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Respiratory Part 2

Deviated Septum
deflection of the normally straight nasal septum
most commonly caused by trauma or congenital deficit
may be surgically corrected
*assess ability to breathe out of both nostrils
*goal of nursing: reduce edema, prevent complications, educate pt, provide emotional support
airway, airway, airway
Nasal Fracture
most commonly caused by trauma
can cause airway obstruction and cosmetic deformity
*assess ability to breathe out of both nostrils
*goal of nursing: reduce edema, prevent complications, educate pt, provide emotional support
airway, airway, airway
Raccoon Eyes
ecchymosis(bruise) involving both eyes
Infectious and Inflammatory Disorders
average person experiences 3 – 5 URI/year
URI most common cause for missing work/school
90% of URI are viral (antibiotics won’t fix)
treat as outpatient
Rhinitis
inflammation of mucous membranes of the nose (cold)
rhinovirus most common cause
spread by inhalined droplets and direst contact
*cough/sneeze into elbow; good hand hygiene
Symptoms of Rhinitis
sneezing, nasal congestion, sore throat, watery eys, cough, low grade fever, HA, malaise
lasts 5 – 14 days
treat symptoms with:
decongestants- loosen mucus
saline gargles- clear throat
antitussives- stop cough at night, to help pt sleep
expectorant- help cough stuff up, during day
antihistamines- blocks histamine, dry mouth, drowsy, (careful in elderly men b/c difficulty urinating antihistamine can increase chance of urinary retention)
When is the common cold most infectious?
at the beginning; within the first few days
What is best way to prevent transmission?
*hand hygiene*
sneeze/cough into elbow
How do you use nasal sprays?
make sure nares are patent; ask them to blow nose
both nares; occlude one have pt sniff, occlude the other have pt sniff
DO NOT SHARE!
What is a common adverse effect of nasal decongestants?
nose bleeds
addictive
rebound
Sinusitis
inflammation of sinuses
maxillary sinus affected most
can lead to infection of the middle ear of brain; happens b/c sinuses are just cavities in the bones of the skull
caused by infection from nose to sunuses and by sinus drainage blockage
allergies can lead to sinusitis
S&S of Sinusitis
HA, fever, pain, nasal discharge, malaise
diagnose with nasal smear which identifies the organism; determines if bacterial, viral, fungal
treat with antibiotic therapy or surgical procdure called Caldwell-Luc (rotorooter of sinuses)
*not all cases get nasal swabs, if going to walk in clinic they will treat off of what is ‘going around’ in the community.
Nursing Management of Sinusitis
inform pt that mouthwashes, humidification and increase fluid intake (to thin mucus secretions; contraindicated in renal failure and HF) can increase comfort
sinus surgery: provide postop care; pt will have nasal packing and drip pad; encourage oral hygiene. (open mouth breathing & smell!); in Fowler’s position
Pharyngitis
inflammation of throat
caused by bacteria and viruses
*most serious*: group A beta-hemolytic streptococci that can lead to cardiac complications (endocarditis), renal complications such as (glomerulonephritis)
highly contagious
*strep throat very dangerous if not treated; can settle on valves of heart; can cause kidney problems
*tx of choice penicillin 10 – 14 days (encourage/stress the importance of completing entire dose; and to prevent mutation of strain/ resistant microorganisms)
Tonsilitis and adenoditis
infected lymphatic tissue (responsible for catching invading microbes)
chronic tonsilitis can lead to airway obstruction
both infections can be primary or secondary (gotten from something else)
*white patches* may be present on tonsils (if group A beta-hemolytic strep is cause)
throat cx and start on antibiotics (then MD will rx new prescription if not covered with old)
Treatment of Tonsilitis
antibiotic therapy
operative procedures (tonsillectomy/adenoidectomy); mostly outpatient
assess bleeding studies bc hemorrhage is greatest risk
pts admitted if: vomiting; excess bleeding; must tolerate PO fluids (in order to not dehydrate at home)
Laryngitis
inflammation and edema of mucous membranes lining the larynx
follows URI due to spread of microorganisms
pt hoarse or have complete voice loss
tx with voice rest (no talking), antibiotics, cessation of smoking
Epistaxis
nosebleed
rupture of tiny capillaries in mucous membrane of nose
caused by trauma, hypertension, tumors, blood dyscrasias (if from hypertension or blood dyscrasias, could be hard to control)
treat with pressure, electrocautery, packing cotton, inflated balloon
What position do you place a patient’s head with epistaxis?
