1.Chapter 30 &31
Acute and Chronic Respiratory Disorders
1

2. Commonly understood to mean movement of air
Accomplished by the pulmonary system, consisting of the airways and lungs, the blood vessels perfusing them, the muscles of the thorax and abdomen, and the innervation of these structures
VENTILATION
2
3. the movement of atmospheric air into and out of the lungs
depends on open airways and contractions of muscles to create pressure gradients for air flow
ventilation is the critical first step in the complex process of respiration
PULMONARY VENTILATION
3
4. provides oxygen for metabolism in the tissues
removes carbon dioxide, the waste product of metabolism
Primary functions of the respiratory system
4
5. facilitates sense of smell
produces speech
maintains acid-base balance
maintains body water levels
maintains heat balance
Secondary functions of the respiratory system
5
6. THE PROCESS OF AIR ENTERING THE LUNGS
ALSO CALLED INSPIRATION
INVOLVES ACTIVE CONTRACTION OF THE MUSCLES AND DIAPHRAGM
NOTED BY ENLARGEMENT OF THE CHEST CAVITY
INHALATION
6
7. THE PROCESS OF AIR LEAVING THE LUNGS
ALSO CALLED EXPIRATION
A PASSIVE PROCESS
MUSCLES RELAX AND CHEST RETURNS TO NORMAL SIZE
EXHALATION
7
8. normally approx 500 ml of air is inhaled and exhaled
APNEA-temp interruption in normal breathing, no air movement occurs
dyspnea-difficulty breathing
orthopnea-difficulty breathing while in a lying position
See Table 30-1 for types of breathing patterns
BREATHING
8
9. respiratory center of the brain located just above the spinal cord in the brain stem
stimulated by changing levels of CO2& Oxygen
Chemoreceptors in the aorta and carotid artery monitor the PH and the amount of carbon dioxide and oxygen in the blood stream.
MEDULLA
9
10. NOSE
SINUSES
PHARYNX
LARYNX
EPIGLOTTIS
UPPER RESPIRATORY TRACT
10
11. Humidifies, warms, and filters inspired air
NOSE
11
12. air-filled cavities within the hollow bones that surround the nasal passages
provide resonance during speech
SINUSES
12
13. located behind the oral and nasal cavities
divided into the nasopharynx, oropharynx, laryngopharynx
passageway for both the respiratory and digestive tracts
PHARYNX (Throat)
13
14. located above the trachea and just below the pharynx at the root of the tongue
contains two pairs of vocal cords, the false and true cords
opening between true vocal cords is the glottis
the glottis plays an important role in coughing
coughing is the most fundamental defense mechanism of the lungs
LARYNX (Voice Box)
14
15. leaf-shaped elastic structure that is attached alone one end to the top of the larynx
it prevents food from entering the tracheobronchial tree by closing over the glottis during swallowing
EPIGLOTTIS
15
16. TRACHEA
MAINSTEM BRONCHI
BRONCHIOLES
ALVEOLAR DUCTS AND ALVEOLI
LOWER RESPIRATORY TRACT
16
17. located in front of the esophagus
branches into the right and left mainstem bronchi at the carina
passagewayfor air to reach the lungs
TRACHEA (Windpipe)
17
18. begins at the carina
a ridgelike structure between the openings of the right and left bronchus
the right bronchus is slightly wider, shorter, and more vertical than the left bronchus
most foreign bodies from the trachea usually enter the right bronchus
the mainstem bronchi divides into five secondary or lobar bronchi that enter each of the five lobes of the lung
MAINSTEM BRONCHI
18
19. the bronchi are lined with cilia, which propel mucus up and away from the lower airway to the trachea where it can be expectorated or swallowed
MAINSTEM BRONCHI
19
20. branch from the secondary bronchi and subdivide into the small terminal and respiratory bronchioles
they contain no cartilage and depend on the elastic recoil of the lung for patency
the terminal bronchioles contain no cilia and do not participate in gas exchange
BRONCHIOLES
20
21. alveolar ducts branch from the respiratory bronchioles
alveolar sacs, which arise from the ducts, contain clusters of alveoli, which are the basic units of gas exchange
cells in the walls of the alveoli secrete surfactant, a phospholipid protein that reduces the surface tension in the alveoli, without this alveoli collapse
ALVEOLAR DUCTS AND ALVEOLI
21
22. innervation of the respiratory structures is accomplished by the phrenic nerve, vagus nerve, and thoracic nerves
the parietal pleural lines the inside of the thoracic cavity including the upper surface of the diaphragm
the visceral pleura covers the pulmonary surfaces
LUNGS
22
23. a thin fluid layer, which is produced by the cells lining the pleura, lubricates the visceral and parietal pleura, allowing them to glide smoothly and painlessly during respiration
blood flows through the lungs occurs via the pulmonary system and the bronchial system
LUNGS CONT
23
24. scalene muscles
elevate the first two ribs
sternocleidomastoid muscles
raise the sternum
trapezius and pectoralis muscles
fix the shoulders
accessory muscles of respiration
24
25. the diaphragm descends into the abdominal cavity during inspiration causing negative pressure in the lungs
the negative pressure draws air from the area of greater pressure, the atmosphere, into the area of lesser pressure, the lungs
in the lungs, air passes through the terminal bronchioles into the alveoli to oxygenate the body tissues
THE RESPIRATORY PROCESS
25
26. at the end of inspiration, the diaphragm and intercostal muscles relax and the lungs recoil
as the lungs recoil, pressure within the lungs becomes greater than atmospheric pressure causing the air that now contains the cellular waste products of carbon dioxide and water to move from the alveoli in the lungs to the atmosphere
THE RESPIRATORY PROCESS
26
27. AGE RELATED CHANGES
ATROPHY (pharynx and larynx)
SLACKENING OF VOCAL CORDS
LOSS OF ELASTICITY
RIGID RIB CAGE
DIAPHRAGM FLATTENS
DECREASED NUMBER OF ALVEOLI
27
28. reduced chest movement
decreased ability to inhale and exhale
less effective cough
increased work of breathing
less tolerance for exercise and stress
AGE RELATED CONSEQUENCES
28
29. smoking
allergies
frequent respiratory illnesses
chest injury
surgery
exposure to chemicals and environmental pollutants
crowded living conditions
family history of infectious disease
geographic residence and travel to foreign countries
RISK FACTORS FOR RESPIRATORY DISEASE
29
30. HEALTH HISTORY
WHAT DO YOU NEED TO KNOW?
Chief complaint and hx of present illness
past medical hx
review of systems
functional assessment
30
31. cough
pain
dyspnea
fever
sweating
nausea/vomiting
effort to treat
response to treatment
PRESENT ILLNESS
31
32. onset-one week ,activity, lying down?
duration-each episode, how long
frequency-frequent, occasionally, constantly
type-dry hacking, wet productive, irritating and scratchy
severity-hard enough to throw up?
COUGH:
32
33. sputum production & characteristics
COLOR-green, yellow, clear, rusty, blood tinged
CONSISTENCY-thick, thin,
ODOR-there either is or there isnt
AMOUNT-scant, copious, large, small
pain-does it hurt when you cough?
have they tried anything to treat it and has it helped
COUGH
33
34. onset
duration
severity
precipitating events
associated symptoms
Dyspnea:
34
35. location
onset
duration
precipitating events
effects on breathing
relief measures
associated symptoms
Pain:
35
36. Colds
pneumonia
tuberculosis/last TB test
chronic bronchitis
emphysema
asthma
cancer of resp. tract
cystic fibrosis
immunizations
Sinus infections
ear infections
diabetes mellitus
heart disease
allergies / current meds
trauma
surgeries
hospitalizations/ last CXR
conditions that suppress the immune system
PAST MEDICAL HISTORY
36
37. Family history
Major respiratory conditions
smoking history
37
38. fatigue
weakness
fever
chills
night sweats
earaches
nasal obstruction
sinus pain
sore throat
hoarseness
edema
dyspnea
orthopnea
Review of symptoms
38
39. occupation
exposure to pathogens
exposure to respiratory irritants
typical day
usual diet
fluid intake
smoking history
# yrs smokedX pkg/d
this equals pack years
role in family
stressors
coping strategies
Functional Assessment
39
40. PHYSICAL EXAM
be alert to any unusually rapid or slow breathing and to tachycardia, which may be a sign of hypoxia
remember normal respiratory rate is 16 - 20 breaths per minute
40
41. Appearance
facial expression
posture
alertness
speech pattern
obvious distress
VSHt. & Wt.
GENERAL SURVEY
41
42. NOSE
patency of nares
nasal flaring(sign of air hunger)
swelling
discharge
bleeding
foreign bodies
mucosa should be bright red in color
deviation of nasal septum
HEAD AND NECK
42
43. SINUSES
palpate sinuses for tenderness
LIPS
pursed-lip breathing, common technique for decreasing dyspnea for pts with chronic respdz
inspect lips, tip of nose, top of auricles, gums and under tongue for cyanosis, a bluish color R/t inadequate O2
PHARYNX
Redness, tonsil exudate or enlargement
HEAD AND NECK
43
44. inspect for deviation, can be indicative for a large atelectasis, pleural effusion, aortic aneurysm, enlargement of part of the thyroid gland, and tension pneumothorax
TRACHEA
44
45. THORAX
look for deformities and lesions
observe breathing pattern and effort, should be regular and symmetric
palpate for lumps and symmetry
palpate for tactile fremitus (What is this?)
