Vesicular Breath Sounds
inspiratory longer than expiratory
heard over entire lung field except over the upper sternum and between the scapulae
Bronchovesicular Breath Sounds
inspiratory and expiratory sounds are about equal.
Often in the 1st and 2nd interspaces anteriorly and between the scapulae (over main bronchus)
Bronchial breath sounds
expiratory sounds last longer than inspiratory ones
over the manubrium, if at all
Bradypnea
slow respiratory rate, usually below 10 respirations per minute
Tachypnea
an abnormally rapid rate of respiration, usually >20 breaths per minute
Hypoventilation
Slow, Irregular Breathing
Hyperventilation
Increased rate and depth of breathing that results in decreased CO2 levels
Inspiration and Expiration are nearly equal
Apnea
period of cessation of breathing; time duration varies; life threatening if sustained
Cheyne-Stokes
regular cycle where the rate and depth of breathing increase, then decrease until apnea occurs
Associated with heart failure and damage to the respiratory center
-drug induced, tumor, trauma
Biot's respiration
periods of normal breathing followed by a varying period of apnea
associated with nervous system disorders
CXR
detection of pathology of the pulmonary tissue, pleura, mediastinum, thoracic wall and heart.
CT scan
assessing mediastinal tumors, needle biopsy can be performed with guidance from this scan
MRI
discriminates between mediastinal nodes and vascular structures useful in PE
Pulmonary Angiography
catheter threaded to the pulmonary artery. Uses are to aid in finding thromboembolic disease of the lungs and vascular changes associated with emphysema
Arterial Blood Gases
assess patient's oxygen transport function, the adequacy of alveolar ventilation and acid base status of the blood.
Respiratory Acidosis
increased CO2
Respiratory Alkalosis
decreased CO2
ABG nursing management
firm pressure to the site
5 minutes radial
10 minutes femoral
-assess for swelling, ecchymosis, numbness, tingling, pain
Spirometer
uses to test lung volumes and capacities.
Useful for pre-op eval of COPD patient
evaluate dyspnea
detect early stages of lung disease
evaluate effects of medications
follow progression of chronic lung disease
C & S
do not rinse or brush teeth
provide adequate fluid the night before to help in sputum collection
obtain first expectorate of the morning
instruct to deep breath and cough
Bronchoscopy
NPO for 6 hours
local anesthetic
post procedure- NPO until gag reflex returns
observe for hemoptysis, hypoxia, hypotension
Thoracentesis
assess for allergy
place in upright position
support arms
after needle is withdrawn, apply pressure
obtain chest x-ray
record amount and type of fluid removed
monitor A,B,C's
Rhinitis
common cold, inflames nasal cavities
Sinusitis
inflamed mucus membranes
-antihistamines
-decongestants
-hand washing
Antihistamines
may cause vertigo, dizziness, hypertension, urinary retention
Epistaxis
rich capillary network in anterior part of nose
cause of epistaxis
trauma, hypertension, leukemias, nose blowing
treatment of epistaxis
sit forward, direct pressure 3-5 inches of loose gauze packing, cautery with silver nitrate, post nasal packing, bed rest and abx
Cancer of larynx
Head and neck
2-3% of all cancers
More than 80% are squamous cell arising from the mucosal epithelium (80% men)
Cure rate is excellent when limited to vocal chords
Risk factors for cancer of larynx
Smoking and voice abuse
1. hoarseness
2. pain in throat
3. cough
4. dyspnea
5. mass in neck, weight loss, foul breath and general debility
Interventions of cancer of larynx
maintain airway and optimal air exchange
radiation 90% cure of early cancer with better voice quality
1. skin care of radiated are (carotid artery weakens)
2. High fowlers
3. scrupulous mouth care
Partial Laryngectomy
small tumor excision, one vocal chord
has temporary tracheostomy
total laryngectomy
for advance lesion
Entire larynx
Permanent tracheostomy
nursing care of tracheostomy patient
establish a trusting relationship
coping with altered self perception, body image, loss of ability to communicate
nutritional support pre-op
prevent aspiration
maintain airway
prevent hemorrhage
post op secretion control (Suction)
communication
tracheosto
Laryngeal Edema
medical emergency arising from anaphylaxis, urticaria, laryngitis, edema
symptoms of laryngeal edema
Partial: gurgling, snoring, stridor
Complete: absent breath sounds, loss of consciousness
endotracheal tube
a catheter that is inserted into the trachea in order for the primary purpose of establishing and maintaining a patent airway and to ensure the adequate exchange of oxygen and carbon dioxide.
