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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Medical Surgical NursingPreparation for Practice
CHAPTERCHAPTER CHAPTERCHAPTER
Nursing Assessment of Nursing Assessment of Patients with Patients with Respiratory DisordersRespiratory Disorders
Nursing Assessment of Nursing Assessment of Patients with Patients with Respiratory DisordersRespiratory Disorders
3333
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Complete Assessment
• History– Biographic and demographic data– Chief complaint– Past medical history– Family history– Risk factors– Social history
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Complete Assessment
• Components of Physical Exam – Inspection– Auscultation– Percussion– Pain– Genetic and gerontological considerations
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Social History
• Patients’ lifestyles and habits and • Risk for developing pulmonary disease• Current and previous work settings• Home environment• Social settings
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Gerontological Considerations
• aging decreases respiratory function• lower arterial oxygen values, • increase risk of pneumonia• Risk of aspiration may increase with aging• Aging may affect patient comfort needs
during the examination
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Genetic Considerations
• Cystic fibrosis (CF): genetic disorder, typically diagnosed in childhood
• CF has serious pulmonary complications – thick mucus builds up in lungs
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Inspection
• Initial assessment activity• General appearance:
– Posture, facial expression and movements – Changes in mental status – Respiratory rates shallow breathing, irregular
patterns of breathing – Size and shape of the thorax, asymmetry– Diminished movement of rib cage, use of
accessory muscles
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Inspection
• Color and appearance of skin– Pallor may indicate decreased oxygen-
carrying capacity of the blood due to anemia– Central cyanosis, where the mouth, lips, and
mucous membranes are blue-tinged, indicates hypoxia in adults
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Inspection
• Inspection of the neck– Appearance of veins, trachea and
musculature may indicate chronic cardiac or pulmonary disease, pneumothorax
– Goiter or lesions may obstruct the upper airway
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Inspection
• Palpation of skin and extremities– Edema of lower extremities– Skin temperature and moisture – Clinical reference points – Chest excursion – Tactile fremitus – Tenderness – Crepitus
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Medical Surgical Nursing: Preparation for Practice
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Clinical Reference Points
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Medical Surgical Nursing: Preparation for Practice
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Occupational Impact on Respiratory Disease
• Exposure to airborne particles, vapors, and irritants
• Can result in acute or chronic respiratory disease in susceptible individuals
• Early recognition, diagnosis, and treatment of occupational asthma can prevent pulmonary complications
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Auscultating Breath Sounds
• Patient should be upright • Use the diaphragm of the stethoscope• Begin at C7 posteriorly and anteriorly from
above the clavicles• Move steadily from right to left upper and
lower• Compare breath sounds bilaterally• Do not auscultate over clothing
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Diaphragm - best for higher pitched sounds, like breath sounds and normal heart sounds.
Bell - is best for detecting lower pitch sounds, like some heart murmurs, and some bowel sounds. It is used for the detection of bruits, and for heart sounds (for a cardiac exam, listen with the diaphragm, and repeat with the bell).
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Figure 33.1 In a respiratory assessment, it is important to palpate and count ribs and interspaces to accurately record the location of lesions or adventitious breath sounds.
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Auscultating Breath Sounds
Figure 33.2 Lobes of the lung—anterior.
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Auscultating Breath Sounds
Figure 33.3 Lobes of the lung—posterior
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Tracheal Breath Sounds
• Auscultated over the trachea• Loud and high pitched• Cause: airflow through tubular trachea• Best heard over the neck and trachea• Occurs during upper airway obstruction
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Bronchial Breath Sounds
• Anterior: heard on either side of sternum, over main stems of the bronchus from 2nd to 4th intercostal spaces
• Posterior: best heard lateral to the spine between 3rd and 6th intercostal spaces
• Loud, harsh, less turbulent and lower than tracheal sounds
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Bronchial Breath Sounds
• Pause between inspiration and expiration; expiration is heard for a longer time than inspiration
• Sounds over smaller airways are low pitched and softer
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Bronchovesicular Breath Sounds
• Heard during inspiration and expiration• Midway in Pitch and loudness between
vesicular and bronchial breath sounds• Best heard in 1st and 2nd intercostal
spaces of anterior chest, between scapulae of the posterior chest
• Represent air movement in the moderate airways between the bronchi and the smaller airways
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Vesicular Breath Sounds
• Heard over most of the thorax• Soft and low pitched, rustling, from air
moving through small airways• Heard longer during expiration, which
generally lasts twice as long as inspiration
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Adventitious Breath Sounds
• Decreased or no sounds where normal sounds should occur
• Breath sounds occurring in abnormal locations
• Diminished breath sounds demonstrate decreased airflow and potentially decreased oxygen exchange
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Adventitious Breath Sounds
• Adventitious/extra sounds: – Represent pathologic conditions of heart or
lungs– Indicate disrupted airflow due to airway
spasm, fluid, or secretions – Crackles (rales-term not used as much),
Wheezes, Stridor, Friction rubs
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Crackles
• Caused by fluid in the airways• Intermittent or discontinuous, nonmusical, or
popping sounds • Caused by fluid, inflammation, infection, or
secretions• Crackles are described as either fine or coarse• Occur when closed airways snap open during
inspiration• Softer, gentler sound may also be heard on
inspiration
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Medical Surgical Nursing: Preparation for Practice
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Wheezes
• Heard equally during inspiration and expiration• High-pitched musical sounds • Caused by air flowing across strands of mucus,
swollen pulmonary tissue that narrows the airway, bronchospasm
• Rhonchi (term for secretions in airways-not used as much)
• Inspiratory/expiratory, continuous/ discontinuous, mild/moderate/severe
• Asthma, allergies, reactive airway disease
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Stridor
• Heard only during inspiration as air attempts to flow across an obstruction
• Heard without stethoscope as high-pitched, crowing sound
• With stethoscope, best heard over large airways, e.g., trachea or bronchus
• Report to the health care provider immediately • Indicates airway obstruction requiring
intervention
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pleural Friction Rubs
• Low-pitched, creaking or squeaking sounds • Occur when inflamed pleural surfaces rub
together • Heard on inspiration• Pitch usually increases with chest expansion• Have the patient hold breath to distinguish
between pleural and pericardial friction
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Adventitious Lung Sounds
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Medical Surgical Nursing: Preparation for Practice
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Travel and Area of Residence
• An important aspect of the history in diagnosing potential respiratory problems
• Exposure to region-specific infectious diseases
• Exposure to environmental conditions, e.g. high altitudes
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High-Altitude Pulmonary Edema (HAPE)
• HAPE – can occur with travel to altitudes greater than 5,000 feet
• Increasing altitude → decreasing atmospheric pressure → decreasing available O2
• Rapid onset of hypoxemia may result• Compensatory increased respiratory rate
may contribute to fatigue
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Medical Surgical Nursing: Preparation for Practice
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High-Altitude Pulmonary Edema (HAPE)
• This causes further respiratory insufficiency
• Initial compensatory mechanisms – pulmonary vascular vasoconstriction
• Later, inflammatory mediators cause vasodilation
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Medical Surgical Nursing: Preparation for Practice
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Percussion
• Assess presence of air, fluid, solid mass in underlying tissues
• Normal lungs produce a resonant, low-pitched clear sound
• Hyperresonance indicates airways are hyperinflated or air is present outside of lung tissue
• Dullness indicates that air is absent– Pneumonia, pleural effusion, hemothorax, solid
tumors
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pain
• Pain during respiration may decrease tidal volumes
• Pain management enables participation in rehabilitative activities
• Also promotes deep breathing to prevent pneumonia and atelectasis
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Standard of Care
• For patients with cardiac and respiratory illness, standard is:– Continuous or intermittent observation of the
patient’s oxygen saturation – End-tidal carbon dioxide levels– Peak flow is utilized to trend treatment
effectiveness in patients with asthma
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Assessment of Arterial Oxygen Levels
• ABG’s• Pulse oximetry• Physical assessment
• FiO2 will increase the PaO2 four times (normal patient)
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pulse Oximetry
• Measures O2 saturation of hemoglobin
• Reflects light off the hemoglobin molecules
• Measures the absorption of light by hemoglobin
• Normal range is from 95% to 100%
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Medical Surgical Nursing: Preparation for Practice