A tremulous vibration of the chest wall during breathing that is palpable on physical examination.It may indicate inflammation, infection, or congestion.
auscultate lungs in systematic manner, usually posterior, sides, anterior
45
46. THORAX
listen for normal movement of air and abnormal sounds
WHEEZE-high-pitched sound caused by air passing through narrowed passageways, as with asthma or COPD
46
47. THORAX
RHONCHUS-dry rattling sound caused by partial bronchial obstruction
CRACKLES(RALES)-associated with many cardiac and pulmonary disorders, sounds like rubbing strands of hair between the thumb and forefinger next to the ear
47
48. THORAX
COARSE CRACKLES- sounds like a velcro fastener being separated
PLEURAL FRICTION RUB-grating, scratchy noise similar to a creaking shoe
48
49. ABDOMEN
inspect the abdomen for distention that might interfere with full expansion of the lungs
49
50. EXTREMITIES
check color of extremities and edema
finger clubbing/chronic resp problems
50
51. HOMANS SIGN
dorsiflex pts foot
suspect thromboplhlebitis if this elicits pain behind the knee or in the calf
important to know, the legs and the pelvis are the source of most pulmonary emboli
51
52. NORMAL BREATHING PATTERNS
should have regular pattern
even depth
rate 12-20 breaths/min
this is the normal respiratory drive
52
53. TACHYPNEA
should have regular pattern
even depth
rate is faster than 20 breaths/min
may be caused by fever, pain, anxiety, respiratory disorders, shock
53
54. BRADYPNEA
should have regular pattern
even depth
rate is slower than 12 breaths/min
may be caused by sedatives, narcotics, alcohol; brain, metabolic, and respiratory disorders
54
55. SIGHING RESPIRATIONS
should have regular pattern
uneven depth; periodic deep breaths (more than 3 sighs/min)
rate is 12 to 20 breaths/min
may be caused by severe anxiety
55
56. CHEYNE-STOKES RESPIRATIONS; APNEA
breaths are progressively deeper, then becoming more shallow, followed by period of apnea
may be caused by severe brain pathology
56
57. KUSSMAULS RESPIRATIONS (WITH HYPERVENTILATION)
should have a regular pattern
deep respirations
rate is faster than 20 breaths/min
may be caused by metabolic acidosis, diabetic ketoacidosis, renal failure
57
58. BIOTS RESPIRATIONS; APNEA
should have an irregular pattern
depth varies, sudden periods of apnea
may be caused by neurologic disorders
58
59. obstructive breathing, rising end-expiratory level with forced expirations
gradual rise in end-expiratory level during forced rapid breathing
may be caused by emphysema
59
60. ABG
SPUTUM C&S
BRONCHOGRAM
CXR
VENTILATION -PERFUSION SCAN
CT
MRI
PULMONARY FUNCITON TEST
BRONCOSCOPY
THORACENTESIS
SPIROMETRY: lung volumes and capacity
DIAGNOSTIC PROCEDURES
60
61. used to provide information regarding the anatomical location and appearance of the lungs
Pre-procedure:remove all jewelry and other metal objects from the chest area, assess ability to inhale and hold breath, question females regarding pregnancy or the possibility of pregnancy
Post procedure:assist the client to dress
CHEST X-RAY STUDY
61
62. a specimen obtained by expectoration or tracheal suctioning to assist in the identification of organisms or abnormal cells
SPUTUM SPECIMEN
62
63. determine specific purpose of collection and check with institutional policy for appropriate collection of specimen
obtain an early morning sterile specimen from suctioning or expectoration after a respiratory treatment, if prescribed
obtain 15 mL of sputum
SPUTUM-PREPROCEDURE
63
64. instruct client to rinse mouth with water before collection; instruct client to take several deep breaths and then cough deeply to obtain sputum
ALWAYS collect specimen before starting antibiotics
SPUTUM-PREPROCEDURE
64
65. if culture of sputum is prescribed, transport to laboratory immediately
assist the client with mouth care
SPUTUM-POSTPROCEDURE
65
66. direct visual examination of the larynx, trachea, and bronchi with a fiberoptic bronchoscope
Used to visualize abnormalities, take biopsy samples or lesions, or remove foreign bodies.
BRONCHOSCOPY
66
67. obtain informed consent
NPO from midnight before the procedure ( or 6-8 hours)
obtain vital signs
monitor coagulation studies
remove dentures or eyeglasses
prepare suction equipment
administer medication for sedation as prescribed
BRONCHOSCOPY pre-procedure
67
68. have emergency resuscitation equipment readily available
BRONCHOSCOPYpre-procedure
68
69. monitor vital signs
maintain semi-Fowlers position
assess gag reflex
maintain NPO status until gag reflex returns
monitor for bloody sputum
monitor respiratory status
monitor for asymmetric chest movement
monitor for swelling of face and neck
monitor for dyspnea, diminished lung sounds
BRONCHOSCOPY post procedure
69
70. monitor for complications such as brohnchospasm, bacteremia, bronchial perforation indicated by facial or neck crepitus, dysrhythmias, fever, hemorrhage, hypoxemia, and pneumothorax
notify physician if fever or difficulty in breathing occurs after the procedure
BRONCHOSCOPYpost-procedure
70
71. an invasive fluoroscopic procedure after injection of iodine, radiopaque, or contrast material through a catheter inserted through the antecubital or femoral vein into the pulmonary artery or one of its branches
Pulmonary Angiography
71
72. obtain informed consent
assess for allergies to iodine, seafood, and other radiopaque dyes
maintain NPO status for 8 hours before the procedure
monitor vital signs
monitor coagulation studies
establish an IV access
Pulmonary Angiography-preprocedure
72
73. administer sedation as prescribed
instruct client to lie still during the procedure
instruct client that he or she may feel an urge to cough, or flushing, nausea, or salty taste after injection of the dye
have emergency resuscitaiton equipment available
Pulmonary Angiography-preprocedure
73
74. monitor VS
avoid taking blood pressures in the extremity used for injection for 24 hours
monitor peripheral neurovascular status
assess insertion site for bleeding
monitor for delayed reaction to the dye
Pulmonary angiography-postprocedure
74
75. Removal of fluid or air from the pleural space via a transthoracic aspiration
Pleural fluid is aspirated and examined for pathogens, other abnormal components.Cells studied for malignance
See figure 30-8 page 522
Thoracentesis
75
76. obtain informed consent
obtain baseline vital signs
prepare client for ultrasound or chest x-ray study if prescribed before procedure
assess coagulation studies
note that client is positioned sitting upright with arms and head supported by a table at the bedside during the procedure
Thoracentesis-preprocedure
76
77. if the client cannot sit up, the client is placed lying in bed on the unaffected side with the head of the bed elevated 45 degrees
inform client not to cough, breathe deeply, or move during the procedure
Thoracentesis-preprocedure
77
78. Thoracentesis-postprocedure
monitor VS
monitor respiratory status
patient is positioned on the unaffected side after the procedure
apply a sterile, pressure dressing and assess puncture site
monitor for signs of pneumothorax, air embolism, and pulmonary edema
observe for uneven chest movements, respiratory distress and hemorrhage
Document amount and color of fluid removed
78
79. included a number of different tests used to evaluate lung mechanics, gas exchange and acid-base disturbance through spirometric measurements, lung volumes, and arterial blood gases
examples: measures of: total lung capacity, forced respiratory volume, functional residual capacity, inspiratory capacity, vital capacity, forced vital capacity (see table 29-4 for definitions)
Pulmonary function test (PFT)
79
80. used to diagnose pulmonary disease
monitor disease progression
evaluate the extent of disability
assess the effects of medication
PFT
80
81. determine if an analgesic that may depress the respiratory function is being administered
consult with physician regarding holding bronchodilators before testing
instruct client to void before procedure and to wear loose clothing
PFT-preprocedure
81
82. remove dentures
instruct client to refrain from smoking or eating a heavy meal for 4 to 6 hours before the test
PFT-preprocedure
82
83. resume normal diet and any broncholilators and respiratory treatments that were held before the procedure
PFT-post procedure
83
84. an instrument that measures the ventilatory function of the lungs
measures volume of air that the lungs can hold
the rate of flow of air in and out of the lungs
the compliance (elasticity) of lung tissue
involves inserting mouthpiece, taking as deep a breath as possible and blowing as hard, as fast, and as long as possible
See Table 30-2 for Lung Volumes and Capacities
Spirometry
84
85. noninvasive measurement of arterial oxygen saturation
A beam of light passes through the tissue , and the amount of light absorbed by oxygen saturated hemoglobin is measured.