head forward/down
*do NOT put head back*
Where do you apply pressure?
at bridge of nose; put ice on bridge of nose
Cancer of the Head and Neck
exposure to various fumes and chemicals may predispose to head an neck cancer
early detection can lead to cure
most laryngeal cancers are squamous cell carcinomas (cancer arises from epithelial cells lining the pharynx)
Malignancies of Upper Airway
male to female ratio 3:1
increasing in women due to rising alcohol and tobacco consumption
90% of head and neck cancers arise after prolonged us of tobacco and alcohol
*throat and cervical cancer linked (same virus)
Cancer of Head and Neck
exposure to various fumes and chemicals may predispose to head and neck cancer
early detection can lead to cure
most laryngeal cancers are squamous cell carcinomas (cancer arises from the epithelial cells lining the pharynx)
Laryngeal Cancer
early symptoms: persistent hoarseness, followed by a lump, then pain when talking.
malignant tissue must be removed immediately
advancing cancer will see weakness, weight loss, pain, anemia
diagnose with laryngoscopy and biopsy
tx depends on age, size of lesion, tumor and presences of metastasis.
may receive chemo and radiation alone or with surgery
Laryngeal Cancer Surgery
laser surgery and partial or complete laryngectomy for early cases
radial neck dissection (lymph nodes, muscles, adjacent tissues) in advanced cases
*4 Goals of Treatment of Laryngeal Cancer*
*
1. cure
2. preservation of safe effective swallowing
3. preservation of a useful voice
4. avoidance of a permanent trach
*
Patients with Laryngectomy
permanent tracheal stoma b/c the trachea is no longer connected to the nasopharynx
only resp organs used are trachea, bronchi, and lungs
no longer feel air entering through the nose; enters and leaves the trach.
Laryngeal Cancer: Communication
loss of speech is devastating (permanent loss of speech)
*alaryngeal communication* (communication without larynx)
espophageal speech: instruct pt to swallow air and regurgitate word, start 1 wk post op, after pt able to take PO fluids
electric larynx: throat vibrator.
tracheoesophageal puncture: resembles normal speech, requires voice prosthesis, trach tube will be some different
*pg 541 – 543
Laryngeal Cancer Preop
assess pt understanding of the procedure and outcomes.
discuss alternative methods of communication and which on pt prefers
let pt express fears and concerns
*goals: increase pt knowledge, decrease anxiety, have communication plan*
Laryngeal Cancer Postop
assess for patent *airway* and *airway* clearance
prevent pain and wound infection
assess stoma site, resp system, oxygenation, *airway* patency
teach family how to dress wound
NO swimming, water enter lungs through trach, careful when showering
avoid fabrics and dressings that fray
*goals: nutrition and hydration, monitor for bleeding, increase body image/self esteem, optimize self care management.*
When assessing post op laryngectomy pt, you discover he has a pulse of 110, resp rate of 26, his skin is cold and clammy. There is thick white sputum bubbling from his trach tube. Your first intervention is?
airway ,airway, airway

position in Fowler’s
suction
*if the airway is not open and patient not ventilating gas exhange can not occur

Disorders of Lower Respiratory Tract
gas exchange occurs in lower resp tract
certain diseases interfere with lower resp tract ability to function
some lead to resp failure
others affect the pts quality of life, can be deadly or disabiling (some curable some treatable)
*where gas exchange occurs*
Atelectasis
closure or collapse of the alveoli
x-ray finding
S&S cough, sputum production, low grade fever, tachypnea, dyspnea, decreased breath sounds, crackles over affected area (from leakage of capillary beds)
CXR reveals patchy infiltrates or consolidated areas
*PREVENTION* is key; turning, coughing, deep breathing, IS, move.
