:
○ Starting at the lowest O2 level, 1L
○ PEEP or CPAP prevents or reverses atelectasis and allows lower oxygen percentages to be
used.
Nursing interventions with pulmonary patients:
● Position: High fowlers
● Hydration: Breaks down the thick mucous, so it can expel easier.
● Identify pollutants: For asthma patients, b/c pollutants/allergens can cause them to have more
attacks.
○ Asthma patients always need to have their inhaler
● TCDB(turn, cough, deep, breath)
○ Will help patients cough up the secretions in their lungs.
●
●
●
●
●
●
■ Teach patient if they do not know
IS: Device ensures that a volume of air is inhaled and the patient takes deep breaths.
○ Used to prevent/treat atelectasis
○ Should be done every 15 min or commercial break about 3-4x each. Around 8- 10x an
hour.
Pursed lip breathing
Chest PT- Machine/nurse that pounds on the pt’s back to loosen secretions. Usually done for
comatose pts, they could drown in their own secretions.
Goals:
■ Removal of bronchial secretions.
■ Improved ventilation.
■ Increased efficiency of respiratory muscles.
Suctioning:
Elevating HOB
What are these interventions called?! RESPIRATORY TOILET
Artificial airways (Trach): Needed for airway disorders
● Provide for adequate oxygenation and ventilation
● Can depress swallowing and gag reflexes
● Increase risk for aspiration
○ HOB needs to be elevated
● Replacement trach and Ambu bag MUST BE AT BEDSIDE
TRACHS:
● Goal: prevent infection → cleaning very good, routine trach care.
● Trach patient should ALWAYS be in Semi-fowler's position
● Prevention of tissue damage
● Humidification & air warming needed
● Suctioning:
○ STERILE procedure
○ NEVER longer than 10-15 seconds
○ Up to 2-3 suction passess
○ Minimize vagal stimulation
● Oral Care
● Site Care
○ Needed when visibly soiled
TRACH complications:
● Complications include: bleeding, pneumothorax, aspiration, pneumonia aspiration
● Long-term complications include: airway obstruction, infection, rupture of the
innominate artery, dysphagia, tracheal dilatation, and tracheal ischemia and necrosis.
● Difficulties with swallowing & communication
Upper respiratory tract disorders: Rhinitis, sinusitis, laryngitis, pharyngitis
● Pathophysiology:
○ Viral: Hard to treat
○ It causes the inability to clear secretions which causes an infection
● Risk factors:
○ Asthma
○ Allergies
○ Deviated septum*
○ Stress
● Diagnostic:
○ Strep culture for pharyngitis
● Assessment findings:
○ Rhinitis/ sinusitis assessment findings: Think of allergies: sneeze, sniffles, congested
○ Pharyngitis
■ Red,swollen throat - like strep throat
■ White patches on throat
■ Enlarged lymph nodes
■ Fever
○ Laryngitis:
■ Hoarseness
■ Severe cough
● TREATMENT:
○ Expectorants: Expels mucus and helps cough it up. Used the most.
○ Mucolytics: Breaks down the mucus. Only works to thin secretions if you drink enough
water. Used the most.
○ Antitussives: Stops the cough.
○ These meds can cause dizziness and HTN - so monitor BP, pt must get up slow
○ Laryngitis → rest the voice and avoid irritants
Sleep apnea: put them on bipap or cpap.
Pt education:
● Tell patient to avoid triggers and irritants
● Stop/avoid smoking
Pneumonia: Droplet precaution
● Pathophysiology:
○ Infection of the lower respiratory tract caused by microorganisms
○ Results from fluid sitting in the lungs.
■ Exposure to foriegn matter → inflammatory response → capillary walls become
“leaky”→ fluid shifts from capillaries to interstitial space, then alveoli → alveoli
fill with fluid → lung tissue consolidates → poorly oxygenated blood returns to
the heart and leads to arterial hypoxia.
