ATI – Medical Surgical – Unit 3 Nursing Care of Clients with Respiratory Disorders

Respiratory Diagnostic and Therapeutic Procedures: Overview
Respiratory diagnostic procedures are used to evaluate a client’s respiratory status by checking indicators such as the oxygenation of the blood, lung functioning, and the integrity of the airway.
Respiratory Diagnostic and Therapeutic Procedures: Respiratory diagnostic procedures
Respiratory diagnostic procedures that nurses should be knowledgeable about include:
o Pulse oximetry
o ABGs
o Bronchoscopy
o Thoracentesis
Respiratory Diagnostic and Therapeutic Procedures: CHEST TUBES
• Chest tubes are a type of therapeutic procedure inserted into the pleural space to drain fluid, blood, or air; reestablish a negative pressure; facilitate lung expansion; and restore normal intrapleural pressure.
• Chest tubes can be inserted in the emergency department, at the client’s bedside, or in the operating room through a thoracotomy incision.
• Chest tubes are removed when the lungs have reexpanded and/or there is no more fluid drainage.
Respiratory Diagnostic and Therapeutic Procedures: PULSE OXIMETRY
• Pulse Oximetry is a noninvasive measurement of the oxygen saturation of the blood, but it is not a replacement for ABG measurement.
o A pulse oximeter is a battery- or electric-operated device with a sensor probe that is attached securely onto the client’s fingertip, toe, bridge of nose, earlobe, or forehead with a clip or band.
o Pulse oximetry measures arterial oxygen saturation (SaO2) via a wave of infrared light that measures light absorption by oxygenated and deoxygenated Hgb in arterial blood. SaO2 and SpO2 are used interchangeably.
Respiratory Diagnostic and Therapeutic Procedures: PULSE OXIMETRY – Indications
o Pulse oximetry is indicated for conditions or situations in which a client’s respiratory status should be monitored, such as during a continuous opioid epidural infusion.
o Client presentation
• The following signs and symptoms indicate that oxygen saturation should be monitored in a client o Increased work of breathing
o Wheezing
o Coughing
o Cyanosis
Respiratory Diagnostic and Therapeutic Procedures: PULSE OXIMETRY – Interpretation of Findings
o The expected reference range for SaO2 is 95% to 100%. Acceptable levels may range from 91% to 100%. Some illness states may even allow for an SaO2 of 85% to 89%.
o Values may be slightly lower in the older adult client and those with dark skin.
o Additional reasons for low readings include hypothermia, poor peripheral blood flow, too much light (sun or infrared lamps), low Hgb levels, client movement, edema, and nail polish.
o An SaO2 below 91 % requires interventions to help the client regain acceptable SaO2 levels. An SaOz below 86% is an emergency. An SaOz below 80% is life-threatening.
The lower the SaOz level, the less accurate the value.
o Values obtained by pulse oximetry are unreliable in cardiac arrest, shock, and other states of low perfusion.
Respiratory Diagnostic and Therapeutic Procedures: PULSE OXIMETRY – Preprocedure
Nursing actions
• Perform hand hygiene and provide privacy.
• Find an appropriate probe site. It must be dry and have adequate circulation.
• Be sure the client is in a comfortable position, supporting the arm if a finger is
used as a probe site.
Respiratory Diagnostic and Therapeutic Procedures: PULSE OXIMETRY – Intraprocedure
Nursing actions
• Apply the sensor probe to the site.
• Press the power switch on the oximeter.
• Note the pulse reading and compare it with the client’s radial pulse. Any discrepancy warrants further data collection.
• Allow time for the readout to stabilize, and then record this value as the oxygen saturation.
• Remove the probe, tum off the Oximeter, and store it appropriately.
• If continuous monitoring is required, make sure the alarms are set for a low and a high limit, they are functioning, and that the sound is audible. Check the condition of the skin under the probe every 4 hour and move the sensor every 24 hour if indicated.
Respiratory Diagnostic and Therapeutic Procedures: PULSE OXIMETRY – Post procedure
o Nursing actions
• Document the findings and report abnormal findings to the provider.