goal of tx: imporve ventilation, remove secretions
if pleural effusion is large & collapsing a lung, tx may include thoracentesis or chest tube insertion
Acute Bronchitis
inflammation of lower resp tract that usually due to infection and occurs most frequently in pts with chronic resp disease
can occur in other individuals as a result of URI
cause is usually viral but can also be caused by infection in smokers and nonsmokers
*viral =clear sputum
*cough make pt seek medical help
Acute Bronchitis S&S
persist cough following acute URI is most common symptom
cough followed by clear, sputum (viral)
fever, HA, malaise
physical exam; mildly elevated temp, pulse, and resp rate with normal sounds
Acute Bronchitis Tx
CXR shows no consolidation as with pneumonia
ttx is supportive, including fluids, rest, cough suppresants
antibiotics if person is smoker or has COPD
COPD pts are prescribed antibiotics when symptoms of acute bronchitis occurs.
increase PO fluids
Pneumonia
an inflammatory process involving the brochioles and alveoli
until 1936 pneumonia was leading cause of death in the US
slufa drugs and penicillin were discovered and used to be tx pneumonia
Community Acquired Pneumonia
out in community; come in contact with in every day life activities
Hospital Acquire Pneumonia
nosocomial: got in hospital; got 48 hours after admission
Aspiration Pneumonia
entry of substances into airway
contents into lung (seen in sick and healthy)
Pneumonia of the immunocompromised
PCP or pt on chemo, steroid excess, not always HIV/AIDS
*rarely observed in immunocompetent hosts
*often initial AIDS defining complaint
Pneumonia Pathophysiology
pneumonia is still common, some forms have high mortality rate
normally, airway distal to larynx is *sterile* due to protective defense mechanisms
organisms reach lungs by inhalation of droplets, aspiration of organisms from the upper airway, infiltration from bloodstream (less common)
localized response fires: capillaries swells and fluid can leak
Typical Pneumonia
bacterial in adult
Atypical Pneumonia
caused by mycoplasmas bacteria without cell walls and have many shapes
Radiation Pneumonia
Chemical Pneumonia
pt inhaled something “huffing”
Lobar Pneumonia
lobe (1 or more) infected
Brochopneumonia
scattered throughout lungs
Hypostatic Pneumonia
bed ridden patients breathing with only part of lung not breathing deep enough
Pneumonia S&S
Bacteria; onset sudden, fever, chills, productive rusty colored sputum, malaise, pain with breathing.
Viral: blood cultures without bacteria, sputum copious, chills less common, respirations and pulse slow.
Less severe than bacterial, but patients are weaker and ill longer than successfully treated bacterial.
***Not possible to dx a specific type of pneumonia by clinical manifestations alone***
Pneumonia Physical Assessment
wheezing, crackling, and decreased breath sounds, increased tactile fremitus
History
Sputum cultures, chest x-rays, lab studies, blood cultures.
*hang antibiotics only *after* blood cx have been drawn
Treatment of Pneumonia
Antibiotics, hydration to thin secretions, oxygen therapy, bed rest, chest physical therapy, bronchodilators, analgesics, antipyretics, cough expectorates and suppressants. Possible intubation and ventilation.
Antibiotics *only if* bacterial pneumonia. If community acquired, health care provider will prescribe based on what is “going around at the time” if unable to get sputum culture or until culture is obtained & reported.
**core measure! timing: first antibiotic dose within first 4hrs after admission**
Pneumonia Nursing Management
Auscultate lung sounds, ABGs, pulse oximetry, quality of breathing.
Assess cough and nature of sputum.
Semi-fowlers position, encourage fluid, respiratory treatments, Intake and output, vital signs, electrolytes, fever reduction. Encourage pneumonia vaccine over 65, or compromised immune system.
*ask every pt if they’ve had the pneumonia or flu vaccines*
*RN must document about vaccines: declined?,why?, contraindicated?, fever?, already received?
Preventing Pneumonia
Turn and position
Promote coughing and expectoration.
Deep breathing and coughing.
Prevent infection and aspiration.
Stop smoking and alcohol consumption.
Pleurisy
Acute inflammation of the parietal and visceral pleura.