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Factors Interfering with Pulse Oximetry
• Nail polish • Automated BP cuffs, hemodialysis fistulas,
or arterial lines interfere with blood flow • Shock and hypovolemia • Patient movement, ambient light, and
venous pulsations may also cause inaccurate readings
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Medical Surgical Nursing: Preparation for Practice
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Peak Flow Meters
• Track trends in a patient’s condition, evaluate air movement to determine severity of asthma exacerbation
• Measure the peak expiratory flow rate• Normal values based on age and body
size• Severity scale: Utilizes red, yellow, and
green zones to determine the severity of decrease in peak flow
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Medical Surgical Nursing: Preparation for Practice
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Arterial Blood Gas Studies (ABG)
• Provide information on arterial oxygen and carbon dioxide levels
• Oxygen saturation, bicarbonate, and blood pH are also calculated
• CO2 is major determinant of respiratory alkalosis/acidosis
• Bicarbonate level is determinant of metabolic acidosis/alkalosis
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Medical Surgical Nursing: Preparation for Practice
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Capnography
• Measurement of exhaled CO2
• Some utilize paper treated to detect the presence of acid such as CO2
• Others use spectrography, generate waveform readings
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Medical Surgical Nursing: Preparation for Practice
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Capnography
• Useful in determining ventilatory status, readiness for extubation
• Also used to determine pulmonary vessel perfusion in patients with pulmonary embolus
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Capnography Monitor
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Medical Surgical NursingPreparation for Practice
CHAPTERCHAPTER CHAPTERCHAPTER
Caring for the Patient Caring for the Patient with Upper Airway Disorderswith Upper Airway DisordersCaring for the Patient Caring for the Patient with Upper Airway Disorderswith Upper Airway Disorders
3434
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Facial Bones
• Mandible • Maxilla• Zygoma• Temporal bones • Frontal bone
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Mandible
• U-shaped bone • Together with the maxilla, largest and
strongest bone of the face• Forms lower jaw, holds the lower teeth in
place• Articulates with temporal bones at the
temporomandibular joint• Only mobile bone of the facial skeleton;
motion is essential for mastication
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Medical Surgical Nursing: Preparation for Practice
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Nursing Management for Mandibular Fractures
• Determine patient’s nutritional requirements and knowledge deficits
• Oral nutrition with high-protein liquid diet and calories is essential
• Avoid weight loss if possible to ensure nutritional adequacy for healing
• Nasogastric or oral gastric tube supports nutrition if patient has extensive facial swelling
• Observe for nausea and vomiting, intervene to prevent aspiration
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Maxilla
• Largest component of the middle third of the facial skeleton
• Attaches laterally to the zygomatic bones • Key bone in the midface, provides
structural support • Fractures less frequently than mandible or
nose due to strong structural support
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Classification System of Maxillary Fractures
• Le Fort I Fracture (horizontal)• Le Fort II Fracture (pyramidal)• Le Fort III Fracture (transverse)
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Zygoma
• A paired bone, commonly called the cheekbone
• Articulates with maxilla, temporal, sphenoid, and frontal bones
• Forms prominence of the cheek• The masseter muscle is suspended from
the zygomatic arch
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Temporal Bone
• Situated at the sides and base of the skull• Houses cochlear and vestibular end
organs, facial nerve, carotid artery, jugular vein
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Nursing Management for Temporal Bone Fractures
• Care is conservative• Assess for nerve damage and hearing loss• Test for otorrhea; may indicate a CSF leak• Monitor lumbar drain if inserted • If facial nerve injury is present, provide eye
care • Institute CSF leak precautions – HOB 30o , no
straining, bending or lifting
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Medical Surgical Nursing: Preparation for Practice
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Frontal Bone
• Makes up the forehead, upper edge and roof of the orbit
• Forms the anterior portion of the cranium• Frontal sinus – air-filled cavity between
lamina of the frontal bone• Serves as a mechanical barrier to protect
the brain
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Infectious Rhinitis
• Usually caused by upper respiratory tract infection of viral origin
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Allergy
• Inappropriate immune response to usually harmless substance in the environment
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Medical Surgical Nursing: Preparation for Practice
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Medical Surgical Nursing: Preparation for Practice
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Sinusitis
• Inflammation of one or more paranasal and frontal sinuses
• Occurs with obstruction of the normal drainage mechanism
• Three classifications of sinusitis– Acute (symptoms lasting <3 weeks),– Subacute (symptoms lasting 3 weeks to 3
months)– Chronic (symptoms lasting >3 months)
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Sinusitis
• Can be caused by bacterial, viral, and fungal infections
• May occur during a Upper RespiratoryInfection when infection in the nose spreads to the sinuses
• Contributing factors:– Air pollution– Diving and underwater swimming– Sudden temperature extremes– Structural defects
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Sinusitis
• Pathophysiology– Paranasal sinuses in direct communication
with nasopharynx– Proximity can cause bacterial infection– When a bacterial or viral infection present,
person develops sinus infection– Tumors, polyps, trauma or benign growths
can cause obstruction
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Sinusitis
• Pathophysiology– Ostia (sinus openings) obstruction can
impede normal flow of air– Reduced flow of air and mucus allows mucus
to become stagnant, contributing to growth of bacteria causes inflammation and swelling
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Medical Surgical Nursing: Preparation for Practice
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Figure 34.4 Sites of sinusitis.
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Medical Surgical Nursing: Preparation for Practice
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Sinusitis
• Clinical manifestations:– Fever– Weakness– Fatigue– Cough– Congestion– Discharge– Pain in face or forehead
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Sinusitis
• Nursing management– Assessment– Thorough history– Education on causes and how to avoid
triggers (air pollutants, diving, underwater swimming, allergies, irritants)
– Education on complications with nasal surgery
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Sinusitis
• Postoperative nursing management– Patient education– Monitor for bleeding– Dressing care
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Medical Surgical Nursing: Preparation for Practice
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Figure 34.5 CT registered with probe for sinus surgery.
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Loss of Smell
• 2 million Americans have smell and taste disorders
• About 200,000 visit a doctor each year• Causes include: nasal congestion, a cold,
obstruction, neurological disorder• May be idiopathic – without any
identifiable cause
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Causes for Loss of Smell
• Temporary anosmia is common with colds and nasal allergies
• Following a viral illness
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Causes for Loss of Smell
• Disorders preventing air from reaching smell receptors:– Nasal polyps– Nasal septal deformities– Nasal tumors– Tumors of the head or brain– Head trauma– Endocrine and nutritional disorders
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Categories of Smell Dysfunction
• Anosmia: a complete loss of smell• Hyposmia: a partial loss of smell• Hyperosmia: enhanced smell sensitivity• Dysosmia: distortion in odor perception
– Includes parosmia (distorted sense of smell) and phantosmia
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Categories of Smell Dysfunction
• Parosmia: distortion of perception of external stimulus
• Phantosmia: smell perception with no external stimulus.
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Determine the Cause of Anosmia
• Complete head and neck examination • Focus on the nose to determine whether it is a
conductive or sensorineural loss • Endoscope is used to provide reliable
observations• Chemosensory testing (“sniffing sticks) and a
neuroradiologic (CT, MRI-to detect problems with olfactory nerve) evaluation also are used
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Treatment of Anosmia
• Antihistamines (if the condition is related to allergy)
• Surgical correction of physical blockages• Changes in medication • If permanent, dietary counseling may
include use of highly seasoned foods and stimulation of taste sensations that remain
• Caution should be taken to ensure safety around the home
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Medical Surgical Nursing: Preparation for Practice
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MUCORMYSIS
• Rare often fatal disease caused by fungi• Opportunistic infection –
immunocompromised• Develops in patients receiving iron
chelating drug called Desferal as treatment for actue iron poisioning
• Can develop in nasal areas, the lungs and brain
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Medical Surgical Nursing: Preparation for Practice
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Disorders Affecting Taste
• Hairy tongue is a condition in which the tongue is covered with hairlike papilla due to the overgrowth of the fungus Candida albicans or Aspergillus niger
• Result of antibiotic therapy that inhibits the growth of normal flora in the mouth
• Dental caries are the result of the destruction of tooth enamel caused by dental plaque
