Section 5 Study Guide What types of breath sounds should be auscultated and where? Positioning patient for thoracentesis The patient is positioned sitting upright with elbows on an overbed table and feet supported. The skin is cleansed and a local anesthetic (lidocaine) is injected subcutaneously. A chest tube may be inserted to permit further drainage of fluid. Know blood gas normal values and what values to report immediately. Signs and symptoms of respiratory acidosis, metabolic acidosis Initial signs of acute respiratory acidosis ● breathlessness ● headache ● wheezing ● anxiety ● blurred vision ● restlessness ● a blue tint in the hands and feet (if oxygen levels are also low) metabolic acidosis ● Confusion ● Fast heartbeat ● Feeling sick to your stomach ● Headache ● Long and deep breaths ● Not wanting to eat ● Vomiting ● Feeling tired ● Feeling weak DKA respiratory pattern Kussmaul respirations (rapid, deep breath­ing associated with dyspnea) Focused assessment when pt is in respiratory distress ● Breathing rate. An increase in the number of breaths per minute may mean that a person is having trouble breathing or not getting enough oxygen. ● Color changes. A bluish color seen around the mouth, on the inside of the lips, or on the fingernails may happen when a person is not getting as much oxygen as needed. The color of the skin may also appear pale or gray. ● Grunting. A grunting sound can be heard each time the person exhales. This grunting is the body's way of trying to keep air in the lungs so they will stay open. ● Nose flaring. The openings of the nose spreading open while breathing may mean that a person is having to work harder to breathe. ● Retractions. The chest appears to sink in just below the neck or under the breastbone with each breath or both. This is one way of trying to bring more air into the lungs, and can also be seen under the rib cage or even in the muscles between the ribs. ● Sweating. There may be increased sweat on the head, but the skin does not feel warm to the touch. More often, the skin may feel cool or clammy. This may happen when the breathing rate is very fast. ● Wheezing. A tight, whistling or musical sound heard with each breath can mean that the air passages may be smaller (tighter), making it harder to breathe. ● Body position. A person may spontaneously lean forward while sitting to help take deeper breaths. This is a warning sign that he or she is about to collapse. Respiratory assessment systematic steps in performance Four major techniques are used in performing the physical examination: inspection, palpation, percussion, and auscultation. The techniques are usually performed in this sequence, except for the abdominal examination (inspection, auscultation, percussion, and palpation). Performing percussion and palpation of the abdomen before auscultation can alter bowel sounds and produce false findings. COPD medications and pt education ● ● ● ● ● Methylxanthines β2-Adrenergic agonists Corticosteroids Anticholinergics Antibiotics Asthma medications and pt education COPD medications and pt education ● ● ● ● ● Methylxanthines β2-Adrenergic agonists Corticosteroids Anticholinergics Antibiotics Spiral CT - note shellfish allergy A spiral (helical) CT scan (also known as CT angiography or CTA) is the most frequently used test to diagnose PE (Table 27-26). An IV injection of contrast media is required to view the pulmonary blood vessels. The scanner continuously rotates around the patient while obtaining views (slices) of the pulmonary vasculature. This allows visualization of all anatomic regions of the lungs. ● Before: Explain procedure. Determine sensitivity to iodine or shellfish if contrast material used. Bronchoscopy patient position, pre-procedure nursing care, post-procedure nursing care. Bronchoscopy can be performed in an outpatient procedure room, in a surgical suite, or at the bedside in the intensive care unit or on a medical-surgical unit, with the patient lying down or seated. The bronchoscope may be inserted through either the nose or the mouth. Before: Obtain signed consent. Instruct patient to be NPO for 6-12 hr before the test. Give sedative (as ordered). After: Keep patient NPO until gag reflex returns. Monitor for recovery from sedation. Blood-tinged mucus is not abnormal. If biopsy was done, monitor for hemorrhage and pneumothorax. Pulmonary emboli diagnostic tests, preps, and post-procedure care. Treatment. Pulmonary embolism (PE) is the blockage of one or more pulmonary arteries by a thrombus, fat or air embolus, or tumor tissue. Conditions cause excess fluid in the lungs and may lead to bibasilar crackles. ● Pneumonia. Pneumonia is an infection in your