tracheostomy tube
catheter that is inserted into the trachea in order for the primary purpose of establishing and maintaining a patent airway and to ensure the adequate exchange of oxygen and carbon dioxide
Respiratory Infections
acute tracheobronchitis
Pneumonia
community-acquired pneumonia
hospital-acquired pneumonia
PCP: pneumocystis jiroveci pneumonia
Aspirator pneumonia
Community Acquired Pneumonia
Streptococcal/Pneumococcal
Haemophilus influenza
legionella pneumophilia
mycoplasma
viral
chlamydial
Atypical pneumonias
mycoplasma, viral-influenza and varicella pneumonias in adults are most common
Hospital-acquired pneumonias
bacterial staphlococcus, pseudamonus
pneumonia in COPD
viral pneumonia Hemophilus-influenza is life threatening to patients
HIV patients pneumonia
protozoal infections- pneumocystic carinii
(opportunistic protozoal pathogen
(mild fever, cough and dyspnea)
Pneumonia
classic inflammatory response, exudate of fibrin containing fluid, bacteria, polymorphonuclear leukocytes, and erythrocytes fills the alveoli and enhance further bacterial growth
Alveolar hypoxia caused by underventilation causes shunting, hypoxemia
(alve
symptoms of pneumonia
cough, chest pain- pleuritic, chills, fever, lethargy
Dyspnea
Orthopnea
Tachycardia increases by 10 BPM with each degree elevevation
inspection of pneumonia
shallow respirations (30-40 per min), nasal flaring, accessory muscle use, cyanosis
auscultation of pneumonia
diminished breath sounds, fine crackles, later signs of consolidation revealed by bronchial breath sounds
percussion of pneumonia
dull to flat
palpation of pneumonia
increased fremitus
ABG's of pneumonia
hyperventilation may decrease CO2
Antimicrobial Drugs
based on results of gram stain and culture, clinical severity, presence of underlying disease and the presence of complications
bacterial antimicrobial drugs
antibiotics
fungal antimicrobial drugs
Amphotericin B
Viral antimicrobial drugs
non specific such as amantadine
Protozoa antimicrobial drugs
or trimethoprim PO, aerosol pentamidine
(these drugs are also given IV as needed)
Response within 24 hours after abx initiated
Medical treatment of Pneumonia
-Supportive treatment includes fluid, oxygen for hypoxia, antipyretics, antitussives, decongestants and antihistamines
-Administration of antibiotic therapy is determined by Gram stain results
-If the etiologic agent is not identified, use empiric antibio
Prevention of Pneumonia
Frequent turning and early mobilization
strategies to improve ventilation; deep-breathing exercises at least every 2 hours, incentive spirometer
-Strategies to remove secretions: coughing exercises, suctioning, aerosol therapy, and chest physiotherapy
Treatment for pneumonia
strategies to improve ventilation and remove secretions
treatments may include PEEP (positive end-expiratory pressure
Bronchoscopy can also be used to remove obstruction
Collaborative Problems with Pneumonia
Continuing symptoms post treatment
Shock
Respiratory failure
atelectasis
pleural effusion
confusion
superinfection
Goals for pneumonia patient
Improved airway clearance
Maintenance of proper fluid volume
Maintenance of adequate nutrition
patient understanding of treatment and prevention
Absence of complications
Improving airway clearance
-encourage hydration: 2-3 L/day
(unless contraindicated)
-Humidification can be used to loosen secretions; face mask or with oxygen
-Coughing techniques
-Chest physiotherapy
-Position Changes
-Oxygen therapy administered to patient needs
Pleurisy
an inflammation of both layers of the pleurae
-Inflamed surfaces rub together with respirations and cause sharp pain that is intensified with inspiration
Pleural effusion