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Treatment
• Good dental hygiene• Antibiotics for bacteria• Mouth rinse
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Medical Surgical Nursing: Preparation for Practice
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Causes of Airway Obstruction
• Foreign object• Allergy • Lesions• Stenosis• Swelling• Viral and bacterial infections• Fire or inhalation burns
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Causes of Airway Obstruction
• Allergic responses to foods, medications, or bee stings
• Infections after dental extraction that have a large amount of swelling
• Laryngeal trauma • Aspiration of food material • Large boluses as well as small pieces of
food, such as peanuts
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Epiglottitis
• Life-threatening bacterial illness that may lead to airway obstruction
• Epiglottis is a flap of tissue and cartilage that covers the opening of the trachea during swallowing
• Seen more frequently in children, but occurs in adults
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Epiglottitis
• Cause of the infection usually is Haemophilus influenzae group B
• Symptoms: cherry red epiglottis, drooling, inspiratory stridor, dyspnea, and high fever
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Nursing Management of Epiglottittis
• Initial treatment focuses on maintaining a patent airway
• Conservative measures of oxygen, humidification, and inhaled respiratory therapy
• Administer Corticosteroids to reduce edema
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Nursing Management of Epiglottittis
• Administer antibiotics as prescribed to thwart the infection
• IV fluids are given for hydration• Prepare for tracheotomy or endotracheal
tube if the airway is in immediate jeopardy
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Endotracheal (ET) Tube Intubation
• May cause laryngeal trauma • Placement of an ET tube may induce
laryngeal swelling, which is a cause of upper airway obstruction after extubation
• Acute complications: perforation or laceration of the trachea or esophagus, bleeding, and arytenoid (cartilage that form larynx) dislocation
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Nursing Management
• Ensure the endotracheal tube remains properly positioned and secured in place
• Unnecessary movement of the tube can irritate and inflame the laryngeal tissue
• Maintain sedation of the patient as ordered if the patient is restless
• Prepare to set up for a tracheostomy tube if intubation is anticipated to be necessary for longer than 7 to 14 days
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Clinical Manifestations of Airway Obstruction
• Stridor (partial obstruction)• Unable to speak (complete obstruction)• Labored respirations and use of accessory
muscles • Air hunger (mild obstruction) vs. cyanosis
(complete obstruction)
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Clinical Manifestations of Airway Obstruction
• Confusion and unconsciousness indicate a progression in the severity of the obstruction
• If not treated, a partial obstruction can lead to a complete obstruction, rapid suffocation, and death
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Nursing Management of Airway Obstruction
• The initial assessment of objective and subjective data includes:– Presence of spontaneous breathing– Rate, depth, and effort of respirations– Presence of grunting or wheezing– Use of accessory muscles of respiration
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Nursing Management of Airway Obstruction
• The initial assessment of objective and subjective data includes: – Symmetry of chest expansion (determined
through palpation) vital signs– Oxygen saturation level– Quality of the voice– Stridor or any type of noisy breathing
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Other Nurse Assessment
• Monitor the patient’s orientation, mentation, and general demeanor
• Assess the patient’s ability to handle oral secretions
• Pain with speaking or swallowing• Assess for frequent drooling or productive
coughing to clear the airway
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Planning Care for the Patient with Upper Airway Obstruction
• A patient with complete airway obstruction appears very anxious, agitated, and apprehensive, and progresses quickly to cyanosis and respiratory arrest
• There is no cough and the patient will be cyanotic and unable to speak
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Planning Care for the Patient with Upper Airway Obstruction
• If the patient is unable to speak, a Heimlich maneuver should be performed in case the obstruction is from a foreign object or food
• Anticipation is the key to saving patients with a complete airway obstruction
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Planning Care for the Patient with Upper Airway Obstruction
• Supplies should be kept at the bedside for creating an immediate artificial airway
• Resuscitation equipment should be brought to the bedside in case there is a subsequent cardiac arrest
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Head and Neck Cancer
• More uncommon cancers; may not present until patient has a large tumor burden
• If detected early; head and neck cancer is treatable and curable
• If not treated; very disfiguring, alters normal functions
• Challenges for patient and family
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Head and Neck Cancer
• Ablative surgery may leave patient with facial disfigurement, functional impairment
• Decisions regarding treatment must be informed decisions that include:– Outcome without treatment – Implications, risks, and benefits of surgery
and radiation therapy
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Etiology
• A variety of risk factors are associated with head and neck cancer
• Some patients do not have any of the known risk factors
• Not possible to know for sure how much they contributed to causing the cancer
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Risk Factors for Oral and Oropharyngeal Cancer
• Alcohol: six times more likely to develop these cancers– Alcohol and smoking combined significantly
increase risk over nonsmoking drinkers
• Ultraviolet light: >30% of lip cancers associated with prolonged exposure to sunlight
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Risk Factors for Oral and Oropharyngeal Cancer
• Tobacco: Approx. 90% of people with oral cavity and oropharyngeal cancer use tobacco– Risk increases with amount smoked / chewed
and duration – Smokers six times more likely than
nonsmokers to develop these cancers– Tobacco smoke from cigarettes, cigars, pipes
all implicated
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Risk Factors for Oral and Oropharyngeal Cancer
• Tobacco: Approx. 90% of people with oral cavity and oropharyngeal cancer use tobacco – Can cause cancers anywhere in the oral
cavity or oropharynx, and larynx– Pipe smoking: significant risk for cancers
where lips contact the pipe stem– Smokeless tobacco increases risk by about
50 times
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Risk Factors for Oral and Oropharyngeal Cancer
• Tobacco: Approx. 90% of people with oral cavity and oropharyngeal cancer use tobacco – Associated with cancers of the cheek, gums,
and inner surface of the lips– Exposure to secondhand smoke (called
passive smoking) also a risk factor
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Risk Factors for Oral and Oropharyngeal Cancer
• Irritation: Long-term irritation to the lining of the mouth from poorly fitting dentures
• Poor nutrition: A diet low in fruits and vegetables increases risk
• Human papillomavirus infection: HPV infection may contribute to around 20% of cases
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Risk Factors for Oral and Oropharyngeal Cancer
• Immune system suppression: Immunosuppressive drugs may increase the risk
• Gender: Twice as common in men as in women
• Ethnicity: Asian heritage, first generation immigrant, are associated with nasopharyngeal cancer from the Epstein-Barr virus
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Nursing Management for Patients with Head and Neck Cancer
• Priorities are airway maintenance, pain management, and nutrition
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Nursing Management for Patients with Head and Neck Cancer
• If surgery, special needs and consideration:– Wound management– Drain assessment and care– Oral care– Wound complications– Carotid artery exposure assessment and
management
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Airway Management – Assessment
• Airway is the first priority• Outcome is to maintain a patent airway and normal
gas exchange• Ongoing assessment: SOB, stridor, blood-tinged
sputum, and infection• Monitor increased WOB, use of accessory muscles
• Assess for increased heart rate and decreased O2 saturation levels
• Assess the type of airway that is being used
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Nurse Interventions
• Secure airway with the appropriate ties • Prevents the possibility of the tube being
dislodged or accidentally removed• Change ties daily or when soiled to
decrease the possibility of infection• Clean the tracheostomy site regularly, e.g.
every 8 hours
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Nurse Interventions
• Clean more frequently p.r.n. to remove secretions that could obstruct the airway
• For tracheostomy tube with inner cannula, change if disposable or clean at every tie tracheostomy care
• Frequent assessment of secretions is essential to patient safety
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Nurse Intervention for Artificial Airway
• Humidification to the airway is necessary• Bag/suction in early postop period if
patient is unable to clear own secretions • Patients may require mechanical
ventilation in early postop period• Monitor pulse oximetry, ABGs, respiratory
rate and effort
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Nurse Intervention for Artificial Airway
• Deflate cuff when the patient is off positive pressure ventilation
• Turn, cough, and deep breathe• Perform respiratory treatments with
bronchodilators, and chest physiotherapy
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Nurse Intervention for Artificial Airway
• Early mobilization and ambulation greatly improve respiratory status – Stimulate coughing – Encouraging greater lung expansion– Recruiting lung fields– Mobilizing secretions
• Early ambulation also benefits circulation and increasing muscle strength
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Laryngectomy Stoma Care
• Permanent change in their airway • Breathe only from their stoma • Clean stoma at least every 8 hours, p.r.n.