sensor clipped to earlobe or fingertip
factors that interfere with an accurate reading include: hypotension, hypothermia, vasoconstriction, and finger movement, also dark fingernail polish if it is placed on the nail
Pulse Oximetry
85
86. visualizes the bronchial tree
radiographic procedure
pts throat and bronchi are anesthetized
Bronchogram
86
87. dye is instilled into the bronchial tree through a catheter or a fiberoptic bronchoscope
pt is tilted in different positions for dye to spread in specific directions
complications include:pneumonia, delayed hypersensitivity reaction and laryngospasm
Bronchogram
87
88. a percutaneous lung biopsy is performed to obtain tissue for analysis by culture or cytological examination
a needle biopsy is done to identify pulmonary lesions, changes in lung tissue, and the cause of pleural effusion
Lung Biopsy
88
89. obtain informed consent
maintain NPO status before the procedure
inform the client that a local anesthetic will be used by that a sensation of pressure during needle insertion and aspiration may be felt
administer analgesics and sedatives as prescribed
Lung Biopsy-preprocedure
89
90. monitor vital signs
apply a dressing to the biopsy site and monitor for drainage or bleeding
monitor for signs of respiratory distress and notify the physician if they occur
monitor for signs of pneumothorax and air emboli and notify physician if they occur
prepare client for chest x-ray study if prescribed
Lung Biopsy-postprocedure
90
91. Demonstrated lung ventilation and perfusion.
the ventilation scan determines the patency of the pulmonary airways and detects abnormalities in ventilation
Detects pulmonary embolism and other obstructive conditions
a radioactive substance may be inhaled or injected for the procedure
Ventilation-perfusion lung scan
91
92. 92
93. obtain informed consent
assess for allergies to dye, iodine, or seafood
remove jewelry around the chest area
review breathing methods that may be required during testing
establish an IV access
Ventilation-perfusion lung scan-preprocedure
93
94. Administer sedation if prescribed
Usually NPO for 4 hours
May take 2 hours
Have emergency resuscitation equipment available
Ventilation-perfusion lung scan-preprocedure
94
95. monitor client for reaction to the radionuclide for 1 hour for anaphylaxis
for 24 hours after the procedure, rubber gloves are worn when urine is being discarded; they should be washed with soap and water before removing, and then the hands should be washed after the gloves are removed( radioactive material is excreted in the urine)
Ventilation-perfusion lung scan-postprocedure
95
96. Instruct the client to wash hands carefully with soap and water for 24 hours after the procedure when voiding (lets hope they already do this)
Ventilation-perfusion lung scan-postprocedure
96
97. allows visualization of slices or layers of the chest
a camera rotates in a circular pattern around the body for a three dimensional assessment of the thorax
usually used to look for the presence of lesions or tumors
radioactive dye containing iodine may be injected IV
COMPUTED TOMOGRAPHY (CT)
97
98. explain the test to the patient
they lie on a platform while a special doughnut-shaped radiographic scanner rotates around them
stress the importance of remaining still during the scanning
assess iodine allergy, if contrast is used, if there is, report it to the radiologist
NPO may be required
CT preparation
98
99. note side effects of contrast:nausea, vomiting, headache
CT postprocedure
99
100. similar to CT but without harmful radiation
doughnut-shaped magnet used
pt lies on a stretcher that slides into a tubelike device
mechanical clanging noises are heard as machine operates
MRI
100
101. metal implants such as cardiac pacemakers and orthopedic implants may be affected by MRI, but are not absolute contraindications
aneurysm clips, intraocular metal, heart valves made before 1964, and middle ear prostheses generally contraindicate MRI
MRI
101
102. explain test to patient
get consent form signed
assess for claustrophobia
anxious pt may require sedation
have pt remove metal watch and jewelry
MRI preparation
102
103. safety precautions if sedated; otherwise, no special after care is needed
MRI postprocedure
103
104. Determine past or present exposure to tuberculosis
A patient who has ever been vaccinated with BCG will test positive regardless of actual exposure
Bacille Calmette-Gurin (BCG) is a vaccine against tuberculosis that is prepared from a strain of the attenuated (weakened) live bovine tuberculosis bacillus, Mycobacterium bovis, that has lost its virulence in humans by being specially cultured in an artificial medium for years.
Tuberculin skin tests
104
105. purified protein derivative or old tuberculin is introduced into the skin using a device with four tines
the device is firmly pressed on the anterior forearm for 1 sec.
This site is marked, recorded, and inspected in 48 to 72 hours for redness and swelling
a reaction equal to or greater than 2 mm at one or more puncture sites is positive
Multipuncture (tine) test (PPD)
105
106. cleanse puncture site
tell pt. The procedure causes pain briefly
stress need to return in 48-72 hr to evaluate response
pt should not scratch site
tell pt skin reaction may persist for a week
PPD preparation
106
107. if PPD is positive this test is done
old tuberculin is injected intradermally in the lower anterior forearm
this site is marked, recorded and inspected after 48-72 hr for swelling and redness
a reaction of 5 mm or more is positive for tuberculosis exposure
Mantoux test
107
108. tell pt to expect some pain with injection
return in 48-72 hours for evaluation of response
swelling may persist up to a week
Mantoux preparation
108
109. May be performed when respiratory disease is suspected
May contain bacterial or malignant cells
Also examined for volume, consistency, color, and odor
Thick foul smelling, and yellow, green, or rust colored sputum usually indicates a bacterial infection
Sputum analysis
109
110. Ordered to determine the presence of bacteria, identify the specific organisms and identify appropriate antimicrobials
Collect specimen before antimicrobial therapy is begun
Culture and sensitivity
110
111. Performed to determine the presence of acid-fast bacilli
Including the bacteria that causes tuberculosis
Usually collected on 3 consecutive days
Cover and refrigerate or deliver to lab within 1 hour
Use sterile container
Acid-fast test
111
112. ABGs
measures pH, PaCO2, PaO2, HCO3 and O2 saturation
detects alkalosis or acidosis, and alterations in oxygenation status that may occur with many respiratory, cardiac, and metabolic disorders
112
113. ABGs Normal Values for adults
PH:7.35 - 7.45
PaCO2:35 - 45 mm Hg
PaO2:75 - 100 mm Hg
HCO3:22 - 26 mEq/L
O2 saturation:96 - 100%
113
114. ABG Preparation
tell the patient a blood sample will be drawn from an artery (usually radial)
an Allens test should be done before an arterial puncture to ensure that the arteries to the hand are patent (page 465)
The patients hand is formed into a fist while the technician compresses the ulnar artery.Compression of the ulnar artery is continued while the fist is opened.If blood perfusion through the radial artery is adequate, the hand should flush and resume a normal pinkish coloration.
114
115. 115
116. ABG postprocedure
apply pressure to the puncture site for 5-10 minutes
note the concentration of any oxygen therapy on lab slip
transport the blood gas syringe to the lab in an ice bath within 15 minutes
respiratory therapist will usually take sample and analyze it
Go to slide 140- (just had ABGs)
116
117. hydrogen ions (H+)
are vital to life
expressed as pH
bodys pH is normally alkaline between 7.35 and 7.45)
117
118. ACIDS:
Produced as end products of metabolism
contain hydrogen ions
the number of hydrogen ions in body fluid determines its acidity, alkalinity, or if it is neutral
118
119. BASES
contain no H+
hydrogen ion acceptors
accept H+ from acids to neutralize or decrease the strength of a base or to form a weaker acid
119
120. Regulating H+ concentration in the blood
BUFFERS: hemoglobin, plasma proteins, carbonic acid/bicarbonate system, phosphate buffer system
LUNGS
KIDNEYS
POTASSIUM
120
121. Lungs regulating system
interacts with the buffer system to maintain acid base balance
in acidosis: pH goes down and the respiratory rate and depth go up in an attempt to blow off acids
the carbonic acid created by the neutralizing action of bicarbonate can be carried to the lungs where it is reduced to C)2 and water and exhaled, thus H+ are inactivatedand excreted
121
122. Lungs regulating system
in alkalosis, the pH goes up and the respiratory rate and depth go down, the CO2 is retained, and the carbonic acid builds to neutralize and decrease the strength of excess bicarbonate
the action of the lungs is reversible in controlling an excess or deficit
122
123. Lungs regulating system
the lungs can hold H+ until the deficit is corrected or can inactivate H+, changing them to water molecules to be exhaled as CO2, thus correcting the excess
the lungs are capable of inactivating only H+ carried by carbonic acid (H2CO3); excess H+ created by other problems must be excreted by the kidneys
123
124. Respiratory Acidosis
the total concentration of buffer base is lower than normal, with a relative increasing hydrogen ion (H+) concentration; thus a greater number of H+ are circulating in the blood than can be absorbed by the buffer system
124
125. due to primary defects in the function of the lungs or by changes in normal respiratory patterns from secondary problems
remember that any condition that causes an obstruction of the airway or depresses respiratory status can cause respiratory acidosis
hypoventilation
COPD, CAL, COLD
CAUSES OF RESPIRATORY ACIDOSIS
125
126. pulmonary edema
pneumonia
atelectasis
asthma
bronchitis or bronchiectasis
infection
medications such as sedatives, narcotics, or anesthetics
CAUSES OF RESPIRATORY ACIDOSIS
126
127. brain trauma
CAUSES OF RESPIRATORY ACIDOSIS
127
128. in an attempt to compensate, the respiratory rate and depth increase
pH less than 7.35 and PCO2 greater than 45 mm Hg
mental status changes such as confusion
drowsiness
restlessness
weakness
DATA COLLECTION
128
129. dizziness
dyspnea
hyperkalemia
DATA COLLECTION
129
130. maintain patent airway
monitor for signs of respiratory distress
administer oxygen as prescribed
place client in semi-Fowlers position unless contraindicated
encourage and assist the client to turn, cough, and deep breathe
prepare to administer chest physiotherapy and postural drainage as prescribed
IMPLEMENTATION
130
131. encourage hydration to thin secretions unless excess fluid intake is contraindicated
suction the client as necessary
monitor electrolyte values
avoid the use of tranquilizers, narcotics, and hypnotics because they further depress respirations
administer antibiotics for infection as prescribed
IMPLEMENTAION
131
132. a deficit of carbonic acid (H2CO3) or a decrease in H+ concentration