a collection of fluid in the pleural space, usually secondary to another disease process
-large effusions impair lung expansion and cause dyspnea
Empyema
accumulation of thick, purulent fluid in the pleural space
-patient is usually acutely ill. Fluid, fibrin development, and location will impair lung expansion. Resolution is a prolonged process
Pleurisy/Pleural effusion etiology
chemical or infectious related to cardiac or pulmonary disease, connective tissue diseases, or malignancy
-treating the underlying cause with antibiotics, drug therapy for congestive failure, or radiation for malignancy, as well as thoracentesis, analgesi
Acute Respiratory Distress Syndrome
a severe form of acute lung injury
-Characterized by sudden and progressive pulmonary edema, increasing bilateral lung infiltrates on the cxr, hypoxemia refractory to oxygen therapy, and decreased lung compliance
symptoms of ARDS
rapid onset of severe dyspnea
hypoxemia that does not respond to supplemental oxygen
management of ARDS
intubation and mechanical ventilation with PEEP to treat progressive hypoxemia
Frequent position changes
Nutritional support
general supportive care
Pulmonary Embolism
thrombus that has traveled the venous system to the right side of the heart and into the pulmonary vasculature
-Most common type of embolism
-strikes more than 500,000 persons annually
may go unnoticed until autopsy
predisposing factors of Pulmonary embolism
1. deep vein thrombosis, prolonged bed rest, obesity, pregnancy and orthopedic casts, leg and pelvic fractures, diabetes, bums and IV drug users
2. coagulation problems precipitated by cancer, polycythemia, sepsis and estrogen replacement
Symptoms of pulmonary embolism
1. anxiety related to SOB and tachypnea
2. elusive signs- cyanosis, cough, hemoptysis, diaphoreses, hypotension, chills, fever, and mental status changes
3. auscultate: pleural friction rub
4. ABG's decreased O2- initially respiratory alkalosis- but progr
tachypnea- pulmonary embolism
as the blood flow to the pulmonary vessels diminishes-hypoemia- increased respiratory rate- chest pain
Diagnosis of pulmonary embolism
Chest x-ray
EKG
Ventilation/Perfusion scan (radioisotope)
Pulmonary Angiogram
Prevention of pulmonary embolism
exercises to avoid venous stasis
early ambulation
anticoagulant therapy
Sequential compression devices (SCDs)
treament of pulmonary embolism
Measure sto improve respiratory and CV status
anticoagulation and thrombolytic therapy
Embolectomy
opening the blood vessel in an attempt to remove clot
Patients who have massive pulmonary emboli
Surgical for pulmonary embolism
insertion of venal caval filter "umbrella"
Prevents recurrence-device traps emboli that have dislodged from a peripheral vein, keeping them from reaching pulmonary vessels.
Alternative to anticoagulant therapy.
-implanted under general anesthesia or percu
Pneumoconioses
Occupational lung disease
Cause of death of 124,846 people in the US between 1968 and 2000
Causative agents
Role of the nurse as employee advocate
role of the nurse in health education and in teaching of preventive measures
Role of OSHA
Lung Cancer
2nd most commonly occurring cancer in both men and women
often asymptomatic
5 year survival rate average 16%
-Leading cause of cancer death in women
- cough is the most common sign
Later symptoms of lung cancer
a change in character of sputum, blood tinged, think and purulent.
may develop dyspnea, wheezing
Metastases of Lung cancer
may cause chest pain, horseness, dysphagia, head and neck swelling, resulting in weakness, weight loss, anorexia and anemia
Small Cell lung cancer
20%, aggressive and spreads bilaterally, considered metastatic because of the usual spread to bone, liver or brain. Small tumor may respond to Tx.