●
How pneumonia occurs:
○ Community - acquired: Occurs before the pt goes into hospital; developed at home
○ Hospital acquired → also known as Nosocomial: Occurs in hospitals, from patients not
doing interventions→ IS.
○ Ventilator Acquired: If pt is on a ventilator and it is not taken care of properly
○ Health care associated: Hospital acquired
○ Immunocompromised: Chemo pts and anyone that is immunocompromised (HIV, AIDs).
○ Aspiration pneumonia: Pt aspirates and it goes into their lungs. This is peg tube, ng tube
and trach patients.
●
Aspiration pneumonia:
○ Risk factors: altered LOC, dysphagia, neurological disorder, recumbent position, artificial
airways, enteral nutrition.
○ Goal is Prevention
■ Semi-fowler’s
■ Assess for N/V
■ Feeding tube placement assessment
●
Assessment findings of Pneumonia:
○ Assessment findings: High Wbc, fever, high HR, Chills, High RR (trying to breath
better), fatigued, lower BP, diminished breath sounds, productive cough (green or
yellow).
■ Dyspnea
■ Pleural pain
■ Respiratory distress
Diagnostic test for pneumonia:
○ Sputum culture: Assists in determining how to treat the infection and figuring out the
correct antibiotic to use.
■ ALWAYS DONE IN AM
■ Always do culture before any antibiotics are given
■ Best diagnostic test.
○ WBC: Will tell us whether you have an infection but will not specify where, it is not
definitive.
○ Chest x-ray: Will show if there is something in the lungs and whites it out. Further testing
is almost always needed.
●
●
●
●
○ Bronchoscopy - last resort - it is invasive.
Treatment:
○ Antibiotics
○ Can give broad spectrum antibiotics before sputum culture results are back to help start
fighting the infection.
Nursing interventions:
○ TCDB, hydration, Semi-fowlers, respiratory toilets.
○ Low O2 levels→ Elevate HOB
Complications: Occur if the infection is not treated.
○ Sepsis
○ Septic shock
Tuberculosis: Airborne precautions
● Pathophysiology:
○ Highly contagious - spread by airborne
○ Infectious disease affects lung parenchyma
● Acid fast bacilli grows slowly, resistant
● Granulomatous infection in lung surrounded by collagen, fibroblasts, & lymphocytes → necrosis
develops into granular mass visible on x-ray
●
Risk factors:
○ Health care workers
○ Drugs abusers
○ Immunocompromised
○ Inadequate healthcare
○ Malnutrition
○ Poverty
○ Overcrowding
●
Assessment findings:
○ Hallmark assessment findings: Night sweats, weight loss, bloody sputum
■ If a patient comes in with these symptoms, isolate the pt and test for TB .
○ Fatigued, night sweats, lose wt, chest pain, temperature, bloody sputum
●
Diagnostics: Mantoux skin test → chest x-ray → AFB
○ Mantoux skin test:
■ Inject antibody and if you have TB the antibody will react. Tests if you were
exposed to TB.
● What do we do next if it is positive? Chest x-ray
○ Chest x-ray
■ Will show if there is something in the lungs - DOES NOT DIAGNOSE. If
something is noted they will then send pt for AFB.
○ Positive acid-fast bacilli (AFB)
■ Confirms diagnosis of TB
●
Demographic will determine pos or neg finding: PPDs done after 48 - 72 hours
○ >15 mm: general pop with no risk factors. Never been exposed to TB.
○
○
●
●
●
>10 mm: drug abuser, long term care facility, socioeconomic risk factors, health care
workers, residents of long-term care facilities.
>5 mm: HIV, or immunocompromised patients that have had recent close contact with
someone with active TB
Treatment: Combination drugs (4 drugs): (6-12 months)
○ Isoniazid (INH)- High risk for liver toxicity. Avoid foods with tyramine (tuna, aged
cheeses, etc).
○ Rifampin - Educate patients that bodily fluids will be orange. Alternate form of birth
control will be needed, anything but the pill. High risk for liver toxicity.