to prevent buildup of secretions, scarring • Position patient’s head so as not to
occlude the airway • Humidification after discharge until the
airway becomes used to room air
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Nurse Management of Pain
• Greatest fears for any patient undergoing cancer surgery is the fear of pain
• High nursing priority to alleviate pain and anxiety related to pain
• Careful and exact assessment of the type and location of the pain
• Have the patient set a goal pain level, using a pain rating scale
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Nurse Management of Pain
• Use the pain scale to evaluate effectiveness
• Note clues for patients who are unable to communicate
• Teach the patient not to wait until the pain is unbearable to request pain medication
• Early, immediate, frequent intervention for pain relief in immediate postop period
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Nurse Management of Pain
• Increase the dosage as the patient’s respiratory status tolerates it
• Consider patient-controlled analgesia (PCA) for alert cooperative patients
• Transition to oral meds as patient is able to swallow safely and in sufficient quantity to sustain nutrition and medication
• Treat joint pain with mobility, ambulation, turning, as early as postop day 1
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Nutrition Management
• Present with inadequate nutrition caused by the tumor burden, cancer cachexia, or the mechanical difficulty of eating because of tumor impingement into the aerodigestive tract
• Early recognition of nutritional inadequacy and early intervention is critical
• Positive nitrogen balance, adequate calories and protein needed for healing
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Nutrition Management
• The best test is serum prealbumin, transthyretin, or thyroxin-binding prealbumin (TBPA)
• Nutritionist in the multidisciplinary team is mandatory
• Nutritional goal for caloric intake in the postop period – roughly 35 kcal/kg
• With artificial airway, extra water loss through expiration, suctioning
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Nutrition Management
• Carefully calculate replacement requirements to ensure proper hydration
• Feeding method depends on patient’s level of consciousness and ability to swallow
• Route may be oral, nasogastric, gastrostomy, jejunostomy
• Nutrition replacement must begin early and continue throughout the therapy
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Nutrition Management
• Most feeding can begin on postop day 1 • Advance to goals as quickly as tolerated• Dysphagia is a common issue; tumor
burden, invasion of the aerodigestive tract, pain
• Aspiration is a significant concern with patients who are unable to maintain their airway protection
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Medical Surgical NursingPreparation for Practice
CHAPTERCHAPTER CHAPTERCHAPTER
Caring for the Patient Caring for the Patient with Lower Airway Disorderswith Lower Airway DisordersCaring for the Patient Caring for the Patient with Lower Airway Disorderswith Lower Airway Disorders
3535
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Restrictive vs. Obstructive Lung Diseases
• Restrictive lung diseases (interstitial lung diseases)– Result in reduced lung volumes – Alteration in lung parenchyma (alveolar tissue w/
terminal bronchioles, respiratory bronchioles, alveolar ducts)
– Disease of pleura, chest wall or neuromuscular apparatus
– Characterized by reduced total lung capacity, vital capacity, or resting lung volume
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Restrictive vs. Obstructive Lung Diseases
• Obstructive lung diseases – A group of disorders – Common characteristic – chronic and
recurring blockage of airways– Limit airflow through the airways and out of
the lungs
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Restrictive (Interstitial) Lung Diseases
• Divided into two groups based on anatomic structures: – Intrinsic lung diseases – Extrinsic lung diseases
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Intrinsic Lung Diseases
• Diseases of the lung parenchyma • Cause inflammation or scarring of lung
tissue or result in filling of the air spaces with exudate and debris
• Characterized according to etiologic factors– Exposure to dust, metals, or organic solvents
and agricultural employment increase risk
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Extrinsic Lung Diseases
• Extraparenchymal diseases – diseases of:– Chest wall– Pleura – Respiratory muscles
• Result in:– Lung restriction– Impaired ventilatory function– Respiratory failure
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Extrinsic Lung Diseases
• Extrinsic disorders of pleura and thoracic cage– Total compliance by the respiratory system is
reduced Lung volumes are reduced
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Restrictive (Interstital) Lung Diseases
• Clinical Manifestations of Intrinsic Lung Disease– Onset can be acute or insidious (subtle
gradual)– Progressive exertional dyspnea– Hemoptysis
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Restrictive (Interstital) Lung Diseases
• Clinical Manifestations of Extrinsic Lung Disease– Onset dyspnea, decreased exercise
tolerance, and respiratory infections– Dyspnea upon exertion, followed by dyspnea
at rest, ultimately advancing to respiratory failure
– Recurrent lower respiratory tract infections
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Restrictive (Interstital) Lung Diseases
• Diagnostic Tests– Generally no positive findings revealed in
intrinsic lung diseases Chest radiography and CT to diagnose intrinsic
disorders Anemia – vasculitis Poycythemia (high RBC count) - hypoxia
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Restrictive (Interstital) Lung Diseases
• Extrinsic disorders – elevated creatinine kinase (CK) may indicate myositis (enflammation of muscle)– Fluoroscopy to diagnose extrinsic disorders– PFT and tests for extrinsic lung disorders:
Bronchoalveolar lavage, lung biopsy, surgical lung biopsy
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Acute Bronchitis
• Etiology– Most prevalent in children and older adults– Incidence is highest in the winter– High Risk
People with allergies, other respiratory illnesses Chronic obstructive pulmonary disease (COPD),
chronic sinusitis, chronic tonsillitis, infected adenoids
Smokers are at a higher risk
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Acute Bronchitis
• Pathophysiology– Inflammation of the lower bronchial mucous membranes– Commonly follows a respiratory viral illness – Causative agents: viruses, bacteria, yeast, fungi,
noninfectious triggers– Most often the cause is viral; adenovirus, influenza virus,
and RSV– Common bacterial causes
Streptococcus pneumoniae, Haemophilus influenzae, and Bordetella pertussis
– Other causes: pollutants, such as ammonia and tobacco
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Acute Bronchitis
• Clinical Manifestations– Fever, cough, chills, and malaise– Mimic pneumonia, but exam and chest
x-ray often are normal– Cough:
Typically gets steadily worse for 10 to 12 days More profound at night Becomes increasing loose over time Most patients have a cough for less than 2 weeks
– Shortness of breath and wheezing
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Acute Bronchitis
• Assessment– Assessment findings reveal a cough – Viral bronchitis – nonproductive cough– Bacterial bronchitis – productive cough, fever,
pain behind the sternum aggravated by coughing
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Acute Bronchitis
• Nursing Diagnoses– Priority nursing diagnoses for the patient with
bacterial bronchitis include:– Ineffective airway clearance– Impaired gas exchange– Activity Intolerance
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Acute Bronchitis
• Outcomes– Relief of the clinical manifestations – Return to the previous level of functioning
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Acute Bronchitis
• Interventions and Rationales– Assist patients with prescribed therapies – Use of antitussives, analgesics, and
bronchodilator medications – Encourage fluids– Teach patients to cough effectively and avoid
infections– Offer mild analgesics for discomfort
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Acute Bronchitis
• Interventions and Rationales– Offer patients deep breathing exercises,
incentive spirometer – Anticholinergics, antibiotic therapy (when
indicated), IV corticosteroids or methylxanthines
– Antibiotics not shown to be effective except in patients with COPD
– Beta-2 agonists (brochodilators)
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Acute Bronchitis
• Prevention/Evaluation– Relief of the respiratory symptoms including
cough, wheezing, and shortness of breath – Teach prevention and avoidance of risk
factors
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Influenza
• A contagious disease caused by the influenza virus
• 10% to 20% of people in US get influenza yearly
• An average of 36,000 deaths per year from influenza in US
• People ages 65+, people with chronic medical conditions more likely to have complications from the flu
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Influenza
• Etiology– Epidemics occur from December – April in the
Northern Hemisphere– Yearly epidemics of influenza begin abruptly
and last 5 to 6 weeks– Influenza A and B are the viruses that cause
epidemic human disease
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Influenza
• Etiology– Pandemics occur when a new virus emerges
for which there is no immunity– Influenza virus type C has not been classified
and usually does not induce illness
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Influenza
• Pathophysiology– Transmission by small-particle aerosols –
droplets from coughs, sneezes– Viruses deposited in the lower respiratory
tract – Attach to and infect epithelial cells – Contact with respiratory droplets, then
touches own mouth or nose
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Influenza
• Clinical Manifestations– Fever, chills, headache, fatigue, dry,
nonproductive cough, sore throat, nasal congestion, and myalgia
– Cough may be associated with chest pain– Fever usually persists for 3-4 days, up to 1
week– Common complication is pneumonia, which
may be primary influenza
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Influenza
• Nursing Management– Primary care goals: relieving symptoms,
preventing secondary infection– Rest, plenty of fluids, avoid alcohol and
tobacco, take mild pain relievers– Work with health care provider to ensure
medications taken appropriately– Antiviral drugs approved for prevention,
treatment
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Medical Surgical Nursing: Preparation for Practice
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Influenza
• Prevention– Flu Vaccine– Avoid contact with others who have the flu
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Pneumonia
• Inflammatory process resulting in edema of the parenchymal lung tissue
• Extravasation of fluid into the alveoli causing hypoxemia
• Primarily affects terminal gas-exchanging portions of the lung
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