lungs. ● Bronchitis. Bronchitis occurs when your bronchial tubes become inflamed. ● Pulmonary edema. Pulmonary edema may cause crackling sounds in your lungs. Remember ABC’s- airway, breathing, and circulation Upper Respiratory Infection (URI) Treatment and patient education These infections affectr sinuses and throat. Upper respiratory infections include: ● ● ● ● ● Common cold. Epiglottitis. Laryngitis. Pharyngitis (sore throat). Sinusitis (sinus infection). Symptoms ● ● ● ● ● ● ● ● Cough. Fever. Hoarse voice. Fatigue and lack of energy. Red eyes. Runny nose. Sore throat. Swollen lymph nodes (swelling on the sides of your neck). Treatment will depend on the cause of your RTI: ● a virus (like colds) – this usually clears up by itself after a few weeks and antibiotics will not help ● bacteria (like pneumonia) – a GP may prescribe antibiotics (make sure you complete the whole course as advised by a GP, even if you start to feel better Procedure for tracheal suctioning and when to perform Perform tracheal suctioning if crackles or coarse breath sounds are present. Types of tracheostomy tubes (cuffed, Uncuffed, Fenestrated) What are the risks associated with uncuffed trach tubes? What do you do if there is accidental decannulation? ● Cuffed Tube with Disposable Inner Cannula-Used to obtain a closed circuit for ventilation ● Cuffless Tube with Disposable Inner Cannula-Used for patients with tracheal problems, Used for patients who are ready for decannulation ● Fenestrated Cuffed Tracheostomy Tube-Used for patients who are on the ventilator but are not able to tolerate a speaking valve to speak ● Fenestrated Cuffless Tracheostomy Tube-Used for patients who have difficulty using a speaking valve Laryngectomy-Know the anatomical changes, emergency care, postoperative care, and patient education A surgical procedure in which part or all of the larynx is removed. For the patient with a total laryngectomy, airflow in and out of the lungs will be altered as a result of surgery and normal voice production will not be possible Emergency care of epistaxis, risk of aspiration with nasal packing. Epistaxis (nosebleed) most often occurs in adults over age 50. Epistaxis can be caused by trauma, hypertension, low humidity, upper respiratory tract infections, allergies, sinusitis, foreign bodies, chemical irritants (such as street drugs), overuse of decongestant nasal sprays, facial or nasal surgery, anatomic malformation, and tumors. Nasal sponges, packing, and balloons may impair respiratory status. Closely monitor the level of consciousness, heart rate and rhythm, respiratory rate, O2 saturation using pulse oximetry (SpO2), and observe for any signs of difficulty breathing or swallowing. Nasal fracture- risk of CSF leak, how to diagnose, report to MD Diagnosis of a nasal fracture is based on the health history and physical examination. Clinical manifestations suggestive of a nasal fracture include localized pain, crepitus on palpation, swelling, difficulty breathing out of the nostrils, epistaxis, ecchymosis, and cosmetic deformity. Although facial deformity with a nasal fracture is common, often epistaxis may be the only initial manifestation of a nasal fracture. Clear, pink-tinged, or persistent drainage after control of epistaxis suggests a possible CSF leak. Checking this fluid for glucose at the bedside to help confirm the presence of CSF is highly unreliable and influenced by many factors. If possible, send a specimen to the laboratory to determine the fluid type. ENT: something stuck in nose have them occlude other nostril and blow the nose. When is a rapid strep test indicated and how is it performed? When you have a sore throat that starts quickly and lasts more than a week and/or you have other symptoms, such as a fever of 101° F or higher or reddened throat and/or tonsils with white or yellow patches or streaks A rapid test and a throat culture are done in the same way. During the procedure: ● You will be asked to tilt your head back and open your mouth as wide as possible. ● Your health care provider will use a tongue depressor to hold down your tongue. ● He or she will use a special swab to take a sample from the back of your throat and tonsils. ● The sample may be used to do a rapid strep test in the provider's office. Sometimes the sample is sent to a lab. ● Your provider may take a second sample and send it to a lab for a throat culture if necessary. Pneumonia signs and symptoms and auscultation findings. Patient education. Tachypnea, use of accessory muscles, duskiness or cyanosis Auscultation: Early: Bronchial sounds Later: Fine and/or coarse crackles, egophony, whispered pectoriloquy Aspiration precautions. ○ SMALL BITES ○ SMALL SIPS ○ Alternate liquid and solid swallows ○ Ensure oral clearance after each bite ○ Sit upright (90 degrees) when eating and drinking and for 30 minutes after eating ○ Multiple swallows per bite/sip ○ Small, frequent meals throughout the day ○ Consume one pill at a time TB testing, sputum tests obtained on 3 consecutive days, types of isolation precautions used, medications, home precautions to take, how to transport patient. PPD- the standard method to screen people for M. tuberculosis. The test is administered by injecting 0.1 mL of PPD intradermally on the ventral surface of the forearm. The test is read by inspection and palpation 48 to 72 hours later for the presence or absence of induration. Induration, a palpable, raised, hardened area or swelling (not redness) at the injection site means the person has been exposed to TB and has developed antibodies Three consecutive sputum specimens obtained on different days are sent for smear and culture. The initial testing involves a microscopic examination of stained sputum smears for AFB. However, the definitive diagnosis of TB requires the demonstration of tubercle bacilli bacteriologically by sputum culture, which can take up to 8 weeks Drug Therapy ● 4-drug regimen consisting of isoniazid, rifampin, pyrazinamide, ethambutol- Given daily for 56 doses (8 wk) OR 5 days/wk DOT for 40 doses (8 wk) Types of PPE to use in preventing exposure -disposable hats, masks, gowns, gloves Chest tube assessment and documentation ● Monitor the patient's clinical status. Assess vital signs, lung sounds, and pain. ● Assess for manifestations of reaccumulation of air and fluid in the chest (↓ or absent breath sounds), significant bleeding (>100 mL/hr), chest drainage site infection (drainage, erythema, fever, ↑ WBC), or poor wound healing. Notify HCP for management plan. ● Evaluate for subcutaneous emphysema at chest tube site. ● Encourage the patient to breathe deeply periodically to facilitate lung expansion and encourage range-of-motion exercises to the shoulder on the affected side. Encourage use of incentive spirometry every hour while awake to prevent atelectasis or pneumonia. Symptoms of pneumothorax and hemothorax and where chest tubes are placed for the two conditions. If enough fluid or air accumulates in the pleural space, the negative pressure becomes positive and the lungs collapse. As a result, chest tubes are inserted to drain the pleural space, reestablish negative pressure, and allow for proper lung expansion. Tubes may also be inserted in the mediastinal space to drain air and fluid postoperatively. Flail chest signs and symptoms ● Fracture of two or more adjacent ribs in two or more places with loss of chest wall stability ● Paradoxical movement of chest wall, respiratory distress. May be associated hemothorax, pneumothorax, pulmonary contusion ● O2 as needed to maintain O2 saturation, analgesia. Stabilize flail segment with positive pressure ventilation (intubation and mechanical ventilation). Treat associated injuries. Surgical fixation. How to prevent atelectasis ● Encourage movement and deep breathing in anyone who is bedridden for long periods. ● Keep small objects out of the reach of young children. ● Maintain deep breathing after anesthesia. Pneumonectomy postoperative care. Nursing care priorities in the postoperative period include assessment of respiratory function, including observation of respiratory rate and effort, sputum volume and color, breath sounds, and chest tube function and drainage. Daily chest x-rays are often ordered. Assessment of pain, monitoring of temperature, and observation of the surgical site are similar to care provided for other postoperative patients Cor Pulmonale signs and symptoms, causes, treatment Cor pulmonale is enlargement of the right ventricle caused by a primary disorder of the respiratory system. Pulmonary hypertension is usually a preexisting condition in cor pulmonale. Cor pulmonale may be present with or without overt cardiac failure. The most common cause of cor pulmonale is COPD. Almost any disorder that affects the respiratory system can cause cor pulmonale. Common symptoms include exertional dyspnea, tachypnea, cough, and fatigue. Physical signs include evidence of right ventricular hypertrophy on ECG and an increase in intensity of the second heart sound. Chronic hypoxemia leads to polycythemia and increased total blood volume and viscosity of the blood. Polycythemia is often present in cor pulmonale secondary to COPD. If heart failure accompanies cor pulmonale, additional manifestations such as peripheral edema, weight gain, distended neck veins, full, bounding pulse, and enlarged liver