○ Pyrazinamide
○ Ethambutol
○ Tb drugs can cause liver toxicity
■ Monitor liver enzymes
■ Monitor BUN and Creatine.
○ Educate pt that if they should not stop taking if they feel better.
Nursing interventions:
○ First thing you should do if the patient comes in coughing with blood tinged sputum:
Mask them
○ When you find out more information and suspect tb what should you do? Isolate the
patient.
■ Isolation until sputum is free of bacteria:
● Patient will be in isolation until 3 negative AFB tests come back.
● Nurses need to wear N-95 masks.
● Isolated in a negative-pressure room.
Pt education:
○ Isolation: Educate about the negative pressure room the pt will be in.
○ Medication:
■ Meds for 6-12 months.
■ Takes at least 3 months to see negative test results.
■ Medication side effects.
○ Lab work: Liver function test - routinely monitoring.
■ Med can be toxic to the kidneys.
■ Monitor LFT’s, BUN & creatine.
Lower respiratory tract disorders:
● Atelectasis: Post op day 1
○ Pathophysiology:
■ Collapse of the alveoli →lower oxygen supply to the tissue
■ Occurs 24 hours after the surgery
■ Loss of lung volume.
○ Risk factors:
■ Bed written, post op patients.
● Secretions begin to sit - most common cause.
○ Assessment findings:
○
●
■ Dyspnea
■ Cough
■ Leukocytosis
■ Sputum production
■ Crackles
■ Decreased breath sounds
Nursing interventions:
■ Prevention: IS, TCDB, Turn or ambulate ASAP, hydration, Nebulizer treatment,
bronchodilators and mucolytics, Chest physiotherapy
Pulmonary embolism: Occurs post op day 2.
○ Patho: If a nurse doesn’t do interventions with pt postoperatively, pt can get DVT → can
turn into pulmonary emboli. Complication of ineffective nursing interventions for
postoperative clients.
■ Blockage of pulmonary arteries by thrombus or fat, or air embolism or tumor
tissue
○ Risk factors:
■ Not ambulating
■ Occurs in postop day 2 patients.
○ Assessment findings:
■ Impending doom - hallmark finding
■ Sudden chest pain
■ High RR
■ Low pulses
■ SOB
■ Dyspnea
■ Red, warm
■ Swollen
○ TX:
■ Clot treatment: treat clot → heparin (for short-term therapy). Long-term would
be a blood thinner.
■ ↓Order of interventions ↓
1. High Fowler’s
2. Oxygen
3. Bed rest
4. Call MD
5. Heparin/Coumadin:Heparin always gets its own IV line.
Disorders of chronic airflow limitation:
● Asthma
○ Patho: Inflammation and constriction of the airway.
■ Reversible airflow obstruction caused by diffuse airway inflammation and
constriction when exposed to irritant.
■
■
■
○
○
○
○
Triggers
Acute closure
Body has allergen → body reacts by coughing/sneezing → body then creates
mucus to protect/cover things → blocking of airway → need to get rid mucus to
breathe
Risk factors:
■ URI
■ Allergens
■ Weather change
■ Exercise
■ Pollutants
Assessment findings:
■ Wheezing: Very end of inspiration and start of expiration.
■ Coughing: Earliest clinical manifestation and 1st sign that the patient is
improving.
■ SOB
Tx:
■ Bronchodilator (ex. Albuterol, Turbutaline (brethine): ALWAYS given 1st
● SE: Tachycardia (check HR before giving drug)
● For Acute asthma
● Open up the bronchioles and relax the smooth muscles.
● Drug is effective once wheezing has resolved
■ Inhaled corticosteroid → pulmicort (Budesonide): decreases inflammation
● Steroids are for long term management for asthma.
● Chronic asthma management
● Wait 2-5 min after administration of bronchodilator then administer
corticosteroid.
● Teach patients to rinse mouth after inhaling the drug because they can
get thrush (oral candidiasis).
■ Advair and spiriva → long term management drugs
● Advair works in the inflammation part. Spiriva works on the
bronchospasm part.