• Etiology– Acute inflammation of lung tissue – Caused by bacteria, viruses, fungi, protozoa, parasites– Inhaled into lungs or transported via the bloodstream– Classified by causal agent, distribution, setting (hospital -
HAP or community - CAP)– Causative microorganism influences S&S, treatment,
prognosis– CAP typically caused by different microorganisms than HAP
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
• Pathophysiology – Damage to bronchial membranes causes
buildup of infectious debris, exudates– Results in dyspnea, ventilation/perfusion
(V/Q) mismatching, and hypoxemia
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
• Pathophysiology– CAP: begins outside hospital or is diagnosed
w/in 48 hours after admission Patient did not reside in a long-term facility prior to
admission Incidence of CAP is highest in winter months Smoking an important risk factor
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
• Pathophysiology– HAP: occurs > 48 hours after hospital
admission HAP has a mortality rate of 20% to 50% 90% of HAP infections are bacterial Compromised immune systems, chronic lung
disease, intubation and mechanical ventilation increase risk
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
• Clinical Manifestations – Fever, chills – Increased respiratory rates– Rusty bloody sputum– Crackles– X-ray abnormalities
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
• Clinical Manifestations– Nonrespiratory symptoms
Headache Abdominal pain Nausea and vomiting Diarrhea Muscle aches
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
• Nursing Management– Administer antibiotics (prime treatment)– Primary nursing intervention: Maintain airway
and O2 saturation above 93%
– Common Nursing Diagnosis – Readiness for Enhanced Comfort
– Promote nutrition and hydration – Provide small, frequent, high-carb, high-
protein meals
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
• Nursing Management– Monitor fluid intake closely– Provide oral hygiene before and after meals– Promote comfort – Monitor for chest pain, note character and
location – Elevate head of bed 45 to 90 degrees– Offer mild analgesics
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
• Discharge Priorities/Prevention– Teach patient about
Importance of rest, gradual increase in activity to avoid fatigue
Maintain resistance with proper nutrition, adequate fluid intake
Avoid chilling and exposure to others with URI, viral infections
Medications that will be continued at home
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pneumonia
• Discharge Priorities/Prevention– Teach patient about
Continue deep breathing and coughing exercises 4x/day, 6-8 weeks
Signs and symptoms to report to health care provider
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tuberculosis
• Etiology– Mycobacterium tuberculosis is nonmotile,
nonsporulating– Transmitted via aerosolization (i.e., an
airborne route)– Affects people with repeated close contact
with an infected but undiagnosed person – TB an opportunistic infections common with
HIV/AIDS
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tuberculosis
• Etiology– Continuous assessment and intervention to
prevent the spread of TB– The newest form of TB is multidrug-resistant
tuberculosis (MDRTB)– Resistant TB is difficult and costly to treat and
can be fatal
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tuberculosis
• Pathophysiology– Highly communicable disease transmitted via
aerosolization– Droplets spread when infected person laughs,
sneezes, or sings– Droplets may be inhaled by others– Tubercle finds a suitable site (bronchi or
alveoli), multiplies freely
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tuberculosis
• Pathophysiology– An exudative response occurs, causing a
nonspecific pneumonitis– Mediated or type IV immunity develops 2-10
weeks after infection – Manifested by a significant reaction to a
tuberculin test
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tuberculosis
• Clinical Manifestations– Dyspnea– Weight loss– Cough– Sputum production– Sleep disturbances– Symptoms present when the disease is well
advanced
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tuberculosis
• Clinical Manifestations– Lethargy, exhaustive fatigue, activity
intolerance, nausea, irregular menses– Low-grade fever may have occurred for
weeks or months– Fever also may be accompanied by night
sweats– Patient finally notes cough, production of
sputum, occasionally streaked with blood
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tuberculosis
• Clinical Manifestations– A dull aching chest pain may accompany the
cough– Dullness with percussion over involved
parenchymal areas– Bronchial breath sounds, increased
transmission of spoken or whispered sounds– Wheezing related to obstruction may also be
heard
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tuberculosis
• Laboratory and Diagnostic Procedures– Tuberculin skin test– Chest x-ray– Acid-fast bacillus smear– Sputum culture
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tuberculosis
• Nursing Management– Administer drug therapy as ordered by health care provider – Report the diagnosis to the local health department– Keep patient in negative pressure room with respiratory
airborne isolation – Maintain isolation until three consecutive sputum cultures
have tested negative– Focus on preventing the spread of the infection– Discuss pain management, handling fatigue, importance of
good nutrition
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tuberculosis
• Health Promotion and Prevention– The main focus of TB management is
preventing spread of the infection– Patient typically must take drugs for 9 months– Test and treat all persons in close contact
with the infected individual
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Lung Abcess
• Etiology: – The incidence of lung abscess is not well
known, as it rarely occurs in isolation. Most often such an abscess is secondary to anaerobic and aerobic organisms that colonize the upper respiratory tract.
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Lung Abcess
• Etiology:Patients presenting with this problem often have a history of pneumonia, possibly complicated by aspiration of oropharyngeal contents. Formation of multiple abscesses and cavities occurs commonly in patients with TB or fungal infections of the lung.
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Lung Abcess
• Clinical Manifestations– Clinical manifestations are often insidious,
although often more acute after pneumonia. Typically they include spiking temperature with rigors and night sweats; cough with foul sputum; pleuritic chest pain; tachycardia; dullness on percussion over the abcessed area. Oxygen saturation may decrease with larger abcesses
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Lung Abcess
• Laboratory and Diagnostic Procedures– CT scan– Pleural fluid and blood cultures may be
obtained (thoracentesis)– Bronchoscopy – Transtracheal aspiration via suction
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Lung Abcess
• Nursing Interventions– Assess the patient for adequate cough– Administer IV antibiotic therapy if ordered– Penicillin G or clindamycin is the
pharmacologic therapy of choice – Assess for recent history of influenza,
pneumonia, febrile illness, cough, and sputum production
– Auscultate breath sounds
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Lung Abcess
• Nursing Interventions– Manage patient’s clinical manifestations– Monitor oxygen levels ongoing– Assess the work of breathing, respiratory and
heart rate – Administer antipyretic, antibiotic, and pain
medications
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Lung Abcess
• Nursing Interventions– Follow-up assessment of effectiveness– Space physical care to allow for periods of
rest between activities
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Lung Abcess
• Outcomes/Prevention– Relief of clinical manifestations – Return to the previous level of function
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Chronic Obstructive Pulmonary Disease
• Refers to a group of respiratory disorders • Characterized by chronic, recurrent
obstruction in pulmonary airways • Encompasses chronic bronchitis and
emphysema– Obstruction is generally permanent and
progressive
• Chronic bronchitis defined in clinical terms
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Chronic Obstructive Pulmonary Disease
• Emphysema defined in terms of anatomic pathology
• Chronic bronchitis and emphysema typically coexist
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Chronic Obstructive Pulmonary Disease
• Unifying symptoms – Dyspnea– Wheezing– Use of accessory muscles– Ventilation/perfusion (V/Q) mismatching– Decreased forced expiratory volume
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Chronic Obstructive Pulmonary Disease
• Emphysema: abnormal, permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Chronic Obstructive Pulmonary Disease
• Chronic bronchitis: characterized by hypersecretion of mucus and chronic productive cough that continues at least 3 months of the year for at least two consecutive years
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Etiology
• The primary cause of COPD is exposure to tobacco smoke. Clinically significant COPD develops in 15% of cigarette smokers. Age of initiation, total pack-years, and current smoking status predict COPD mortality
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pathophysiology of Chronic Bronchitis
• Inflammatory changes in the bronchial walls
• Causes them to thicken and impinge on the airway lumen
• Diffuse airway obstruction occurs • Initially affects only larger bronchi;
eventually involves all airways
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pathophysiology of Chronic Bronchitis
• Obstructed airways are likely to close on expiration
• Traps air in the distal portions of the lung, causing:– Hypoventilation (increased PaCO2)
– Ventilation/perfusion mismatching– Hypoxemia
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pathophysiology of Chronic Bronchitis
• Characterized by an increase in mucus production
• Mucus is thicker and more tenacious than normal
• Bacteria become embedded in the airway secretions and reproduce
• Ciliary function is impaired
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pathophysiology of Chronic Bronchitis
• Edema and accumulation of inflammatory cells lead to bronchial wall inflammation and thickening
• Airway enlargement, loss of elastic recoil in the alveoli trap air, limit outflow
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pathyphysiology of Emphysema
• Enzymes called proteases break down elastin, cause alveolar destruction
• Result is collapse or narrowing of the small airways
• Eliminates portions of the capillary bed necessary for gas exchange
• Airway enlargement, loss of elastic recoil combine to trap stagnant air
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pathyphysiology of Emphysema
• Airway resistance is increased due to compromised alveolar walls
• Bullae and blebs (thin walled balloon-like extensions or air sacs) develop due to hyperinflation of alveoli
• inflammatory hyperactivity can lead to additional airway narrowing
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of COPD Patient
• Assess for dyspnea, muscle fatigue,↑ work of breathing, worsening symptoms