During the acute phase the pleurae are inflamed, thick, and swollen, exudate forms and the pleurae becomes rigid.
*During inspiration the inflamed pleurae rub together causing severe pain.
*deep breaths, coughing, sneezing make worse
Pleurisy S&S
*key symptom is PAIN*
*Respirations become shallow due to pain.* Pleural fluid accumulates as inflammation worsens. (air moving in and out makes worse)
Friction rub heard during inspiration and early expiration. (like sandpaper rubbing together)
Usually occurs secondary to pneumonia or secondary infections.
May need thoracentesis to remove fluids from the chest.
How do you assess for a friction rub?
pain
auscultate
What does a friction rub sound like?
sandpaper
Pleurisy Tx
Treat with analgesics and antipyretic drugs. *Nonsteriodal anti-inflammatory such as indomethacin(Indocin)* helps with pain and promotes coughing.(physician initiated)
Nursing (interventions): help splint chest wall by turning onto the affected side, using hands, and pillow.
Provide emotional support.
Pleural Effusion
Collection of fluid between the visceral and parietal pleurae.
Complication of cancer, TB, pulmonary embolism, etc.
The fluid *may be great enough to collapse the lung* on the affected side b/c its pushing against air sacs.
Fever, pain, dyspnea, diminished breath sounds, friction rub. Chest x-ray shows fluid in the involved area.
*Severity of Pleural Effusion Symptoms Depends on 3 Factors*
*size* of effusion
*speed* of formation (slowly developed vs fast development)
*underlying disease* process
Pleural Efusion Tx
eliminate the cause
tx with antibiotics, analgesics, v drugs to control CHF, thoracentesis, and cancer surgery
nurse will assist with thoracentesis ans provide support
take care of chest tube if inserted
external sign seen in trachea shift. moves away from affected side collapsing. problem on R, trachea moves to L (and vice-a-versa)
Empyema
*a localized infection in the lung that has been ‘walled off’ like an abscess*
Pus or infected fluid within the pleural cavity. Infection following stabs, GSW, pneumonia, TB, etc.
The abcessed area will be walled off and enclosed by a membrane.
Fever, chest pain, dyspnea, anorexia, and malaise. Diminished breath sounds.
Empyema Tx
*drain cavity and achieve complete expansion of lung*
Aspirated by thoracentesis, provide antibiotic therapy, chest tube.
Thoracatomy (surgical opening of the thorax) and one or more chest tubes are inserted. The tubes are connected to underwater-seal drainage bottle.
Healing is long, provide emotional support, turn cough and deep breathing.
Thoracic Surgery
Thoracotomy is surgical opening in the chest wall. **Performed for many reasons; remove fluids, pneumonectomy, lobectomy, repair structures, such as open heart, chest trauma, biopsy, remove foreign objects(bullets or metal fragments).**
Preoperative management is performed
Preop Nursing Management
Assessment- obtain hx; hands on physical assessment
Improving airway clearance-
patient teaching- preop discuss talking and deep breathing
relieving anxiety
Thoracic Surgery
Postoperative management: When the thorax is opened, atmospheric pressure collapses the lungs. *Anesthesia ventilates the patient(during surgery).*
After surgery air, blood, and secretions are drained so that the lungs can expand. This is done with water-seal.
Thoracic Surgery Postop
Immediate postoperative standards are as previously discussed.
Assess resp function.
Assess sputum production.
Assess level of pain using pain scale. treat
Suction as needed. (sputum production)
Turn, cough, and deep breath. Ambulate as soon as possible.
Discuss fears and anxiety( Look at functional health assessment)
Post Op Positioning
pneumonectomy: turn q 1 hr from back to operative side & should not be turned completely to unoperated.
Lobectomy: turn either side
Check with surgeon for specifics but should go from supine to low to mid fowlers as soon as possible
Penetrating Wounds
Penetrating wounds are serious due to positive pressure entering the negative chest cavity.
The positive pressure causes a pneumothorax. Death can occur.
Large wounds make a sucking sound as air enters and leaves the chest.
Penetrating wounds can involve pneumothorax and hemothorax Subcutaneous emphysema may be present. Sudden pain and dyspnea are symptoms.