Non Small Cell lung cancer
Adenocarcinoma: 40% in lung periphery and metastasizes to brain, bone, liver, kidney and other lung
Squamous Cell: 30% grows locally and causes atelectasis (better prognosis)
Diagnostic Tests for lung cancer
chest x-ray
sputum cytology
thoracentesis (if has pleural effusion)
Percutaneous fine needle aspiration complications
Bronchoscopy
Post-operative care for lung cancer
-Improved gas exchange
-VS every 15 minutes for first 2 hours
-pulse oximetry- greater than 95%
coughing and deep breathing
Head of bed 30-40 degrees
Pneumonectomy- position on operative side
Lobectomy- position on nonoperative side
radiation
as combination or alone. Complications include coughing, skin charges, dysphagia, dyspnea
Spontaneous Pneumothorax
collection of air within the pleural cavity, no external trauma (closed)
Traumatic pneumothorax
chest wall- laceration (fx ribs, gunshot) may be an open or closed.
Open is sucking chest wound
Etiology of pneumothorax
rupture of a bleb (air from ruptured alveoli) into pleural space, most often at the apex of the lung
-open-air enters pleural space from outside during inspiration, lung collapses, mediastinal shift to contralateral side then incomplete expansion of other
Closed Chest Drainage
Chest tubes, chest catheter is inserted into pleural space, the proximal end is attached to tubing connected to a water seal container
Purpose of chest tube
To remove air or fluid from pleural space
Aid in the re-expansion of lung tissue
Re-establish normal negative intrathoracic pressure
re-establish the mediastinal structure in normal place
Principals of chest tube
1. water seal drainage acts as a one way valve so that air and fluid may escape from the pleural space into the container
2. water seal maintains the negative intra thoracic pressure
3. water seal prevents air from entering the pleural space
Tuberculosis
infection most commonly found in the lungs
-caused by mycobacterium but may be spread to other organs
Patients at risk for TB
debilitated patients, malnutrition, cancer, chemotherapy, or steroids make persons more susceptible because of their reduce immune system. Higher risk if patients has lived in area where medical care is scarce
Etiology of TB
airborne transmission from coughing, talking, sneezing, laughing, singing, a single droplet nuclei
-bacteria multiply in the alveoli
symptoms of TB
fever, cough, night sweats
Diminished breath sounds, crackles or wheezes
Diagnostic for TB
mantoux - .1ml of PPD intradermally- read 48-72 hours after
Induration of .5cm is significant
AFB sputum, CXR, bronchoscopy
TB medications
medications are used in combination to prevent the formation of drug-resistant bacteria
1. Isoniazid- (liver toxic)
2. Rifampin
3. Pyrazinamide (PZA)
4. Streptomycin
5. Ethambutal
-instruct on importance of drug compliance. Test all TB infections as they
Nursing Interventions for TB
1. Isolation- place in a room with negative pressure and adequate airflow for two weeks or until clinical symptoms improve
2. Use a respirator mask when caring for patient (AFB precautions)
Prevention of Aspiration
-Elevated HOB
-Turn patient to the side when vomiting
prevention of stimulation of gag reflex with suctioning or other procedures
-Assessment and proper administration of tube feeding
-Rehabilitation therapy for swallowing
Atelectasis
Collapse or airless condition of the alveoli caused by hypoventilation, obstruction to the airways, or compression.
Cause of atelectasis
Bronchial obstruction by secretions due to impaired cough mechanism or conditions that restrict normal lung expansion on inspiration.
-Post Op patients are at high risk
Symptoms of atelectasis
insidious and include cough, sputum production, and a low-grade fever
Respiratory distress, anxiety and symptoms of hypoxia occur if large areas of the lung are affected
COPD
Emphysema
Chronic Bronchitis
Emphysema
permanent enlargement of air spaces distal to the terminal bronchioles, characterized by destructive changes in the alveolar walls.