may also be found. Various laboratory tests and imaging studies are used to confirm the diagnosis of cor pulmonale Diagnostic Assessment • History and physical examination • ABGs, SpO2 • Serum and urine electrolytes • b-Type natriuretic peptide (BNP) • ECG • Chest x-ray • Echocardiography • CT scan • MRI • Cardiac catheterization Management • O2 therapy • Low-sodium diet Drug Therapy • Bronchodilators • Diuretics • Vasodilators (if indicated) • Calcium channel blockers (if indicated) • Inotropic agents Lung transplant patient education, when to notify the physician the patient needs to be able to perform self-care activities, including medication management and activities of daily living, and to accurately identify when to call the transplant team. Patients should be instructed on pulmonary clearance measures, including aerosolized bronchodilators, chest physiotherapy, and deep-breathing and coughing techniques, to help minimize any potential complication. Home spirometry is useful in monitoring trends in lung function. Teach patients to keep medication logs, laboratory results, and spirometry records. Patients are placed in an outpatient rehabilitation program to improve physical endurance. Antibiotics for pneumonia are the priority Many different types of antibiotics can be used to treat community-acquired pneumonia. Your doctor will select the most appropriate antibiotic based on your infection and other medical conditions, the patterns of local antibiotic resistance, cost, and other patient-specific characteristics such as your age, weight, allergies, and previous antibiotic treatment.First-line antibiotics that might be selected include the macrolide antibiotics azithromycin (Zithromax) or clarithromycin (Biaxin XL); or the tetracycline known as doxycycline. Low O2 sat- treat immediately report to the provider. In the case of severe hypoxemia, especially with acute respiratory distress syndrome, healthcare providers may use a machine that breathes for you (ventilator). If hypoxemia doesn’t resolve, a condition known as refractory hypoxemia, additional medications or therapies may be used. Treatments, which focus on the underlying cause, may include: ● ● ● ● Inhalers with bronchodilators or steroids to help people with lung disease like COPD. Medications that help to get rid of excess fluid in your lungs (diuretics). Continuous positive airways pressure mask (CPAP) to treat sleep apnea. Supplemental oxygen may be used to treat an ongoing risk of hypoxemia. Oxygen devices vary, but you can expect to get a machine that delivers extra oxygen through a breathing mask or small tube (cannula). You may receive oxygen at home, with a portable machine while you travel, or in the hospital. Drug interactions can occur with retrovirals for HIV and TB meds Some anti-HIV drugs can interact with antihistamines, asthma inhalers or nasal sprays(which contain steroids), treatments for indigestion and statins (drugs that are used to control cholesterol, or lipid levels). The most important drug-drug interactions in the treatment of HIV-related tuberculosis are those between rifampin and the NNRTIs, efavirenz and nevirapine. Rifampin is the only rifamycin available in most of the world, and initial antiretroviral regimens in areas with high rates of tuberculosis consist of efavirenz or nevirapine Flolan infusion disconnected is an emergency. What is it and what is the half-life of the med? Flolan infusion disconnected- Stopping the medication: When epoprostenol is stopped suddenly, or the dose is decreased by a large amount, symptoms of pulmonary hypertension may occur. Epoprostenol has a short half-life of 2 mins to 3 mins and is unstable at room temperature. Any rapid rate decrease or interruption of the infusion due to either an occluded catheter or pump malfunction can cause severe rebound pulmonary hypertension and death Assess the respiratory distress pt or pt with pleuritic chest pain prior to administering pain meds. ● Check the rate of respiration. ● Look for abnormalities in the shape of the patient’s chest. ● Ask about shortness of breath and watch for signs of labored breathing. ● Check the patient’s pulse and blood pressure. ● Assess oxygen saturation. If it is below 90 percent, the patient likely needs oxygen. Auscultate the chest, back, and sides with a focus on signs of loud or labored breathing. Signs of abnormal breathing include: ● Crackling, popping, or bubbling sounds, which may indicate pneumonia or pulmonary edema. ● Wheezing, which can signal pulmonary disease, asthma, allergies, or an infection. ● Pleural friction. This grating sound occurs when the pleural surfaces rub together and suggests pneumonia.