Assessing a Penetrating Wound
Auscultation of the chest, history of injury and physical are used for diagnosis.
X-ray shows the amount of collapse and the amount of air and blood present.
Thoracotomy may be needed to remove bullets and knives. Removal at the scene can allow air to enter.
Emergency management include covering the site to prevent air.
Tension pneumothorax: air enters and cannot escape. The lungs, heart, and trachea shift away.
Spontaneous pneumothorax: just happens
Purpose of Chest Tube
The tube is inserted in the pleural space. This restores neg intrathoracic pressure needed for lung re-expansion after surgery or trauma
Nursing Management of Chest Tubes
Maintain and restore patients highest level of respiratory function.
Protect from injury caused by malfunctioning equipment.
Chest Tubes Assessment
Check medical record for reason, date, and amount of chest tubes.
Check orders for amt of suction if any.
Assess patient as soon as possible.
Look for hemostats at bedside.
.Monitor pulse oximetry
Assess lung sounds.
Inspect dressing.
Palpate skin around tube for subcutaneous emphysema (presence of air).
Inspect all connections for secure tape.
Check tubing for kinks and that it hangs freely.
Observe fluid in water-seal chamber.
If constant bubbling, (in the water seal chamber)clamp tubes at the chest and few inches below.
Continue releasing hemostats until bubbling stops.
Place tape around the tube where the last clamp was released.
Regulate suction for gentle bubbling.
Air leaks are indicated by…
constant bubbling in the water seal chamber or in the air leak indicator in dry systems with a one way valve.
Chest Tubes
Keep the system below the chest
Curl and secure tubing to bed, be careful when turning.

Encourage deep breathing and coughing.
If tube accidentally pulled out, cover with petroleum gauze dressing.
Mark the drainage at the end of the shift, never empty the container.
Monitor for air leaks

To Clamp or Not to Clamp?
Pulmonary Circulatory Disorders
Pulmonary hypertension results from heart disease and lung disease.
Resistance of blood flow in pulmonary circulation causes pulmonary hypertension.
Normal pulmonary arterial pressure is 25/10.
Pulmonary hypertension can be 40/15mmhg.
Pulmonary Hypertension
Primary pulmonary hypertension rare and exists without other diseases.
Secondary pulmonary hypertension occurs with other diseases such as COPD.
Pulmonary Hypertension Assessment
Most common dyspnea on exertion and weakness.
Secondary symptoms include: chest pain, fatigue, weakness, distended neck veins, orthopnea, peripheral edema.
Diagnostic: ECG (right ventricular hypertrophy.
Abnormal ABG.
Pulmonary Hypertension Medical Management
Vasodilators and anticoagulants.
The primary form has poor prognosis.
May be candidates for heart-lung transplantation.
Secondary: treat underlying disease.
Oxygen to increase arterial oxygenation.
Right ventricular failure: digitalis, rest, and diuretics.
Nursing Management:Respiratory assessment, oxygen therapy, and rest.
Pulmonary Embolism
Involves obstruction of one or more pulmonary vessels.
Results form thrombus formation in veins or right side of heart.
Embolus is any foreign substance: blood clot, air, fat that travels to lungs.
Occludes a pulmonary vessel leading to infarction distal to clot.
Usually occur from clots in deep veins of lower extremities or pelvis.
Fat embolus from fracture of long bone, especially femur.
Recent surgery, prolonged bedrest, trauma, postpartum.
Assessment of PE
Small area of lung: less severe, pain, tachycardia, dyspnea, maybe fever, cough, bloody sputum.
Larger areas: dyspnea, severe pain, cyanosis, tachycardia, restlessness, and shock.
Sudden death if large embolism occludes a main section of artery
Pulmonary Embolism Manifestations
Small area of lung: less severe, pain, tachycardia, dyspnea, maybe fever, cough, bloody sputum.
Larger areas: dyspnea, severe pain, cyanosis, tachycardia, restlessness, and shock.
Sudden death if large embolism occludes a main section of artery
Pulmonary Embolism Nursing Management
embolism usually occurs suddenly, assessment and early recognition important.