results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids
Respiratory alkalosis
132
133. due to conditions that cause overstimulation of the respiratory status
hyperventilation
hypoxemia
fever
early stages of salicylate poisoning
reactions to certain medications
pain
Causes of respiratory alkalosis
133
134. anxiety
hysteria
Causes of respiratory alkalosis
134
135. initially, the hyperventilation and respiratory stimulation will cause abnormal rapid and deep respirations (tachypnea)
in an attempt to compensate, respiratory rate and depth then go down
pH is greater than 7.45 and PCO2 is less than 35 mm Hg
altered mental status
pallor around the mouth
DATA COLLECTION
135
136. tingling of the fingers
dizziness
spasms of the muscles of the hands
hypokalemia
DATA COLLECTION
136
137. maintain a patent airway
provide emotional support and reassurance to the client
encourage appropriate breathing patterns
IMPLEMENTATION
137
138. provide cautious care with ventilator clients so that the client is not forced to take breaths too deeply or rapidly
monitor electrolyte values
administer sedatives as prescribed
IMPLEMENTATION
138
139. Thoracentesis
breathing exercises
chest physiotherapy
suctioning
humidification & aerosol
oxygen
IPPB
artificialairways
mechanical ventilation
chest tubes
thoracic surgery
video thoracoscopy
drug therapy
THERAPUTIC MEASURES
139
140. performed to aid in lung expansion and expectoration of respiratory secretions
indicated when pts are immobilized or after general anesthesia
Breathing Exercises
140
141. sit in a semi-Fowlers position for maximal lung expansion
place on hand on the abdomen to feel it rise and fall with breathing
inhale deeply through the nose, pause 1 to 3 seconds, and exhale slowly through the mouth
Deep Breathing and Coughing
141
142. after 4 to 6 deep breaths, cough deeply from the lungs to aid in the expectoration of sputum
after thoracic or abdominal surgery, splint the incision with a pillow to minimize discomfort and support the incision
Deep Breathing and Coughing
142
143. used to inhibit airway collapse and to decrease dyspnea in pts with chronic lung disease
instruct pt to pucker lips as if to whistle, blow out a candle, or blow through a straw
then they should inhale through the nose and slowly exhale through pursed lips
exhalation should last twice as long as inhalation
Pursed-Lip Breathing
143
144. chest percussion and vibration
postural drainage
Chest physiotherapy
144
145. goal is to improve oxygen and carbon dioxide exchange in the lungs by removing excessive mucous secretions with a suction catheter
Suctioning
145
146. use strict aseptic technique
administer oxygen before inserting the suction catheter because the procedure temporarily interferes with the patients air flow
moisten the catheter in sterile water and insert the catheter through the nose or mouth before applying suction
Suctioning Key Points
146
147. apply suction intermittently as the catheter is rotated and withdrawn from the airway
maintain the pressure gauge between 80 and 100 mm Hg
limit each suction pass to 10 seconds (try holding your breath while you do this)
allow the patient to rest briefly, encourage deep breathing, and rinse the catheter with sterile solution between suction attempts
Suctioning Key Points
147
148. monitor the patients response to suctioning
if tachycardia or increased respiratory distress develops, stop the procedure and give the patient oxygen as ordered
document the amount, color, odor, and consistency of the patients secretions as well as the patients status before and after the procedure
Suctioning Key Points
148
149. creates water vapor to raise the relative humidity of inspired gas to 100%
there are room humidifiers and medical oxygen is humidified as it bubbles through a container of water
sterile water should be used to prevent the spread of bacteria
Humidifiers
149
150. suspended liquid particles of bronchodilators or inactive fluids such as water or saline
delivered by devices called nebulizers (pts call them puffers sometimes)
can be hand held
may be connected to an oxygen mask
pt should sit upright and slowly inhale, hold the breath briefly and exhale slowly
Aerosol therapy
150
151. Air in the atmosphere contains approximately 21% oxygen, which is usually sufficient
Individuals with pulmonary disease or injury may need supplemental oxygen
Oxygen is considered a drug and should be treated as such, you need an order and there may be serious side effects as well as benefits
Oxygen therapy
151
152. If you observe a patient becoming lethargic or bradypneic, immediately notify a supervisor or physician, these are symptoms of adverse effects of oxygen therapy
Oxygen is delivered from a bulk system, mounded on the wall of a patients room or it can be delivered from a cylinder unit on wheels
Oxygen therapy
152
153. A tube is needed to connect the flowmeter to the specific oxygen delivery device
This tube is then attached to the patient via nasal cannula or mask
Oxygen therapy is ordered in liters per minute or FIO2
FIO2 mean fraction of inspired oxygen
It is written as 0.30, which means 30% oxygen concentration
Oxygen therapy
153
154. The most common used delivery device is the nasal cannula
It fits around the face and directly into the nares by way of two prongs
It is designed to deliver a flow of oxygen from 1 to 6 L/min with approximate FIO2 of 0.24 to 0.44 or 24 to 44% oxygen concentration delivered
Oxygen therapy
154
155. 24% @ 1 L/min
28% @ 2 L/min
32%@ 3 L/min
36% @ 4 L/min
40% @ 5 L/min
44% @ 6 L/min
Anything over 6 L/min will not increase the % of O2 delivered, using nasal cannulas
Nasal Cannula (nasal prongs)
155
156. If you notice, anytime you add a liter, you have a 4% increase in the O2 delivered, you can remember 1L will give you 24% then add 4% every time you go up a liter
Nasal Cannula (nasal prongs)
156
157. Used for client with chronic airflow limitation (CAL, COPD) and for long-term oxygen use
The CAL or COPD pt who retains CO2 should never receive O2 at a rate higher than 2 to 3 liters/min
The potential for apnea or respiratory distress occurs
Nasal Cannula (nasal prongs)
157
158. Place the nasal prongs in the nostrils with the openings facing the patient
Add humidification as prescribed when a flow rate higher than 2 liters /min is prescribed
Check the water level and change the humidifier as needed
Monitor the client for changes in respiratory rate or depth
Implementation
158
159. Assess mucosa as high flow rates have a drying effect and increase mucosal irritation
Monitor skin integrity as the oxygen tubing can irritate the skin
Provide water-soluble jelly to the nares PRN
Do not use any petroleum based lubricant
Implementation
159
160. There are 4 types of available
Simple oxygen mask
Partial rebreathing mask
Nonrebreathing mask
Air entrainment (Venturi) mask
Masks
160
161. Designed to deliver an FIO2 ranging from 0.35 to 0.55
Which is 35% to 55%
It must be 6 L/min at least
If not 6L/min, CO2 may build up in the mask, which would be very dangerous for your patient
Seen on page 525
Simple mask
161
162. Flow rate must be set to at least 6 L/min
45%-50% @ 6 L/min
55%-60% at 8 L/min
Simple mask
162
163. Includes a reservoir bag to elevate the potential FIO2
Pt rebreathes part of their own exhaled gas
Design of the mask allows almost no rebreathed gas to contain CO2 from pts lungs, only enriched oxygen
Expected FIO2 range 0.35-0.60 (35 to 60%)
Flow setting must be at least 6
Partial rebreathing mask
163
164. None of the pts exhaled gas is rebreathed
Includes a reservoir bag
Series of valves to direct fresh supply of gas with each breath
Expected FIO2 should be 1.0(100%)
Controversy stating only 0.7 (70%)(because experimentally the highest F1O2 is approximately 0.7%)
Also must be 6-10 on flow meter
Used most often in client who may need to be placed on a ventilator
Nonrebreathing mask
164
165. Provides a specific FIO2
Usually must place an attachment to the mask
% of oxygen delivered is determined by the color of the attachment, must read the manufactures instructions
Example: Pink=50%, Blue=60% etc.
This mask delivers the highest concentration of O2 when compared with the other masks
Air entrainment mask (Venturi)
165
166. Be sure mask fits securely over nose and mouth, as a poorly fitting mask reduces the FIO2 delivered
Monitor the skin and provide skin care to the area covered by the mask because pressure and moisture under the bag may cause skin breakdown
Monitor the client closely for risk of aspiration because the mask limits the clients ability to clear the mouth, especially if vomiting occurs
Implementation
166
167. Provide emotional support to decrease anxiety to the client who feels claustrophobic
Consult with physician regarding switching the client from a mask to a nasal cannula during eating
With a reservoir bag, make sure it does not twist or kink, which results in a deflated bag
Implementation
167
168. Fits over the clients chin, with the top extending halfway across the face
O2 content varies
Useful instead of a tight-fitting mask for the client who has facial trauma and burns
Face tent
168
169. Can be used to deliver high humidity and the desired oxygen to the client with a tracheostomy
Special adapter called the T piece can be used to deliver any desired FIO2 to the client with a tracheostomy, laryngecotmy, or endotracheal tube
Oxygen delivered 24% to 100% with flow rates at least 10L/min
Tracheostomy collar and T piece
169
170. Change delivery system to a nasal cannula during mealtimes
Ensure that aerosol mist escapes from the vents of the delivery system during inspiration and expiration
Empty condensation from the tubing to prevent the client from being lavaged with water and to promote an adequate flow rate
Ensure that there is sufficient water in canister and change the aerosol water container as needed
Keep the exhalation port on T-piece open and uncovered(if occluded, the client can suffocate)
Implementation
170
171. Monitor the liter flow to be sure it is as prescribed
Assess the patients response to therapy; monitor reports of blood gas analyses
Inspect the tubing for kinks, obstructions, loose connections, listen for hissing sound in O2 mask: feel for adequate O2 flow
Maintain sterile water in the humidifier reservoir
Key points with oxygen therapy
171
172. Clean and replace oxygen therapy equipment according to agency policy
Post a no smoking sign and advise the patient and visitors that smoking is not allowed because oxygen supports combustion
Key points with oxygen therapy
172
173. Assess color and vital signs before and during treatment
Place an oxygen in use sign at clients bedside
Assess for presence of chronic lung problems
Humidify the oxygen
Implementation
173
174. Intermittent Positive Pressure Breathing Treatments
Used to achieve maximal lung expansion
The IPPB equipment delivers humidified gas with positive pressure, which forces air into the lungs with inhalation and allows passive exhalation.