• Monitor ABG results• Assist patient to manage the anxiety that
often occurs
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of COPD Patient
• A major role of the nurse is patient and family education– Breathing retraining– Use of postural drainage techniques– Energy conservation– Physical reconditioning
• Single most important factor in preventing COPD – smoking cessation
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Asthma
• A chronic hyperreactive disorder of the airways (bronchioles)
• Episodic reversible airflow obstruction and airway inflammation
• Inflammatory process causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Asthma
• Caused by a complex interaction of genetic and environmental factors
• Airflow obstruction can be caused by a variety of changes, including:– Acute bronchoconstriction– Airway edema– Chronic mucous plug formation– Airway remodeling
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Clinical Manifestations
• Persons with asthma exhibit a wide range of signs and symptoms
• Episodic wheezing, feelings of chest tightness to acute immobilizing attacks
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of the Patient with Asthma
• A holistic approach to care through the nursing process
• Educate patient and family about prevention of attacks
• Thoroughly assess symptoms and history of attacks
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of the Patient with Asthma
• Assesses patient’s respiratory status by monitoring:– Severity of symptoms – Breath sounds– Peak flow meter– Pulse oximetry– Vital signs
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of the Patient with Asthma
• Administer medication• Educate public on symptoms and dangers
of asthma
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Etiology and Pathophysiology - Cystic Fibrosis
• A person is born with CF, and it affects boys more than girls • Affects Caucasians 5 times more often than African American
people• Typical features: mucous plugging, chronic inflammation,
infection • Peripheral bullae or blebs may develop due to obstruction,
airway wall weakening• Affects mucous glands of the lungs, liver, pancreas, and
intestines• Causes progressive disability due to multiple-system failure
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Clinical Manifestations of CF
• Acute exacerbation characterized by:– Increasing breathlessness– Change in sputum volume, color, and
viscosity– Tiredness– Loss of appetite– Weight loss
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Clinical Manifestations of CF
• Include barrel chest and digital clubbing• GI: malabsorptive symptoms e.g. frequent
loose and oily stools, cramping
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Clinical Manifestations of CF
• Signs and symptoms of diabetes including abnormal glucose tolerance, polydipsia, polyuria, and polyphagia
• Subtle manifestations: chronic sinusitis, nasal polyps, rectal prolapse
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of CF
• Assist patient to maintain adequate airway clearance, reduce risk factors, perform ADLs
• Prevent complications• Involve patient/family in planning and
implementing the therapeutic regimen• Obtain objective and subjective data from
the patient and family
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of CF
• Encourage use of corticosteroids, bronchodilators, and antibiotics
• Functional health patterns
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of CF
• Assessment of general impressions– Mood, anxiety, depression, restlessness,
failure to thrive– Cyanosis of skin and nail beds– Persistent runny nose, diminished breath
sounds, sputum characteristics – Tachycardia– Protuberant abdomen, abdominal distention,
foul and fatty stools
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of CF
• Possibly abnormal ABGs and PFTs; abnormal sweat chloride test, chest x-ray, and fecal fat analysis
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Diagnoses
• Ineffective airway clearance related to thick and abundant mucus, weakness, fatigue
• Ineffective breathing pattern related to bronchoconstriction, anxiety, and airway obstruction
• Impaired gas exchange related to lung infections• Imbalanced nutrition related to dietary intolerances,
intestinal gas, and altered pancreatic enzyme production
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Goals
• Focus on the patient having adequate airway clearance• Reduced risk factors associated with respiratory infections • Assist clients to perform ADLs, stay free of complications,
actively participate in planning and implementing a restorative regimeAssist patients in gaining and maintaining independence by assuming responsibility for their own care. Active interventions include relief of bronchoconstriction, airway obstruction, and airflow limitation
• Encourage frequent hand washing, especially after coughing
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Goals
• Frequent mouth care, especially after chest physical therapy regime
• Avoid exposure to persons who are ill especially with Upper Respiratory Infections
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pulmonary Embolism
• Thrombus breaks loose and blocks a branch of the pulmonary artery
• Produces widespread pulmonary vasoconstriction
• Predominantly a disease of older individuals
• Highest incidence of recognized PE occurs in hospitalized patients
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pulmonary Embolism
• Pulmonary embolism is a complication of a DVT
• Most common risk factors for PE are:– Prior history of DVT or PE– Recent surgery or pregnancy– Prolonged immobilization– Underlying malignancy
• Risks also include situations of venous stasis or increased hypercoagulability
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pathophysiology and Clinical Manifestations of PE
• A pulmonary occlusion occurs when a bloodborne substance occludes a branch of the pulmonary artery and obstructs blood flow
• Hemoptysis, dyspnea, and chest pain • Pleuritic chest pain, chest wall tenderness,
a pulmonary friction rub, or hypotension
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pathophysiology and Clinical Manifestations of PE
• Tachypnea, crackles, an accentuated second heart sound, tachycardia, fever, diaphoresis, S3 or S4 gallop, thrombophlebitis, lower extremity edema, cardiac murmur, and cyanosis
• Massive PEs typically present with sudden crushing substernal chest pain, shock, and loss of consciousness
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of PE
• The nursing process guides the nursing care for patients with a PE
• Evaluation of risk factors on admission and throughout the patient’s hospital stay
• Initially clients may be on bed rest• Nurses should encourage maximal
mobility, including range of motion and walking where appropriate while also staying alert to symptoms of DVT
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of PE
• Nursing diagnoses: ineffective tissue perfusion and impaired gas exchange
• Assist the patient to maintain the therapeutic regime during the acute period
• Anticoagulant medication should be given at the same time each day– Monitor liver function when patients receive
anticoagulants
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of PE
• Monitor hemoglobin, hematocrit, platelet, and the international normalized ratio (INR) levels, and other clotting studies as needed to assess the effectiveness of anticoagulants
• Assess for symptoms of bleeding and heparin-induced thrombocytopenia (HIT)
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management of PE
• Discharge priorities include educating the patient and family about risk factors and treatment regimes
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Cor Pulmonale
• Alteration in the structure and function of the right ventricle
• Caused by a primary disorder of the respiratory system– Chronic lung disease– Pulmonary embolism– Interstitial lung disease– Primary pulmonary hypertension
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Cor Pulmonale
• Pathophysiological mechanisms lead to Primary Pulmonary Hypertension and consequently, cor pulmonale– Pulmonary vasoconstriction due to alveolar hypoxia– Anatomic compromise of the pulmonary vascular
bed– Increased blood viscosity secondary to blood
disorders – Idiopathic primary pulmonary hypertension
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Two Forms of Cor Pulmonale
• Acute: usually results from massive PE or injury d/t mechanical ventilation for ARDS
• Chronic cor pulmonale usually caused by COPD
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Laboratory and Diagnostic Procedures
• Echocardiography gives information about the size of the heart
• Chest x-rays and CAT scan • PFT evaluate ventilation/perfusion
mismatch• ABG tests identify gas exchange,
presence of acidosis and alkalosis
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Medical Surgical Nursing: Preparation for Practice
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Clinical Manifestations
• Asymptomatic initially• Later, as right ventricular (RV) pressures
increase, physical signs commonly include:– Left parasternal systolic lift (visible pulsations
to left midsternal)– Loud pulmonic component of the second
heart sound (S2)– Murmurs of functional tricuspid and pulmonic
insufficiency
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Clinical Manifestations
• Later, as right ventricular (RV) pressures increase, physical signs commonly include: – Later, an RV gallop rhythm (third [S3] and
fourth [S4] heart sounds)
– Distended jugular veins, hepatomegaly– Lower extremity edema
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Clinical Manifestations
• Later, as right ventricular (RV) pressures increase, physical signs commonly include: – Patient may complain of fatigue, dyspnea or
chest pain on exertion, cough– In advanced stages, hepatic congestion leads
to anorexia, RUQ abdominal discomfort
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Nursing Management
• Physical assessment findings: – Increased chest diameter– Labored respirations with retractions of the
chest wall and use of accessory muscles– Hyperresonance to percussion– Diminished breath sounds– Wheezing, rarely– Cyanosis
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Nursing Management
• Physical assessment findings: – Auscultation of the heart may reveal a split
second heart sound, a systolic ejection murmur with a sharp ejection click over the pulmonary artery, along with a diastolic regurgitation
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The Primary Role of the Nurse
• Manage dyspnea by administration of oxygen
• Administer medications to treat right ventricular hypertrophy and pulmonary hypertension
• Provide patient education re: managing equipment and medications
• Refer to home health and pulmonary rehabilitation
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The Primary Role of the Nurse
• Regularly assess oxygen needs and medications
• Single most preventive measure – encourage smoking cessation
• Avoid exposure to secondhand smoke and respiratory pollutants
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LEARNING OBJECTIVE 4
• Compare and contrast the etiology and nursing management for patients with a variety of chest trauma and thoracic injuries.