• If a client’s SaO2 is less than 90% (indicating hypoxemia):
o Confirm that the sensor probe is properly placed.
o Confirm that the oxygen delivery system is functioning and that the client is receiving prescribed oxygen levels.
o Place the client in a semi-Fowler’s or Fowler’s position to maximize ventilation.
o Encourage the client to deep-breathe.
o Report significant findings to the provider.
o Remain with the client and provide emotional support to decrease anxiety.
Respiratory Diagnostic and Therapeutic Procedures: ABGs (Arterial Blood Gases)
• An ABG sample reports the status of oxygenation and acid-base balance of the blood.
o An ABG measures:
• pH – The amount of free hydrogen ions in the arterial blood (H+).
• PaOz- The partial pressure of oxygen.
• PaCOz – The partial pressure of carbon dioxide.
• HC03 – The concentration of bicarbonate in arterial blood.
• SaOz – Percentage of oxygen bound to Hgb as compared to the total amount that can be possibly carried.
o ABGs can be obtained by an arterial puncture or through an arterial line.
Respiratory Diagnostic and Therapeutic Procedures: ABGs (Arterial Blood Gases) – Indications
o Potential diagnoses
• Blood pH levels may be affected by any number of disease processes (respiratory, endOcrine, or neurologic).
• These assessments are helpful in monitoring the effectiveness of various treatments (such as acidosis interventions), in guiding oxygen therapy, and in evaluating client responses to weaning from mechanical ventilation.
Respiratory Diagnostic and Therapeutic Procedures: ABGs (Arterial Blood Gases) – pH normal range
7.35 to 7.45
Respiratory Diagnostic and Therapeutic Procedures: ABGs (Arterial Blood Gases) – PaO2 normal range
80 to 100 mm Hg
Respiratory Diagnostic and Therapeutic Procedures: ABGs (Arterial Blood Gases) – PaCO2 normal range
35 to 45 mm Hg
Respiratory Diagnostic and Therapeutic Procedures: ABGs (Arterial Blood Gases) – HCO3 normal range
22 to 26 mEq/L
Respiratory Diagnostic and Therapeutic Procedures: ABGs (Arterial Blood Gases) – SaO2 normal range
95 to 100%* (Older adult values may be slightly lower)
Respiratory Diagnostic and Therapeutic Procedures: ABGs (Arterial Blood Gases) – Abnormal pH Values
Blood pH levels below 7.35 reflect acidosis, while levels above 7.45 reflect alkalosis.
Respiratory Diagnostic and Therapeutic Procedures: ABGs (Arterial Blood Gases) – Complications – Hematoma, arterial occlusion
• A hematoma occurs when blood accumulates under the skin at the IV site.
• Nursing Actions
o Observe the client for changes in temperature, swelling, color, loss of pulse, or pain.
o Notify the provider immediately if symptoms persist.
o Apply pressure to the hematoma site.
Respiratory Diagnostic and Therapeutic Procedures: ABGs (Arterial Blood Gases) – Complications – Air embolism
• Air enters the arterial system during catheter insertion.
• Nursing Actions
o Monitor the client for a sudden onset of shortness of breath, decreases in SaO2 levels, chest pain, anxiety, and air hunger.
o Notify the provider immediately if symptoms occur, administer oxygen therapy, and obtain ABGs. Continue to assess the client’s respiratory status for any deterioration.
Respiratory Diagnostic and Therapeutic Procedures: Bronchoscopy
Bronchoscopy permits visualization of the larynx, trachea, and bronchi through either a flexible fiberoptic or a rigid bronchoscope.
o Bronchoscopy can be performed as an outpatient procedure, in a surgical suite under general anesthesia, or at the bedside under local anesthesia and moderate sedation.
o Bronchoscopy can also be performed on clients who are receiving mechanical ventilation by inserting the scope through the client’s endotracheal tube.