Facilitates maximal exchange of oxygen and carbon dioxide gases in the alveoli and promotes a productive cough.
Mucolytics and bronchodilators common
IPPB
174
175. Oral airway
Nasal airway
Endotracheal tube
Tracheostomy
Artificial Airways
175
176. Orotracheal
Nasotracheal
Endotracheal tubes
176
177. Used to maintain a patent airway
Indicated when the client needs mechanical ventilation
If client requires artificial airway for longer than 10 to 14 days, a tracheostomy may be created to avoid mucosal and vocal cord damage than can be caused by the endotracheal tube
The cuff located at the distal end of the tube, when inflated, produces a seal between the trachea and the cuff to prevent aspiration and ensure delivery of a set tidal volume when mechanical ventilation is used, an inflated cuff also prevents air from passing to the vocal cords, nose or mouth
Endotracheal tubes
177
178. Allows use of a larger diameter tube and reduces the work of breathing
Indicated when the client has a nasal obstruction or a predisposition to epistaxis
Uncomfortable and can be manipulated by the tongue causing airway obstruction; an oral airway may be needed to keep the client from biting on the tube
Orotracheal
178
179. Smaller-sized tube increased resistance and increases clients work of breathing
Discouraged in clients with bleeding disorders
More comfortable for the client, and the client is unable to manipulate with tongue
Nasotracheal
179
180. Placement is confirmed by chest x-ray study (correct placement is 1 to 2 cm above carina)
Placement is assessed by auscultating both sides of chest while manually ventilating with resuscitation bag
If breath sounds and chest wall movement are absent on the left side, the tube may be in the right mainstem bronchus
Implementaion
180
181. Auscultation over the stomach is performed to rule out esophageal intubation
If the tube is in the stomach, louder breath sounds will be heard over the stomach than over the chest, and abdominal distention will be present
Secure the tube immediately after intubation with adhesive tape
Implementaion
181
182. Monitor position of tube at lip or nose
Monitor skin and mucous membranes
Suction only when needed (Why)
Implementaion
182
183. The oral tube needs to be moved to the opposite side of the mouth daily to prevent pressure and necrosis of the lip and mouth area, prevent nerve damage, and facilitate inspection and cleaning of the mouth; moving the tube to the opposite side of the mouth should be done by two health care providers
Implementaion
183
184. Prevent pulling or tugging on the tube to prevent dislodgement; suction, coughing and speaking attempts by the client place extra stress on the tube and can cause dislodgement
Keep a resuscitation (Ambu) bag at bedside at all times
Assess pilot balloon to ensure cuff is inflated
Implementaion
184
185. Hyperoxygenate the client and suction the endotracheal tube and the oral cavity
Place client in semi-Flowers position
The cuff is deflated and the tube is removed at peak inspiration
Instruct the client to cough and deep breathe to assist in removing accumulated secretions in the throat
Extubation
185
186. apply oxygen therapy as prescribed
Monitor respiratory status for signs of obstruction and notify physician if they occur
Inform client that hoarseness or a sore throat is normal and to limit talking if it occurs
Extubation
186
187. A tracheotomy is a surgical incision made into the trachea to establish an airway
A tracheostomy is the stoma or opening that results from the tracheotomy
The tracheostomy can be temporary or permanent
Tracheostomy
187
188. Monitor respirations
Monitor ABGs and pulse oximetry
Encourage coughing and deep breathing
Maintain a semi-to high-Fowlers postion
Implementation
188
189. Monitor for bleeding, difficulty breathing, absence of breath sounds, and crepitus, which are indications of hemorrhage, pneumothorax, and subcutaneous emphsema
Implementation
189
190. provide respiratory treatments as prescribed
Suction as needed:hyperoxygenate the client before suctioning
If client is allowed to eat, sit the client up for meals and ensure that the cuff is inflated(if the tube is not capped) for meals, and for 1 hour after meals
Implementation
190
191. Assess the stoma and secretions for blood or purulent drainage
Follow physicians orders and agency policy for cleaning the tracheostomy site and inner cannula; usually half-strength hydrogen peroxide is used
Administer humidified oxygen as prescribed as the normal humidificaiton process is bypassed in a client with a tracheostomy
Implementation
191
192. Obtain assistance in changing tracheostomy ties: cut and remove old ties holding the tracheostomy in place
Keep a resuscitation (Ambu) bag, obturator, and a tracheotomy set at the bedside
Implementation
192
193. Tube obstruction
Tube dislodgement
Pneumothorax
Subcutaneous emphysema
Bleeding
Infection
Tracheal stenosis
Tracheoesophageal fistula
Trachea-innominate artery fistula
Complications of a Tracheostomy
193
194. Used to overcome the clients inability to ventilate or oxygenate adequately
It may be intermittent or continuous, short or long term
Mechanical Ventilation
194
195. Depending on the patients needs, ventilators may be programmed to control or assist the rate of ventilation.
Ventilators deliver oxygen ranging in concentration from 21% oxygen to 100% oxygen. (Oxygen concentration = FI02)
Tidal volume is the present amount of oxygenated air delivered during each ventilator breath (usually 10 15ml/kg)
Respiratory rate setting is the total number of breaths delivered per minute.
Positive end expiratory pressure may be prescribed to keep the pressure in the lungs above the atmospheric pressure at he end of expiration.
This reduces collapse of small airways and alveoli, increasing the functional residual capacity and improving ventilation.
Mechanical Ventilation
195
196. Assess the client first and the ventilator second
Assess vital signs, respiratory status, and breathing patterns
Monitor color, particularly in the lips and nail beds
Monitor the chest for bilateral expansion
Obtain a pulse oximetry reading
Implementation
196
197. Assess the need for suctioning and observe type, color, and amount of secretions
Ensure that the alarms are set
If a cause of an alarm cannot be determined, ventilate the client manually with a resuscitation bag until the problem is corrected
Implementation
197
198. Empty ventilator tubings when moisture collects
Turn client at least every 2 hours or get client out of bed as prescribed to prevent complications of immobility
Have resuscitation equipment available at the bedside
Establish an alternate method of communication because the patient cannot speak while intubated
Implementation
198
199. Increased secretions in the airway
Wheezing or bronchospasm causing decreased airway size
Displacement of the endotracheal tube
Obstructed endotracheal tube because of water or a kink in the tubing
Client coughs, gags, or bites on the tube
Client is anxious or fights the ventilator
Causes of high pressure alarms
199
200. Disconnection or leak in the ventilator or in the clients airway cuff
The client stops spontaneous breathing
Causes of low pressure alarms
200
201. Hypotension caused by the application of positive pressure, which increases intrathoracic pressure and inhibits blood return to the heart
Respiratory complications such as pneumothorax or subcutaneous emphysema as a result of positive pressure
Complications of ventilation therapy
201
202. Gastrointestinal alterations as stress ulcers
Malnutrition
Infections
Muscular deconditioning
Ventilator dependence or inability to wean
Complications of ventilation therapy
202
203. The process of going from ventilator dependence to spontaneous breathing
Weaning
203
204. Continuous positive airway pressure
Maintains positive pressure in the airway during sleep
Avoids apnea
Small and have a nose mask that is worn during sleeping
CPAP
204
205. Inserted to drain air or fluid from the PLEURAL SPACE of the lungs
Permits re-expansion of a collapsed lung
Used in pts with hemothorax, pneumothorax or pleural effusion
Inserted under sterile conditions by physician
Page 523
Chest Tubes ( watched video)
205
206. Performed in OR or at bedside/ED
Small incision made to insert tube
Fourth intercostal space to remove air (pneumothorax)
Eigth or ninth intercostal space to remove fluids (hemothorax)
Tubes are sutured in place at insertion and an air tight, sterile dressing is applied
Chest Tubes
206
207. The other end of the plastic chest tube (distal end) is connected to a rubber tubing that leads to a pleural drainage device
This device has three chambers:
The collection chamber
The water seal chamber
The suction chamber
Chest Tubes
207
208. Chest fluid and air drain into the collection chamber
Air is diverted to the water seal chamber
When the drainage chamber is full, it can be changed without changing out the whole device
The collection chamber just twists out and a new one is twisted in
Collection chamber
208
209. Air is diverted here
It can be seen bubbling up through the water
It should not be a constant bubbling, more like an intermittent bubbling
If it is constant there may be an air leak
Waterseal chamber
209
210. Agency policy may permit the chest tubing to be clamped for 10 seconds while the leak is found
Check your connections and your dressing at the site of insertion
You should have hemostats in the room for just this purpose
Waterseal chamber
210
211. Suction pressure is controlled here
Gentle bubbling is expected in the suction chamber
Inside the chamber is a tube that is partially submerged in water
The depth of the tube in the water regulates the amount of suction
Suction Control Chamber
211
212. This tube is hollow and will have a water in it
There will be a rise and fall of water in this tube during inspiration and expiration (tidaling)
During chest tube insertion, the water is added to the control chamber and how much is instilled is determined by the physician depending on the amount of suctioning required
Suction Control Chamber
212
213. A chest radiograph is obtained to confirm placement of the tube
Chest Tubes
213
214. Monitor VS and breath sounds frequently
Assess dressing to be sure a tight seal is maintained
Tape tubing connections and inspect frequently to detect air leaks
Coil extra tubing on the bed to avoid kinks
Implementation
214
215. Keep drainage system on the floor
Monitor drainage for blood clots or lung tissue which could clog the tube
Implementation
215
216. Observe the water seal chamber for bubbling, it is usually seen unless the lung has reexpanded or the tubing is occluded
After checking for kinks or occlusion of the tubing, notify the charge nurse or physician of reexpansion
Always chart the bubbling and if there is no bubbling, checking for occlusion and finding none and then notifying the physician or CN
Implementation
216
217. Drainage is monitored by marking the drainage level on the drainage receptacle, do this on your first assessment of the patient and chart it!