-Called Pink Puffers
Chronic Bronchitis
Chronic airflow limitation like emphysema, characterized by airway disease, daily productive cough for at least 3 months over a period of 2 years
-Called Blue Bloaters
Etiology of Chronic Bronchitis
Smoking, air pollution small % familial
Symptoms of Chronic Bronchitis
Breathlessness
Cyanosis
Edema
Bloated Appearance
Sputum production at least 3 months
Symptoms of Emphysema
Dyspnea on exertion
use of accessory muscles
Barrel chest and thin
Cyanosis rare
Assessment of COPD
Increase in A/P diameter, SOB, tachypenic, purse lip breathing
Palpation: Increase vibration
Percussion: Hyperresonance
Auscultation: crackling and wheezing
ABG's: hypoxemia, low O2 sat
PFT's: increased TLC, residual volume increased, expiratory flow decr
Risk Factors for COPD
Tobacco smoke causes 80-90% of COPD
Passive smoking
Occupational exposure
Ambient air pollution
Genetic abnormalities
Collaborative problems with COPD
-Respiratory insufficiency or failure
-Atelectasis
-Pulmonary Infection
-Pneumonia
-Pneumothorax
-Pulmonary Hypertension
Goals for COPD
-Smoking cessation
-Improved activity intolerance
-max. self management
-Improved coping ability
- Adherence to therapeutic regimen and home care
-Absence of complications
Improving Gas Exchange
-Administer Corticosteroids and Bronchodilators
-Reduce pulmonary irritants
-Directed coughing
-Chest PT
-Breathing exercises to help reduce air trapping (Diaphragmatic breathing, Pursed Lip breathing)
-Use of Supplemental oxygen
Asthma
(Reversible airway disease)
-Characterized by an increased responsiveness of the airways to various stimuli and manifested by slowing of forced expiration which changes in severity after therapy or spontaneously
3 Types of Asthma
1. Allergic Asthma
2. Idiopathic non allergic asthma
3. Mixed Asthma- may exist with COPD
Symptoms of Asthma
Cough, wheezing, dyspnea
Medications for Asthma
1. Bronchodilators: Beta adrenergic agonists, Antichollinergics, Corticosteroids
2. Inhalers-metered dose inhalers
3. Nebulizers- hand held propels medicine into the airways and lungs via microscopic particles in a mist
3. Oral
Oxygen Therapy
-PaO2 less than 55 mmHg or O2 sat less than 90%
-Symptoms: hypoxemia, include change in mental status, restless, confused, tachycardia, HTN
-Late Symptoms: Headache, hypotension (vasodilate), lethargy, drowsiness, bradycardia, dyspnea, cyanosis
-Devices:
Methods to maintain a patient airway
Cough, Incentive Spirometer, Moisture of oxygen, chest PT
Incentive Spirometer
Mechanical device, encourages deep breaths
1. Assist patient to semi-fowlers
2. exhale normally-inhale deeply through the mouthpiece and hold for 3 seconds- remove mouthpiece and exhale-cough-observe sputum
3. Increase goal by 100-200 for each successive
Chest PT
1. Chest percussion
2. Chest vibration
3. Postural Drainage
Pursed Lip Breathing
prolong emptying time from the lungs, and keeps airways open, exhalation should be twice as long as inspiration improves (3-4%), tighten abdominal muscles while breathing out, fold arms across abdomen while sitting then bend over while exhaling
Mechanical Ventilation
Process of delivering gases into the lungs by a mechanical device indications: inadequate ventilation and hypoxemia
Settings for Mechanical Ventilation
1. mode-positive pressure forcing inspiration- passive exhalation
2. Respiratory Rate (per minute)
3. FiO2- concentration of oxygen
4. I/E Ratios
Cystic Fibrosis
-Hereditary
-Median expected survival age is 37
-Respiratory manifestations: productive cough, wheezing, hyperinflation of the lungs (x-ray)
-Other: pancreatic insufficiency, abdominal pain, vitamin deficiences