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Chest Trauma and Thoracic Injuries
• 16,000 deaths in the United States each year
• Cause of death in 25% of all trauma patients
• ↑ hand gun use has contributed to rise in penetrating injuries
• These injuries impair airway patency, breathing, and circulation
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Rib Fractures
• Most common blunt thoracic injury in adults
• Associated with other injuries such as flail chest, pulmonary contusion, and pneumothorax
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Etiology
• Usually are caused by a direct blow to the ribs
• Sternal fractures are most common in motor vehicle accidents
• Forceful compression of the rib cage
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Nursing Management
• Astute assessment for respiratory complications
• Diligent patient monitoring for dyspnea, hypoxemia, and pain
• Administer pain medication and assess for pain relief
• Auscultate lung fields regularly for adventitious sounds
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Nursing Management
• Provide written instructions regarding the plan of care
• Teach patient and family when to call members of the health team
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Pneumothorax
• Partial or complete collapse of the lung on the affected side
• Under normal circumstances the pleural cavity is free of air
• When air or gas enters the pleural space pneumothorax results
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Spontaneous Pneumothorax
• Occurs unexpectedly in healthy individuals ages 20-40
• More common in tall, thin men • Smoking also is a risk factor, due to
disease in the small airways• Caused by a ruptured, air-filled bleb or
blister on the lung surface
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Spontaneous Pneumothorax
• Bleb rupture allows atmospheric air to enter the pleural cavity
• Results in a loss of negative pressure and collapse of the lung
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Tension Pneumothorax
• Rapidly developing complication of blunt chest trauma
• Occurs as a result of an air leak in the lung or chest wall
• Caused by blunt chest trauma • Parenchymal injury has failed to seal,
causes complete collapse of the lung
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Hemothorax
• Common problem encountered following blunt chest trauma
• Blood loss of <2,000 mL into the thoracic cavity
• Absence of breath sounds over the lung and dullness to percussion
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Clinical Manifestations
• Pleuritic pain • Breathlessness • Respiratory distress• Breath sounds are unilaterally decreased
or absent
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Nursing Management
• Assess pulmonary status quickly • The nurse focuses on relieving dyspnea
and supporting oxygenation • Mobilize health team to provide re-
expansion of the lung via a chest tube• Prepare for insertion of the chest tube• Monitor patency of chest tube
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Nursing Management
• Provide the patient with written instructions regarding the plan of care
• Encourage patients/caregivers to call health team for persistent problems
• Explain risk of reoccurrence
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LUNG CANCER - Etiology
• Prevention efforts target preventing exposure to known risk factors, e.g. smoking
• Cellular genetic destruction results from repeated exposure to carcinogens
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Etiology
• Smoking accounts for 87% of all lung cancer deaths
• Other risk factors: occupational hazards, air pollution, genetics, dietary factors, advancing age, and race
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Pathophysiology
• Four major histologic types of lung cancer– Small cell carcinoma (SCLC)– Squamous cell carcinoma– Adenocarcinoma – Large cell carcinoma
• SCLC accounts for 15% of cases in US– SCLC disseminates widely by the time of
diagnosis, leads to a poor prognosis
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Pathophysiology
• 85% of all lung cancers are non-small cell lung cancer (NSCLC)
• NSCLCs all have unique patterns of growth and clinical appearance– Squamous cell tumors malignancies tend to
be slow growing
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Pathophysiology
• NSCLCs all have unique patterns of growth and clinical appearance– Adenocarcinoma – most common form of lung
cancer, most common type in nonsmokers Progression is slow Adenocarcinoma invades the lymphatic/blood
vessels early Result is a worse prognosis compared to that for
SCLCs
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Pathophysiology
• NSCLCs all have unique patterns of growth and clinical appearance– Large cell lung cancer commonly located in
periphery of the lung Often spreads to the subsegmental bronchi or
larger airways
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Clinical Manifestations
• Cough• Dyspnea • Sputum production• Wheezing • Hemoptysis • Chest pain• Dysphagia
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Clinical Manifestations
• Hoarseness • Fatigue • Weakness • Nausea • Disturbed sleep• Memory impairments• Anorexia
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Clinical Manifestations
• Night sweats• Early diagnosis of lung cancer is difficult • Typically no symptoms until disease has
metastasized
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Nursing Management
• Close postoperatice observation for cardiac and pulmonary complications
• Dyspnea is the most common postoperative symptom
• Effective pain management enables participation in progressive mobilization
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Lung Transplant
• Viable alternative for patients with advanced pulmonary disease
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Lung Transplant
• Indications:– AAT deficiency (Alpha-1 antitrypsin (AAT) deficiency is a condition in
which the body does not make enough of a protein that protects the lungs and liver from damage.)
– Bronchiectasis – Cystic fibrosis– Emphysema – Idiopathic pulmonary fibrosis – Interstitial lung disease– Pulmonary hypertension
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Lung Transplant
• Persons >60 years of age not recommended for single lung transplant
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Lung Transplant
• The following do not qualify for lung transplant:– Colonization with antibiotic-resistant
organisms– Noncompliance with medical regime– Inability to walk 600 feet – Diagnosis of a malignancy within 2 years– Renal or liver insufficiency– Positive for HIV
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Lung Transplant
• Infection postoperatively is the leading cause of morbidity and mortality
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Occupational Lung Disorders: Pneumoconiosis
• Long-term exposure to toxic dust and particulates can lead to irreversible chronic pulmonary disease
• Most common causes: silica, asbestos, and coal
• Dust deposits are permanent
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Occupational Lung Disorders: Pneumoconiosis
• No definitive treatment for the pulmonary fibrotic changes
• Treatment is palliative • Focuses on preventing further exposure
and improving workplace safety
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Occupational Asthma
• Exposure to particulate matter, workplace chemicals, gases, cereal grains, or irritants
• Causes inflammation and edema of any portion of the respiratory tract
• Results in bronchospasm, hypersecretion of mucus, dyspnea, wheezing
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Occupational Asthma
• Symptoms are dyspnea, wheezing, and chest tightness
• Difficult to recognize because symptoms continue when away from the source of exposure
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Coal Miner Pneumoconiosis
• Known as black lung or coal miner’s lung• Caused by coal dust deposits in the lung• Disease affects about 4.5% of coal miners• Patients experience a restrictive disease in
which they cannot fully expand their lungs as well as an obstructive disease from secondary emphysema
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Asbestosis
• Progressive lung disease • Caused by exposure to microscopic fibers
of asbestos • Results in diffuse interstitial fibrosis with
diaphragmatic calcification• Fibrous tissue eventually obliterates the
alveoli• Latency period 10-20 years between
exposure and symptoms
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Whose at Risk for Asbestosis?
• Asbestos miners, millers• Those employed in building trades and
shipyards• Insulation workers, pipe fitters and
steamfitters• Sheet metal workers, welders
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Diagnosis and Clinical Manifestations
• PFT findings – restrictive ventilatory defect, restricted lung volume
• Dyspnea and hypoxemia• Removal of the individual from exposure is
essential • Crackles of a dry quality can be
auscultated in 70% to 90% of patients• Clubbing also is present frequently
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Diagnosis and Clinical Manifestations
• Chronic cough and sputum production, similar to acute bronchitis
• Sputum is expectorated in large amounts– May contain black fluid, particularly with
smokers
• Respiratory failure and cor pulmonale result
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Nursing Management
• Offer supportive care and education for patient and caregiver
• Address issues: dyspnea, fatigue, and activity tolerance
• Teach physical conditioning and breathing exercises are helpful
• Encourage liberal fluids intake
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Nursing Management
• Administer bronchodilators, glucocorticoids, and antibiotics
• Address emotional issues such as depression, anxiety, and anger
• Educate patient prior to discharge about all aspects of the treatment regime
• Provide relevant contact numbers to the patient and caregiver
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Medical Surgical NursingPreparation for Practice
CHAPTERCHAPTER CHAPTERCHAPTER
Caring for the Patient Caring for the Patient with Complex with Complex Respiratory DisordersRespiratory Disorders
Caring for the Patient Caring for the Patient with Complex with Complex Respiratory DisordersRespiratory Disorders
3636
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Complex Respiratory Disorders
• Lead to alteration of oxygen perfusion• Caused by problems elsewhere in the
body
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Goals of Treatment
• Medical Management– Correct and treat hypoxemia– Discover and correct primary organ system
failure
• Nursing Management– Manage the airway– Manage oxygen for perfusion
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The Alveolar-Capillary (A-C) Membrane
• Central component of gas exchange in lungs
• Oxygen diffuses from alveoli into pulmonary capillaries – Attaches to the hemoglobin in the red blood
cells
• Carbon dioxide moves in the opposite direction, into the lungs
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The Alveolar-Capillary (A-C) Membrane
Figure 36.2 Alveolar-capillary membrane
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Ventilation/Perfusion
• Ventilation (V) – movement of air• Perfusion (Q) – the movement of blood
carrying oxygen• Near equal relationship of ventilation
(4L/min) and perfusion (5L/min)• Acute Respiratory Failure commonly
caused by mismatch of ventilation and perfusion
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Figure 36.4 Ventilation/perfusion relationships: (A) normal unit; (B) dead space unit; (C) shunt unit; (D) silent unit.