You will then have the correct amount of drainage that occurred by the end of your shift, which you will chart as output
Implementation
217
218. An alternate to the large chest drainage system
The valve is a disposable unit that is attached to the chest tube and to a sterile drainage receptacle
air and fluid can flow in but cannot flow backward into the chest
This is good for the client who can ambulate
Heimlich Flutter Valve
218
219. Thoracotomy
The surgical opening of the chest wall
Reasons for thoracic surgery
To evaluate chest trauma
Removal of tumors and cysts
Thoracic Surgery
219
220. Pneumonectomy
Lobectomy
Segmental resection
Wedge resection
Surgical procedures on the Lungs
220
221. The removal of an entire lung
Pneumonectomy
221
222. The removal of one lobe of a lung
Lobectomy
222
223. The extensive dissection and removal of a section of the lung
Segmental resection
223
224. The removal of a small, triangular section of lung tissue
Wedge resection
224
225. Stripping of the membrane that covers the visceral pleura
Decortication
225
226. The removal of ribs
Thoracoplasty
226
227. Everything that goes along with any type of surgery
What you want to stress are breathing exercises and explanation of a chest tube if one may be required
Preoperative nursing care
227
228. Everything that goes with any type of surgery
What you want to stress
Vital signs
Lung sounds
Mental state
Dressings
Chest tube function and drainage
Postoperative nursing care
228
229. Drug Therapy
View table on page 532 - 533
230. Decongestants
Decongestants are adrenergic agents
231. Mimic the action of epinephrine and norephinephrine
Cause constriction of nasal blood vessels and reduce the swelling of mucous membranes
Sudafed (common over the counter)
With systemic vasoconstriction they may elevate the blood pressure
Systemic effects are less severe with topical drops and sprays
People with hypertension, heart disease, and hyperthyroidism should not take over the counter cold remedies without talking to the Dr or pharmacist.
231
Decongestants
232. Antitusives
Antitussives suppress the cough reflex
233. Antitussives
When a cough is nonproductive, creates pain and interferers with sleep or wound healing cough suppression may be indicated
Codeine is effective (but is an opioid with many side effect)
Dextromethorphan is commonly used
Be careful suppressing the cough because it is a protective mechanism.
233
234. Antihistamines
Antihistamines are also called histamine 1 blockers
235. They block the effects of histamine(one of the chemicals that causes allergic symptoms)
Prescription and over the counter
Dry nasal secretions
Benadryl - common first generation antihistamine
May cause dizziness, dry mouth, constipation, blurred vision, urinary retention, tachycardia, drowsiness and impaired judgment
235
Antihistamines
236. Second generation
Claritin less likely to cause drowsiness
236
Antihistamines
237. Expectorants
Thin respiratory secretions
238. Thin respiratory secretions so they are more readily mobilized and cleared from the airways
238
Expectorants
239. Antimicrobials
Kill or inhibit the growth of bacteria, viruses, or fungi
240. Usually treat only bacterial infections because they are not effective against viruses or fungi
Specific antimicrobials are best selected after culture and sensitivity tests are performed on a specimen of respiratory secretions
Instruct on proper self medications
240
Antimicrobials
241. Bronchodilators
Relax smooth muscle in the bronchial airways and blood vessels
242. Asthma and COPD
Primary drawback is their tendency to cause cardiac and CNS stimulation
Some bronchodilators act primarily to prevent bronchial constriction where as other relieve it.
242
Bronchodilators
243. Corticosteroids
Anti-inflammatory drugs
244. Parenterally, orally, inhalation
Reduce inflammation and edema in the respiratory tract
Less commonly used to treat COPD
Do no discontinue steroid therapy abruptly
244
Corticosteroids
245. Mast Cell Stabilizers
Used to prevent acute asthma attacks
246. Intal
Tilade
Not useful in stopping an attack after it starts
246
Mast Cell Stabilizers
247. Leukotriene Inhibitors
Leukotriens Mediate allergic responses
248. Useful in the treatment of asthma they inhibit the allergic response helping to prevent but not interrupt acute asthmatic attacks
Accolate
Zyflo
Singulair
248
Leukotriene Inhibitors
249. mucolytics
Reduce the viscosity and elasticity of mucus
250. Mucomyst is used as an inhalant to thin the secretions
Important for the patient to remain well hydrated
250
mucolytics
251. Thrombolytics
Dissolve blood clots
252. Streptase
Abbokinase
Alteplase
Activase
252
Thrombolytics
253. Lung Herbs
9 Lung Herbs For Colds and Respiratory Help
254. Mullein is a soothing expectorant that makes the mucous more fluid and less sticky, hence it can be coughed up more easily. It also helps relax the muscles in the bronchial passage. It is used for bronchitis, colds, persistent coughs, tuberculosis, pleurisy, and whooping cough
254
Mullein
255. Angelica is a warming remedy that is good for the digestive system as well as the respiratory system. It is an expectorant, which means it will encourage coughing and the elimination of excess mucous. It helps strengthen the lungs when they are weakened, and was traditionally used for many types of infections.
255
Angelica
256. Ginger is great in cases of excess phlegm, and bronchitis, and can also be used at the beginning of a cold. Like many of these lung herbs, its great for the digestive system also. Ginger is often used for nausea, and helps circulation.
256
Ginger
257. Garlic has been studied a lot for its immune benefits. Its great both in the digestive system, and the lungs. It helps 'sterilize' the bronchial passage in the lungs, and has been used in bronchial infections like tuberculosis. It's great for the 'common cold', and garlic capsules can be bought. Kyolic garlic is excellent. even though its an aged garlic. Fresh garlic, consumed within 15 minutes of being cut open, in a tea with honey and lemon juice, is also an excellent remedy, with very strong antibacterial and antimicrobial benefits. It's great for tonsillitis, throat infections, and similar. As well as its cleansing effect on the lungs, garlic helps encourage mucous to coughed up.
257
Garlic
258. Cinnamon should not be used in pregnancy. As a lung herb it's more warming than angelica, and can be used at the beginning of chesty colds. Mills suggests making a tea of powdered cinnamon and fresh ginger. It is also used in chest infections. Cinnamon is also great for the digestive system, and was also traditionally used in convalescence.
258
Cinnamon
259. This is a great lung herb for getting rid of excess mucous through coughing. It is very soothing, however, and the types of coughs it encourages are not dry hacking coughs that just produce more irritation. Its great for chronic bronchitis in the elderly, or for those who are weakened physically in some way. It can also be used for nervous coughing, and is a digestive tonic similar to angelica
259
Elecampane
260. Coltsfoot is also an expectorant. It's great for dry coughs, and because of its mucilage content, is very soothing when the bronchial passages are irritated.
260
Coltsfoot
261. More than a seasoning for cooking, this lung herb has antiseptic properties as well as being an expectorant and digestive tonic. It helps 'disinfect' the air passages, and also has a calming effect on the bronchial tube. It is generally used for more asthmatic conditions and dry coughs, but not really for bronchitis. Large amounts of thyme should not be taken during pregnancy.
261
Thyme
262. This lung herbis used as a cough suppressant, which as indicated above, should only be used under some circumstances. But it is used in helping treat strong and incessant coughing to the point of exhaustion.