Respiratory Diagnostic and Therapeutic Procedures: Bronchoscopy – Indications
o Potential diagnoses
• Visualization of abnormalities such as tumors, inflammation, and strictures
• Biopsy of suspicious tissue (lung cancer)
o Clients undergoing a bronchoscopy with biopsy have additional risks for bleeding and/or perforation.
• Aspiration of deep sputum or lung abscesses for culture and sensitivity and/or cytology (pneumonia)
o Note – Bronchoscopy is also performed for therapeutic reasons, such as removal of foreign bodies and secretions from the tracheobronchial tree, treating postoperative atelectasis, and to destroy and excise lesions.
Respiratory Diagnostic and Therapeutic Procedures: Bronchoscopy – Interpretation of Findings
A bronchoscopy can identify airway problems, cancer and lung disease.
Respiratory Diagnostic and Therapeutic Procedures: Bronchoscopy – Preprocedure
Nursing actions:
• Check clients for allergies to anesthetic agents or routine use of anticoagulants.
• Verify that a consent form is signed by clients prior to the procedure.
• Remove the client’s dentures, if applicable, prior to the procedure.
• Maintain the client on NPO status prior to the procedure as ordered, usually 8 to 12 hours, to reduce the risk of aspiration when the cough reflex is blocked by anesthesia.
• Obtain baseline vital signs and place pulse oximeter for continuous monitoring during the procedure.
• Administer preprocedure medications as prescribed, such as viscous lidocaine or local anesthetic throat sprays.
Respiratory Diagnostic and Therapeutic Procedures: Bronchoscopy – Postprocedure
o Nursing actions
• Monitor clients returning from the PACU. Ensure gag reflex is present before resuming oral intake.
• Monitor vital signs and pulse oximeter reading every 15 minutes until stable.
• Monitor clients for development of significant fever (mild fever for less than 24 hours is not uncommon), productive cough, significant hemoptysis indicative of hemorrhage (a small amount of blood-tinged sputum is expected), and hypoxemia.
• Provide oral hygiene to clients.
Respiratory Diagnostic and Therapeutic Procedures: Bronchoscopy – Postprocedure for older adults
• For older adult clients, encourage coughing and deep breathing every 2 hours. There is an increased risk of respiratory infection and pneumonia in older adult clients due to delay in return of the cough reflex, decreased cough effectiveness and decreased secretion clearance. Respiratory infections may be more severe and last longer in older adult clients.
Respiratory Diagnostic and Therapeutic Procedures: Bronchoscopy – Postprocedure Client education
• Instruct clients that gargling with salt water or use of throat lozenges may provide comfort for soreness of the throat.
• Discourage smoking, talking, and coughing for several hours.
Respiratory Diagnostic and Therapeutic Procedures: Bronchoscopy Complications – Laryngospasm
• Laryngospasm is uncontrolled muscle contractions of the laryngeal cords (vocal cords) that impede the client’s ability to inhale.
• Nursing Actions
* Continuously monitor clients for signs of respiratory distress.
* Call for assistance if indicated.
* Maintain a patent airway by repositioning clients or inserting an oral or nasopharyngeal airway as appropriate.
* Administer oxygen therapy to clients as prescribed. Humidification can decrease the likelihood of laryngeal edema.
Respiratory Diagnostic and Therapeutic Procedures: Bronchoscopy Complications – Aspiration
• Aspiration can occur if clients choke on oral secretions.
• Nursing Actions
– Prevent aspiration in clients by withholding oral fluids or food until the gag reflex returns (usually 2 hours).
– Perform suctioning as needed.
Respiratory Diagnostic and Therapeutic Procedures: Thoracentesis
Thoracentesis is the surgical perforation of the chest wall and pleural space with a large-bore needle. It is performed to obtain specimens for diagnostic evaluation, instill medication into the pleural space, and remove fluid (effusion) or air from the pleural space for therapeutic relief of pleural pressure.
o Thoracentesis is performed under local anesthesia by a provider at the client’s bedside, in a procedure room, or in a provider’s office.
o Use of an ultrasound for guidance decreases the risk of complications.