(a) V/Q is equal to 0.8 – no miss match
(b) V/Q is >0.8 – there is ventilation but no perfusion
(c) V/Q is <0.8 – there is perfusion but little or no ventilation
(d) V/Q no perfusion and no ventilation
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Acute Respiratory Failure
• Defined as a failure of gas exchange
• Respiratory system unable to provide O2 and remove CO2
• Results in failure of oxygenation, failure of ventilation, or both
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Classification of Acute Respiratory Failure (ARF)
• Hypoxemia (deprived of oxygen)– Caused by failure of oxygenation
• Hypercapnea (high CO2 in blood)– Caused by failure of respiratory system to
ventilate
• Failure of respiratory centers in the brain
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Classification of ARF
• Hypoxemia: – PaO2 below normal (<60 mmHg)
– SaO2 <90% on room air
• Hypercapnea: – PaCO2 above normal (>50 mmHg)
– pH <7.3
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Pathophysiology
• Hypoventilation• Shunting• Ventilation/perfusion mismatch: most
common cause
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Acute Pulmonary Edema
• Abnormal accumulation of fluid in the lungs
• Occurs rapidly – over minutes or hours• Etiologies – all relate to failure of heart
and/or lungs
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Cardiogenic Pulmonary Edema
• Initial insult is caused by heart failure– ↑ Pulmonary venous pressure leads to– ↑ Hydrostatic pressure in pulmonary
capillaries Result: pulmonary edema
• Cardiac dysfunction is most common factor
• Fluid overload, and chronic hypoxemia may also be present
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Noncardiogenic Pulmonary Edema
• Insult to the A-C membrane• Changes the permeability of the A-C
membrane• Major causes: sepsis, inflammation,
inhaled toxins, drugs
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Neurogenic Pulmonary Edema
• Direct insult to central nervous system– Examples: seizures, cerebral hemorrhage,
head injury
• Dyspnea (shortness of breath) is primary presenting symptom– Other symptoms may be present– Crackles, pink frothy sputum
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Negative Pressure Pulmonary Edema
• Caused by ventilation with airway obstruction
• High pressures required • When obstruction is relieved
– Hydrostatic pressure pushes fluid into lungs
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PE and Specific Populations
• Mountain climbers• Heroin users• Scuba divers/hyperbaric chamber users• Excessive intravenous fluid administration
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Clinical Manifestations of Cardiogenic PE/Non-Cardiogenic PE
• Respiratory clues are identical• Agitation, confusion common to both CPE
and NCPE• Distinguishing factors are subtle• Most evident in cardiac assessment, skin
appearance
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Differentiating CPE/Non-CPE
• Mostly evident in cardiac assessment, skin appearance– Example 1: tachycardia with hypotension and
cool diaphoretic skin suggests CPE– Example 2: tachycardia with hypertension,
bounding pulses and dry skin suggests NCPE
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Differentiating CPE/Non-CPE
• Other Distinguishing Factors– Jugular Vein Distension more common in
CPE– If coronary artery catheter is used, Pulmonary
Artery Occlusion Pressures (PAOP) or Pulmonary Capillary Wedge Pressure (PCWP) above 18mmHg confirms CPE
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Acute Respiratory Distress Syndrome (ARDS)
• Most severe type of respiratory failure• Caused by injury to A-C membrane• Mortality rate = 40%• Acute lung injury (ALI) less severe than
ARDS
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Acute Respiratory Distress Syndrome (ARDS)
• Lets fluids, proteins etc. flow into the lungs• Lung injury
→ Inflammation→ Pulmonary edema
→ Hypoxemia
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Acute Injury to the Lungs
• Causes of direct injury– Aspiration of gastric contents – most common
cause of ALI – Trauma, Infection
• Indirect injury – intermediary process causes injury– Sepsis, acute pancreatitis, major inflammatory
process
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Treatment of ARDS/ALI
• Specific therapy to treat underlying cause• Supportive treatment
– Oxygen– Mechanical ventilation– Fluid management
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How the Ventilator Works
• Monitors respiratory rate, pressure, volume
• Delivers specified volume, pressure, or both
• Controls concentration of oxygen • Mixes compressed air with oxygen to
reach desired FiO2
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Nursing Issues
• Complexity of equipment is increasing• Variety of equipment is increasing• No standard terminology among
manufacturers
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Terminology
• Spontaneous breaths• Mandatory breaths• Assisted breaths• Types of ventilation• Modes
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Types of Breath
• Spontaneous breaths– Patient initiates breath– Patient controls switch from inspiration to
expiration
• Assisted breaths– Patient initiates breath– Ventilator controls switch to expiration– Ventilator controls volume and pressure
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Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Terminology
• Mandatory breaths – controlled entirely by ventilator– Inspiration– Expiration– Volume/pressure of gas delivery
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Types of Ventilation
• Volume – clinician controls tidal volume; pressure can vary – can set rate, set volume
• Pressure – clinician controls pressure; tidal volume can vary - set rate, set pressure, need to monitor minute volumes
• No clinical consensus on preferred type
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Common Ventilator Modes
• Mode: describes the pattern of breath delivery
• Common modes– Assist control mode (ACM) – Synchronized mandatory intermittent
ventilation (SIMV) – Pressure support (PS or PSV) – Pressure controlled ventilation (PCV)
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Assist Control Mode
• ACM delivers a preset volume or a preset pressure for each breath
• Patient can trigger a breath or the breath can be time triggered (CMV, A/C)
• Commonly used in care of in the postoperative patient
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Assist Control Mode
• Nursing Implications of ACM – As patient awakens, she or he may begin
initiating breaths– Machine may not have time to deliver set
volume– Patient can become hypoxic by attempt to
breathe faster, stacking breaths– Pressure builds; lungs may be injured
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Assist Control Mode
• Nursing Implications of ACM– Nurse must monitor to assure that patient and
machine are working together
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Synchronized Intermittent Mandatory Ventilation
• Very common mode in US• SIMV sets the mandatory respiratory rate
(VE )• Ventilator will deliver a set volume or
pressure• Patient can also initiate a breath
– Ventilator waits for the patient, to breathe– Synchronizes delivery of breath in concert
with the patient
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Synchronized Intermittent Mandatory Ventilation
• Nursing Implications of SIMV – Desirable for patient to “overbreathe” the
machine; i.e. breathe faster than the VE
– In SIMV, patient may initiate breaths, some are assisted and some are not
– Team should evaluate VE, level of sedation or analgesia
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pressure Support
• PS is a form of assisted ventilation• Requires stable respiratory effort from
patient• IF ventilator senses negative pressure on
inspiration– THEN ventilator supports the patient-initiated
breath
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pressure Support
• Does not control the rate or tidal volume– Therefore, usually used with SIMV, CPAP
mode– PS not triggered unless patient breathes
above the VE (mandatory rate)
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pressure Support
• Nursing Implications of PS with SIMV– If patient does not “overbreathe” the machine,
no benefit from PS– The nurse should assess the patient and talk
to the team to determine a course of action
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pressure Control Ventilation
• Clinician sets rate and pressure• Tidal volume is allowed to vary• Usually reserved for patients with
noncompliant lungs, difficult to ventilate and oxygenate
• Gas delivery distinguishes PCV from PS– Breath triggers rapid delivery of gas to reach
set pressure, then the flow is decelerated
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pressure Control Ventilation
• Nursing Implications of PCV– The nurse should trend the VE and the
expiratory volume over time– Volume decrease may indicate lungs are
becoming less compliant– Adjust Pressure to Achieve the Same Volume
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Positive End-Expiratory Pressure
• PEEP is a ventilator setting, not a mode• Provides resistance at end of exhalation• Prevents alveoli from collapsing• CPAP – continuous positive airway
pressure – related to PEEP
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Three Types of PEEP
• Physiological PEEP – 5 cm of H2O
• Treatment PEEP – >5 cm of H2O
• Auto-PEEP • For most ventilated patients, PEEP of at
least 5 cm of H2O required to prevent alveolar collapse
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Implications of PEEP
• PEEP of greater than 5 cm of H2O can cause decreased cardiac output
• Pneumothorax at higher levels of PEEP• The nurse should be aware of the level of
PEEP
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Auto-PEEP
• Potential problems– Ventilator set rate is too high– Overaggressive use of an Ambu bag
• Result: pressure builds in the lungs– Disconnect the ventilator or Ambu briefly– Allows the excess pressure to dissipate
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
CPAP
• Commonly used prior to extubation• Patient is breathing spontaneously• Ventilator support at end of expiration only
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Assessment in ARF
• Priorities are airway and oxygenation status
• Frequent, ongoing assessment is vital
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Assessment Data
• Ask if the patient feels s/he is getting enough air
• Evaluate for anxiety
• Respiratory rate, work of breathing, SO2, vital signs
• Assess skin and nail beds for cyanosis and pallor
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Diagnosis
• Impaired gas exchange • Ineffective tissue perfusion:
cardiopulmonary and peripheral• Deficient knowledge related to the disease
process• Self-care deficit• Ineffective airway clearance• Ineffective breathing pattern
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Interventions in ARF
• Encourage deep breathing and coughing• Encourage incentive spirometer use, if
ordered• Frequent turning and repositioning
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Indications for Endotracheal Intubation
• Inability to maintain oxygenation/ ventilation
• Airway protection• Elective surgery
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nurse’s Role
• Know the proper equipment and its use• Anticipate the health provider’s needs • Position the patient • Preoxygenate the patient• Provide suction as necessary• Monitor the patient• Provide information and reassurance
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
How Intubation Works
Figure 36.6 Endotracheal tube.
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Documentation
• Size of ET tube• Location of ET tube in airway• Medications administered• Patient’s tolerance of procedure
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Suctioning
• Performed based on assessment only• Never routinely ordered• DO: Hyperoxegenate before/after
suctioning• DON’T: Routinely instill normal saline
before suctioning
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Complications
• Hypoxemia• Bronchospasm• Cardiac arrhythmias• Tissue injury• Increased risk of infection
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Closed Suctioning System
• Patient with high PEEP, high FiO2
– Closed system keeps pressure up
• Patient cannot tolerate use of open system• Patient with airborne infectious disease
– Avoids exposing others to aerosolized infectious secretions
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
LEARNING OBJECTIVE 9
• State two indications for insertion of a chest tube in a patient in an acute care setting.
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Chest Tube
• Another major intervention for respiratory compromise
• Tension pneumothorax – common reason for chest tube insertion