262
Wild Cherry Bark
263. DISORDERS OF THE RESPIRATORY SYSTEM
263
264. ACUTE VIRAL RHINITISTHE COLD
264
265. Last 2 - 14 days,
first 3 days most contagious
headache
sneezing
stuffiness
sore throat
runny nose
Fatigue
lethargic
Fever and chills in severe cases
SIGNS AND SYMPTOMS
265
266. DIAGNOSIS
HISTORY AND EXAM
267. Rest
fluids
diet
antipyretics
analgesics
Antivirals (not commonly used)
Vitamin C
antihistamines
decongestants
TREATMENT
267
268. Acute Bronchitis
268
269. Follows a cold or the flu
usually viral
Bacterial: Streptococcus pneumoniae, haemophilus influenzae
Irritation and inflammation : increase mucous
ETIOLOGY AND RISK FACTORS
269
270. FEVER
COUGH
YELLOW OR GREEN SPUTUM
RAPID BREATHING
OCCASIONALLY CHEST PAIN
SIGNS AND SYMPTOMS
270
271. DIAGNOSIS
HEALTH HISTORY
ASSESSMENT FINDINGS
272. MEDICAL TREATMENT
BROAD SPECTRUM ANTIBIOTIC FOR
7 - 10 DAYS
273. INFLUENZA
273
274. Acute viral respiratory infection
Several types then subtypes (A,B,C)
Most susceptible:
very young
elderly
institutionalized
chronic disease
you
Etiology and Risk Factors
274
275. Bronchitis
Viral or Bacterial Pneumonia
myocarditis
pericarditis
Rye Syndrome
confusion
Guillain-Barre
toxic shock
Myositis (swelling of the muscles)
renal failure
COMPLICATIONS
275
276. Chills
fever
muscle pain
headache
dry hacking cough
SIGNS AND SYMPTOMS
276
277. MEDICAL DIAGNOSIS
SYMPTOMS
ASSESSMENT
278. Rest
fluids
diet
analgesics
antipyretics
Antivirals (Symmetrel, Flumadine, Tamiflu, Relenza for type A & B)
prevention; flu shot
TREATMENT
278
279. PNEUMONIA
279
280. Inflammation of the alveoli & bronchioles
infectious
Psuedomonas
Candidia
noninfectious
fumes
dust
chemicals
Nosocomial
poor hand washing
poor sterile technique
contaminated equipment
contact
Etiology and Risk Factors
280
281. SMOKERS
ALTERED CONSCIOUSNESS
IMMUNOSUPRESSED
CHRONICALLY ILL
PROLONGED IMMOBILITY
Those at risk
281
282. Lobar Pneumonia
one or more lobes
Bronchopneumonia
bronchioles & alveoli
Interstitial pneumonia
lung tissue surrounding the alveoli
Gram + bacteria
pneumococcal
staphylococcal
streptococcal
Gram - bacteria
pseudomonas
influenza
legionnaires disease
Viral
PATHOPHYSIOLOGY
282
283. PLEURISY
PLEURAL EFFUSION
ATELECTASIS
LUNG ABCESS
DELAYED RESOLUTION
EMPYEMA
SYSTEMIC COMPLICATIONS
pericarditis
arthritis
meningitis
endocarditis
COMPLICATIONS
283
284. Fever
chills
sweats
chest pain
cough
sputum production
hemoptysis
dyspnea
headache
SIGNS & SYMPTOMS
284
285. BACTERIAL
abrupt onset
severe shaking chills
sharp stabbing lateral chest pain
intermittent cough productive of rusty sputum
VIRAL
burning or searing chest pain in sternal area
continuous barking hacking cough with small amount of sputum production
headache
SIGNS & SYMPTOMS
285
286. History
exam
CXR
sputum gm. Stain
sputum C&S
CBC
Blood culture
DIAGNOSIS
286
287. 3L of fluid/24 hours
bedrest
analgesics
antipyretics
oxygen
IPPB
antibiotics
Vaccine
not recommended for children under age 2
only given once in a lifetime/There have been some questions regarding the once in a lifetime
TREATMENT
287
288. Ineffective airway clearance R/T
Increased sputum production
Thick secretions
Ineffective cough
Nursing diagnoses
288
289. What can a nurse do?
Decrease production of sputum and promote expectoration by administering antimicrobials, decongestants and expectorants as ordered
Teach and encourage deep breathing and coughing
Change positions at least every 2 hours to help mobilize secretions
Chest physiotherapy and aerosol therapy
Suctioning if needed
Provide tissues and receptacle
Chart amount, color, consistency of secretions
Ausculate lung sounds frequently to assess the effects of interventions
Ineffective airway clearance
289
290. Edema and secretions with pneumonia may interfere with gas exchange
Pt may have hypoxemia-low O2 in blood or hypercapnia-accumulation of CO2 in blood
Need to improve gas exchange
Impaired gas exchange
290
291. Whats a nurse to do?
Monitor vital signs, lung sounds and skin color to assess gas exchange
Be alert for signs of hypoxemia: restlessness, tachycardia and tachypnea
Report abnormal ABGs
Check hemoglobin values, signals less O2 carrying ability
Mobilize secretions as mentioned before
Elevate HOB
Administer O2 as ordered
Impaired gas exchange
291
292. Activity usually restricted but may range from bed rest to BRP
Schedule nursing care to prevent over tiring
Allow periods of uninterrupted rest
Provide assistance until pt is able to do self-care
Encourage visitors not to tire pt with long visits
Evaluate ability to tolerate ADLs
Activity intolerance
292
293. Whats a nurse to do?
Assess pts usual dietary habits
Monitor weight by weighing pt before breakfast using same scale
Monitor albumin and lymphocyte blood counts to detect low levels that are common with inadequate protein
Typical diet: high protein, soft
Assist pt with meal if needed
Document intake
Provide oral care before meals
Elevate HOB arrange tray in attractive and convenient manner
Nasal cannula recommended during meals
If pt tires, more frequent smaller meals would be better
Altered nutrition: less than body requirments
293
294. Fever, mouth breathing and inadequate intake may increase the risk for this diagnosis
Dehydration causes secretions to be thicker and more difficult to expectorate
Risk for fluid volume deficit
294
295. Decreased skin turgor
Concentrated urine
Dry mucous membranes
Elevated hemoglobin and hematocrit
Signs and symptoms of fluid volume deficit
295
296. Whats a nurse to do?
Encourage 3L of fluid daily unless contraindicated
Administer IV fluids as ordered
If permitted give hard candy which stimulates thirst and fluid intake
Record intake and output
Fluid volume deficit
296
297. Monitor temp q2-4h
Administer antipyretics as ordered
Keep pt dry and lightly covered
Keep room comfortable temp, avoid chilling
Tepid sponge baths for fevers as ordered
Hypothermia blanket as ordered to reduce temp
Fluid volume deficit
297
298. Administer analgesics as ordered
Position pt for comfort
Encourage splinting painful areas during deep breathing and coughing
Massage to promote comfort
Notify the physician if pain is unrelieved or worsens
Pain
298
299. Gradually increase activities as you recover, fatigue may persist for several weeks
Avoid people with colds or other infections
Get plenty of rest, good nutrition and 3 L of fluids each day unless contraindicated
Complete any prescribed drugs after discharge
Nursing Care Plan page 539
Teaching Plan for Pneumonia 540
Nutrition Concepts page 540
What to teach regarding pneumonia
299
300. ASPIRATION PNEUMONIA
PREVENTION
301. PREVENTING ASPIRATION
301
302. Keep suction equipment on hand
Position upright with neck in neutral position
Thinken liquids
302
Prevention measures:
303. Elevate the head of bed if enteral feeding
Measure residual before each bolus feeding
If greater than 100ml with hold the feeding and notify the physician
Stop continuous feeding for 20-30 min before lowering the patients head
If they must be kept flat then place on right side
Check the residual every 4 hours and if more than 20% of hourly rate consult the physician
303
Prevention of Aspiration Pneumonia
304. PLEURISY
Inflammation of the pleura
305. Pneumonia
tuberculosis
chest wall injury
pulmonary infarction
Tumors
Common Causes
305
306. Abrupt and severe pain
one side of the chest
breathing and coughing aggravate the pain
Symptoms
306
307. UNDERLYING DISORDER
PAIN RELIEF
Analgesics
anti-inflammatory
antitussives
antimicrobials
local heat
TREATMENT
307
308. Pain R/T inflammation
Ineffective breathing pattern R/T splinting, pleural effusion
Nursing diagnoses for pleurisy
308
309. When reported, obtain complete description
Location
Severity
Precipitating factors
Alleviating factors
Use pain scale
Interventions for pain
309
310. Administer ordered analgesics
Splinting for the affected side
Splint rib cage when coughing
Apply heat if ordered
Give antitussives if ordered to decrease painful coughing
If on bed rest, assist pt with regular position changes
Administer NSAIDs as ordered to reduce pain and inflammation
Interventions for pain
310
311. Monitor breathing pattern, pay attention to chest symmetry during breathing
Encourage pt to turn, take deep breaths and couth
Encourage to ambulate if permitted
Elevate HOB
Ineffective breathing pattern
311
312. If pleural effusion develops, progressive dyspnea, decreased or absent breath sounds in the affected area and decreased chest wall movement on the affected side, a thoracentesis may be done to remove accumulated fluid
If done at bedside you, the nurse will assist
So be ready!!!
Complications
312
313. CHEST TRAUMA
313
314. PENETRATING
Gunshot, stab wounds
pneumothorax
tears of aorta, vena cava, other major vessels
NONPENETRATING
MVA, Falls, Blast
rib fx
pneumothorax
pulmonary contusions
cardiac contusions
CATEGORIES OF CHEST TRAUMA
314
315. Obvious trauma
chest pain
dyspnea
asymmetrical chest wall movement
cyanosis
weak rapid pulse
decreased blood pressure
tracheal deviation
distended neck veins
bloodshot or bulging eyes
SIGNS & SYMPTOMS
315
316. Stabilization
prevention
dressing tape three sides(called a vented dressing)
An airtight dressing could cause a tension pneumothorax
do not remove impaled objects
VS
LOC
O2
semi-fowlers
MEDICAL TREATMENT
316
317. PNEUMOTHORAX
An accumulation of air in the pleural cavity that results in complete or partial collapse of a lung.
Air enters the space between the chest wall and the lung either through a hole in the chest wall or through a tear in the bronchus, bronchioles, or alveoli.