Respiratory Diagnostic and Therapeutic Procedures: Thoracentesis – Indications
Potential diagnoses
• Transudates (heart failure, cirrhosis, nephrotic syndrome)
• Exudates (inflammatory, infectious, neoplastic conditions)
• Empyema
• Pneumonia
• Blunt, crushing, or penetrating chest injuries/trauma or invasive thoracic procedures, such as lung and/or cardiac surgery
Respiratory Diagnostic and Therapeutic Procedures: Thoracentesis – Client presentation
• Large amounts of fluid in the pleural space compress lung tissue and can cause pain, shortness of breath, cough, and other symptoms of pleural pressure.
• Assessment of the effusion area may reveal decreased breath sounds, dull percussion sounds, and decreased chest wall expansion. Pain may occur due to the inflammatory process.
Respiratory Diagnostic and Therapeutic Procedures: Thoracentesis – Interpretation of Findings
o Aspirated fluid is analyzed for general appearance, cell counts, protein and glucose content, the presence of enzymes such as lactate dehydrogenase (LDH) and amylase, abnormal cells, and culture.
Respiratory Diagnostic and Therapeutic Procedures: Thoracentesis – Preprocedure
o Percussion, auscultation, radiography, or sonography is used to locate the effusion and needle insertion site.
o Changes in fat deposition in many older adult clients may make it difficult for the provider to identify the landmarks for insertion of the Thoracentesis needle.
o Nursing actions
• Verify that clients have signed the informed consent form.
• Gather all needed supplies.
• Obtain preprocedure x-ray as prescribed to locate pleural effusion and to determine needle insertion site.
• Position clients sitting upright with his arms and shoulders raised and supported on pillows and/or on an overbed table, and with his feet and legs well-supported.
Respiratory Diagnostic and Therapeutic Procedures: Thoracentesis – Client education
• Instruct clients to remain absolutely still (risk of accidental needle damage) during the procedure and to not to cough or talk unless instructed by the primary care provider.
Respiratory Diagnostic and Therapeutic Procedures: Thoracentesis – Intraprocedure
o Nursing actions
• Assist the provider with the procedure (strict surgical aseptic technique).
• Prepare clients for a feeling of pressure with needle insertion and fluid removal.
• Monitor the client’s vital signs, skin color, and oxygen saturation throughout the procedure.
• Measure and record the amount of fluid removed from the client’s chest.
• Label specimens at the bedside and promptly send them to the laboratory.
o Note – The amount of fluid removed is limited to 1 L at a time to prevent cardiovascular collapse.
Respiratory Diagnostic and Therapeutic Procedures: Thoracentesis – Postprocedure
o Nursing actions
• Apply a dressing over the puncture site and position clients on the unaffected side for 1 hr.
• Monitor the client’s vital signs and respiratory status (respiratory rate and rhythm, breath sounds, oxygenation status) hourly for the first several hours after the Thoracentesis.
• Encourage clients to deep breathe to assist with lung expansion.
• Allow clients to resume normal activity after 1 hour if no signs of complications are present.
• Obtain a Postprocedure chest x-ray (check resolution of effusions, rule out pneumothorax).
• Document the procedure to include the client’s response; volume and character of fluid removed; and vital signs.
Respiratory Diagnostic and Therapeutic Procedures: Thoracentesis – Complications – Pneumothorax
• Pneumothorax is a collapsed lung. It can occur due to injury to the lung during the procedure.
• Nursing Actions
o Monitor clients for signs and symptoms of pneumothorax, such as
diminished breath sounds.
o Monitor Postprocedure chest x-ray results.
Respiratory Diagnostic and Therapeutic Procedures: Thoracentesis – Complications – Bleeding
• Bleeding can occur if clients are moved during the procedure or are at an increased risk for bleeding.
Respiratory Diagnostic and Therapeutic Procedures: Thoracentesis – Complications – Bleeding – Nursing Actions
o Monitor clients for coughing and/or hemoptysis.
o Monitor the client’s vital signs and laboratory results for evidence of bleeding (hypotension, reduced Hgb level).