● Long acting beta 2 agonists and inhaled glucocorticoid.
● SE: Dry mouth
○ Teach patients to suck on candy to help with the dry mouth
● Inhale that powder
Drugs are effective once clear lung sounds are heard.
■ Histamine to help reduce the allergens.
● Prevents constriction in the airway
■ Anticholinergics
Intervention:
■ Avoid pollutants
■ STOP smoking
■ Avoid triggers
■
●
●
●
●
Exercise: Excessive balls to the walls exercise. Encourage them to slow it down
but not avoid exercise.
● Histamines can help.
COPD:
○ Pathophysiology:
■ Air gets trapped in the lungs and converts to CO2, the patient stops breathing
because of too much CO2. Characterized by chronic airflow limitation not fully
reversible.
● Must do something to get the airway open!
■ Emphysema: Loss of the elasticity of the alveoli; very weak and flabby.
■ Chronic bronchitis: rigidity of the airway due to chronic inflammation and
scarring. No movement going on.
● Rhonchi and wheezing present b/c they hold onto secretions.
Risk factors:
○ Smoking
○ Allergens
○ Air Pollutants
○ Recurrent infection
○ Genetics
○ Environmental / occupational factors
○ Aging
Assessment findings: Need to know early from late.
○ Hallmark sign: Barrel chest
○ Thin: b/c they can’t catch their breath to eat, because it tires them out.
○ Tripod positioning: air hungry, always trying to get air.
○ History, physical exam, PFT’s
○ Dyspnea (Late)
○ Chronic cough
○ Sputum production
○ Diminished breath sounds
○ Prolonged expiration
○ Rhonchi & wheezes
[Main ones: Clubbing, barrel chest, lots of accessory muscles (late)]
○
●
Watch for signs of respiratory failure! These are all late
■ Severe dyspnea unresponsive to treatment
■ Alternating tachypnea & bradypnea and apnea – fatigue
■ Hyperventilation
■ Anxiety
■ Change in mental status
■ Worsening hypoxia despite oxygen therapy
■ Worsening hypercapnia
■ Use of accessory muscles
Nsg management - COPD: Goals – monitor disease, reduce symptoms, promote maximum lung
function, prevent premature disability
○ Nursing interventions:
■ Pursed lip breathing: increases the pressure and forces the air out of the lungs.
■ Oxygen: Start w/ 1L, if that does not increase O2 sats to 88% then go up to 2L.
Then follow this process up to 4L. NEVER go more than 4L.
● Nasal cannula: start with this this first
● Venturi mask: this is 2nd. Opening helps prevent oxygen toxicity.
Provides the patient with room air and oxygen with the small openings in
the mask.
● CPAP/BIPAP: This provides a high amount of pressure to lungs, it is
noninvasive. Great way to stop/prevent oxygen toxicity to occur.
● High calorie small meals because they get tired when eating. Meals that
are easy to chew so they don’t use as much energy.
○ Patient education
■ Steps to prevent and control acute attacks:pursed lip breathing, inhaler, tripod
position, diaphragmatic breathing
● Hydration: Lots of water to try to get rid of pulmonary secretions
● Pulmonary toilet: TCDB techniques
■ Coughing/deep breathing: Getting rid of junk in their chest
■ Conserving /maximizing energy for activities: Pace daily activities, simple
activities (walking)
■ Minimizing exposure to allergens/irritants: Humidifier and avoid triggers.
■ Smoking cessation.
■ Encourage them to participate in rehab programs and support groups
■ Preventative interventions: Recognize early signs of infections: Fever, flu-shots,
quit smoking, annual pneumonia vaccine
○ Medications
■ Bronchodilators
■ Inhaled Corticosteroids
■ Antibiotics - when they get an infective process these are used.
■ Antipyretics
■ Anticholinergics
○
○
○
○
Nutrition - High calorie small meals → so they don’t use that much energy with the small
meals
Pulmonary Rehab
Supplementary oxygen – monitor flow rate carefully!!
Surgical treatments