317
318. Tension
air is repeatedly entering the pleural space
lung on affected side collapses
mediastinal shift
Open
chest wound
air moves in and out freely
lung on affected side collapses
medistinal flutter
TENSION / OPEN PNEUMO
318
319. Dyspnea
tachypnea
tachycardia
restlessness
pain anxiety
decreased movement of the involved chest wall
Asymmetric chest movement
diminished breath sounds
progressive cyanosis
chest wound
sucking chest wound (air can be heard or felt from wound)
SIGNS & SYMPTOMS
319
320. Needle aspiration of fluid/air from pleural space
chest tube insertion
surgical repair of a tear
If persistent air leak( variety being studied)
intrapleural tetracycline
blood patches
fibrin glue
TREATMENT
320
321. If chest tube: monitor insertion site
Document amount and characteristics of drainage
Add to I&O
Give chest tube care
Monitor for increasing respiratory distress:
Tachycardia
Dyspnea
Cyanosis
Restlessness
Anxiety
Nursing care
321
322. Inspect trachea for deviation which may be caused by mediastinal shift
occurs when a lung collapses and the heart, trachea, esophagus, and great blood vessels shift toward the unaffected side
Mediastinal flutter
Occurs with an open pneumothorax, everything may shift back and forth toward the unaffected side with inspiration then toward the affected side with expiration
Nursing care
322
323. Check ABGs for hypoxemia and hypercapnia
Immediately report deteriorating respiratory status
Protect chest tube and monitor its function
Nursing care/ineffective breathing pattern
323
324. Position pt for comfort in a Fowlers or semi-Fowlers position, avoid side-lying until affected lung has re-expanded, could cause mediastinal shift
Support and encourage pt to deep breath and cough q2h while awake
Administer O2 as ordered
Nursing care/ineffective breathing pattern
324
325. Speak calmly to pt, explain every procedure
Tell pt about chest tube
Give pt opportunity to ask questions and express fear
Nursing care/fear
325
326. Monitor pulse and blood pressure
If blood pressure falls and pulse rate increases, you should suspect mediastinal shift, notify physician immediately, this could be fatal
Nursing care/risk for decreased cardiac output
326
327. Monitor for signs of pain
Document characteristics of pain
Administer analgesics as ordered
Document the effects of drug therapy
Rate pain on 0-10 scale
Use positioning, massage, distraction etc.
Notify physician if measures fail and pain is not relieved
Nursing care/pain
327
328. Monitor for signs and symptoms of infection
Fever
Increased pulse and respirations
Foul drainage from tube insertion site
Elevated WBC
Nursing care/risk for infection
328
329. Use sterile technique for invasive procedures and dressing changes
Administer prescribed antimicrobials
Monitor hydration status and promote fluid intake of 2 to 3 L/d unless contraindicated
Before discharge instruct pt on chest tube care and to notify physician of S/S of infection
Fever or increasing redness, swelling, or drainage from insertion site
Nursing care/risk for infection
329
330. Accumulation of blood between the chest wall and the lung
Pressure around the lung increases, causing partial or complete collapse of the lung
Results from lacerated or torn blood vessel, lung malignancy, pulmonary embolus
May also be caused by anticoagulation therapy
HEMOTHORAX
330
331. Essentially like a pneumothorax, nursing care is similar
Surgical intervention may be necessary to control bleeding
Pt is at risk for decreased cardiac output due to hemorrhage
Hemothorax treatment
331
332. RIB FRACTURES
Most common chest injuries
blunt injury/MVA-hit steering wheel
Ribs 4 to 9 most commonly affected
Takes approx 6 wks to heal
333. Pain at injury site (especially during inspiration)
bruising
Swelling
Visible bone fragments at site of injury
shallow breathing
protective holding of the chest
SIGNS & SYMPTOMS
333
334. Pain relief to allow adequate chest expansion
intercostalnerve blocks
no binders or rib belts restricts expansion of chest
encourage deep breathing every four hours
Complication: pneumonia or atelectasis due to inadequate chest expansion
TREATMENT
334
335. Goal: effective breathing pattern
Breathing exercises to prevent pulmonary complications
Instruct splinting while deep breathing and coughing
Adequate pain control is essential, monitor q2h, rate pain on scale 0-10
Administer prescribed analgesics
Provide a calm environment
Encourage pt to rest
Evaluate effects of pain measures
Inform physician if pain isnt controlled
Nursing care
335
336. FLAIL CHEST
Two adjacent ribs on the same side of the chest are broken in two or more places.Results in paradoxical movement
337. Severe dyspnea
cyanosis
tachypnea
tachycardia
paradoxical movement-affected part will move in with inspiration and moves out with expiration-opposite of how it should be
SIGNS & SYMPTOMS
337
338. History
Exam CXR
ABG
DIAGNOSIS
338
339. Adequate oxygenation
Cough & deep breathing
IPPB
pain management
Respiratory Distress
intubation
ventilator
TREATMENT
339
340. PULMONARY EMBOLUS
Foreign substance carried through the blood
Usually blood clots but may be fat, air, tumors, bone marrow, amniotic fluid or clumps of bacteria
Ventilation-perfusion mismatch.
Alveoli are ventilated + no blood flow= no gas exchange
340
341. If a large pulmonary vesselis obstructed, alveoli collapse, cardiac output falls, there is constriction of the bronchi and the pulmonary artery, and sudden death may ensue.
341
342. Surgery of the pelvis or lower legs
Immobility
Obesity
Estrogen therapy
Clotting abnormalities
If a large pulmonary vessel is obstructed, alveoli collapse, cardiac output falls, there is constriction of the bronchi and the pulmonary artery, and sudden death may occur
Etiology and risk factors
342
343. Sudden chest pain worsens with breathing
tachypena
dyspnea
apprehensive
diaphoretic
cough
hemoptysis
Crackles may be heard on auscultation
fever
tachycardia
SIGNS & SYMPTOMS
343
344. History and physical
ABG
EKG
lung scan
Pulmonary angiogram
DIAGNOSIS
344
345. MEDICAL
Heparin to establish and maintain (PTT 2 -2.5 times the normal rate)
Coumadin 6 months
Fibrinolytics
oxygen
intubation
ventilation
SURGICAL
embolectomy
vena cava interruption
venous thrombectomy
See pg 546 for pictures of filters
TREATMENT
345
346. Must monitor risk factors that led to the embolism
Homans sign assessed in each leg
Nursing care
346
347. Monitor respiratory rate and effort
Breath sounds
Skin color
Pulse
Blood pressure
Nursing care/altered cardiopulmonary tissue perfusion
347
348. ABGs report abnormalities to physician
Elevate HOB
Administer O2 as prescribed
Administer prescribed IV fluids
Document I&O
Active/passive ROM
Early ambulation after surgery
Antiembolism and pneumatic compression stockings
Nursing care/altered cardiopulmonary tissue perfusion
348
349. Remain calm
Tell pt what is being done
Explain equipment and procedures in terms pt can understand
Encourage pt to express concerns and ask questions
Permit family member to remain with the patient
Nursing care/anxiety
349
350. See patient teaching plan page 547 for pulmonary embolism
350
351. ARDS
Acute Respiratory Distress Syndrome
351
352. Progressive pulmonary disorder that follows lung trauma.
Infiltratedevelopment
fluid shift
pulmonary edema
atelectasis
Cardiac dysrhythmias
renal failure
stress ulcers
thrombocytopenia
DIC (disseminated intravascular coagulation)
oxygen toxicity
sepsis
ETIOLOGY & RISK FACTORS
352
353. Increased respiratory rate
fine crackles
restless
agitated
confused
increased pulse rate
cough
Dyspnea with retractions
cyanosis
diaphoresis
diffuse crackles and rhonchi
SIGNS & SYMPTOMS
353
354. History
exam
CXR
ABG
pH increases Co2 falls
O2 falls despite O2
pH decreases respiratory acidosis
DIAGNOSIS
354
355. Intubation with ventilator
treat underlying cause
corticosteroids debatable issue
TREATMENT
355
356. Characterized by interstitial hemorrhage associated with intraalveolar hemorrhage resulting in decreased pulmonary compliance
The major complication is acute respiratory distress syndrome (ARDS)
Pulmonary Contusion
356
357. Dyspnea
Hypoxemia
Increased bronchial secretions
Hemoptysis
Restlessness
Decreased breath sounds
Rales and wheezes
Signs and Symptoms
357
358. Maintain airway and ventilation
Place client in high Fowlers position
Administer oxygen as prescribed
Monitor for increased respiratory distress
Maintain bed rest and limit activity to reduce oxygen demands
Prepare for mechanical ventilation as prescribed
Implementation
358
359. Occurs when the client cannot eliminate carbon dioxide from the alveoli
The carbon dioxide retention results in hypoxemia
Oxygen reaches the alveoli but cannot be absorbed or used properly
The lungs can move air sufficiently but cannot oxygenate the pulmonary blood properly
Respiratory failure
359
360. Respiratory failure occurs as a result of mechanical abnormality of the lungs or chest wall, a defect in the respiratory control center in the brain, or an impairment in the function of the respiratory muscles
Respiratory failure
360
361. Dyspnea
Headache
Confusion
Restlessness
Tachycardia
Cyanosis
Dysrhythmias
Decreased level of consciousness
Alterations in respirations and breath sounds
Respiratory failure/Signs and Symptoms
361
362. Identify and treat the cause
Administer O2 as prescribed to maintain the PaO2 level above 60 mm Hg
Place the client in high Fowlers position
Encourage deep breathing
Administer bronchodilators as prescribed
Prepare the client for mechanical ventilation if supplemental O2 cannot maintain acceptable PaO2 levels
Respiratory failure/what to do?
362
363. The collection of fluid in the pleural space
Any condition that interferes with either secretion or drainage of this fluid will lead to pleural effusion
Pleural effusion
363
364. Pleuritic pain that is sharp and increases with inspiration
Dyspnea on exertion
Dry nonproductive cough caused by bronchial irritation or mediastinal shift
Malaise
Pleural effusion/signs and symptoms
364
365. Tachycardia
Elevated temperature
Decreased breath sounds
CXR shows pleural effusion and a mediastinal shift away from the fluid
Pleural effusion/signs and symptoms
365
366. Identify and treat underlying cause
Monitor vital signs
Monitor breath sounds
Place client in high Fowlers position
Enco