IV infusion before shock.
Vasopressors (dopamine) for hypotension.
Oxygen for dyspnea( most important at this time), pain medication.
Monitor vital signs, Intake and output, ABGs, electrolytes, respiratory status, coagulation studies, PTT, PT.
Assess for bleeding.
Discharge instructions about bleeding.
Medications as prescribed.
Follow-up blood work and office visits.
Flail Chest
Complication of blunt chest trauma
Steering wheel injury/air bag
Three or more fractured ribs at two or more sites, free floating ribs segments
Chest looses stability =respiratory impairment= respiratory distress.
*Flail Chest
*As chest expands on inspiration, the detached rib segment (flail segment) moves in a paradoxical manner.
Moves inward during respiration ( limits air that can get into lungs)
On expiration, flail section bulges outward, impairing the patient’s ability to exhale
Retained secretions and atelectasis usually accompany flail chest.
Patient has hypoxemia,resp acidosis, metabolic acidosis, decreased tissue perfusion
Flail Chest Medical Management
Treatment usually supportive
Ventilatory support, clearing secretions, controlling pain
Turn, cough, db, suction, IV analgesics
Monitor for respiratory compromise
Severe flail chest: endotracheal intubation and mechanical ventilation
Rarely surgery is used to stabilize fractures
Flail Chest Management
Carefully monitor with chest x-rays, ABGs, pulse ox., and pulmonary function studies
Pain control is key to successful treatment: PCA, nerve blocks, epidural analgesia
Acute Respiratory Failure
When CO2 elimination and O2 supply cannot keep up with body supply and demand: Hypoxia (PO2 less than 50), Hypercapnia (PCO2 greater than 50) pH less than 7.35
Common causes: decreased respiratory drive; brain injury, multiple sclerosis, sedatives, hypothyroidism (chemoreceptors in brain do not receive normal responses) drug overdose
Dysfunction of chest wall
Dysfunction of Lung Parenchyma
..
Assessment of Acute Respiratory Failure
restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure, adventitious breath sounds
Treatment of Acute Respiratory Failure
correct underlying cause and restore gas exchange, may have to ventilate.
Nursing: assist with intubation and maintain ventilator; assess resp. status, mouth care, turn, pulse ox. Vital signs, skin care. Initiate some form of communication.
Assess resp. system and ask questions specific to this episode of distress
As patient improves initiate patient education
Lung Cancer
Number one cancer killer among men and women in US
Continues to rise in women
Risk factors: smoking, second-hand smoke, environmental and occupational exposures, gender, genetics, and dietary.
*70% of pts. spreads to lymphatics by dx*
Lung Cancer Assessment
: develops insidiously and is asymptomatic until late.
Most frequent is chronic cough, nonproductive at first, then productive as infection occurs. Often ignored.
Wheezing, hemoptysis, fever, chest or shoulder pain, pleural effusion.
Most common site of metastases: lymph nodes, bone, brain, lung, liver, adrenal glands
Lung Cancer Dx
Chest x-ray, ct scans, MRI, fiberoptic bronchoscopy
Lung Cancer Tx
depends on cell type, stage, and physiologic condition.
Surgery, radiation, or chemo; or combination of all.
Surgery is preferred method if possible (lobectomy or pneumonectomy)
Lung Cancer Radiation Therapy
Lung Cancer Chemo
Lung Cancer Paliative therapy
radiation to shrink tumor or to relieve pain
Lung Cancer Hospice
end -of- life care for pt and family
Pulmonary Edema
Accumulation of fluid in the interstitium and alveoli of lungs
Right side of heart delivers more blood to pulmonary circulation that left side can handle
Fluid escapes capillary walls and fills airways
*Severe: life threatening condition*
Pulmonary Edema Assessment
dyspnea, sob, feeling of suffocation
Cool, moist skin, cyanotic skin
Blood tinged sputum, and frothy fluid
Crackles can be heard without stethoscope
Emergency treatment: lasix, oxygen, dopamine, digoxin (improve ventricular function), calcium channel blockers
*sever resp distress
air hungry, drowning in fluid

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