Respiratory Diagnostic and Therapeutic Procedures: Thoracentesis – Complications – Infection
• Infection can occur due to the introduction of bacteria with the needle puncture.
• Nursing Actions
o Insure that sterile technique is maintained.
o Monitor the client’s temperature following the procedure
Respiratory Diagnostic and Therapeutic Procedures: Chest Tube Systems – Types of chest drainage systems:
o Single-chamber systems have a water seal and a drainage collection in the same chamber.
o Two chamber systems have a water seal and a drainage collection in separate chambers, which allows for the collection of larger amounts of drainage.
o Three chamber systems have a water seal, a drainage collection, and suction control in separate chambers.
o Disposable chest tube drainage systems are now commonly used.
Respiratory Diagnostic and Therapeutic Procedures: Chest Tube Systems – Water Seals

Water seals are created by adding sterile fluid to a chamber up to the 2 cm line. The water seal allows air to exit from the pleural space on exhalation and stops air from entering with inhalation.

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Respiratory Diagnostic and Therapeutic Procedures: Chest Tube Systems – Water Seals Maintenance
o To maintain the water seal, the chamber must be kept upright and below the chest tube insertion site at all times. The nurse should routinely monitor the water level due to the possibility of evaporation. The nurse should add fluid as needed to maintain the 2 cm water seal level
o The height of the water in the suction control chamber determines the amount of suction transmitted to the pleural space. A suction pressure of -20 cm H2O is common. The application of suction results in continuous bubbling in the suction chamber. The nurse should monitor the fluid level and add fluid as needed to maintain the prescribed level of suctioning.
Respiratory Diagnostic and Therapeutic Procedures: Chest Tube Systems – Water Seals Tidaling
o Tidaling (movement of the water level with respiration) is expected in the water seal chamber. With spontaneous respirations, the water level will rise with inspiration
(increase in negative pressure in lung) and will fall with expiration. With positive-pressure mechanical ventilation, the water level will rise with expiration and fall with inspiration.
o Cessation of tidaling in the water seal chamber signals lung reexpansion or an obstruction within the system.
Respiratory Diagnostic and Therapeutic Procedures: Chest Tube Systems – Chest Tube Insertion: Indications
Indications
o Diagnoses
• Pneumothorax (collapsed lung)
• Hemothorax (blood in lung)
• Postoperative chest drainage (thoracotomy or open-heart surgery)
• Pleural effusion (fluid in lung)
• Lung abscess (necrotic lung tissue)o Client presentation
• Dyspnea
• Distended neck veins
• Poor circulation
• Cough

Respiratory Diagnostic and Therapeutic Procedures: Chest Tube Systems – Chest Tube Insertion: Client Outcomes
o The client will maintain adequate gas exchange.
o The client will be free from pain.
o The client will remain free from infection.
Respiratory Diagnostic and Therapeutic Procedures: Chest Tube Systems – Chest Tube Insertion: Preprocedure
o Nursing actions
• Verify that the consent form is signed.
• Reinforce client teaching. Breathing will improve when the chest tube is in place.
• Check for allergies to local anesthetics.
• Assist clients into the desired position (supine or semi-Fowler’s).
• Prepare the chest drainage system prior to the insertion per the facilities protocol (fill the water seal chamber).
• Administer pain and sedation medications as prescribed.
• Prep the insertion site with povidone iodine (Check for iodine allergy.). Drape the insertion site.
Respiratory Diagnostic and Therapeutic Procedures: Chest Tube Systems – Chest Tube Insertion: Intraprocedure
o Nursing actions
• Assist the charge nurse and provider with insertion of the chest tube, application of a dressing to the insertion site, and setup of the drainage system.
o The chest tube tip is positioned up toward the shoulder (pneumothorax) or down toward the posterior (Hemothorax or pleural effusion).
o The chest tube is then sutured to the chest wall and an airtight dressing is placed over the puncture wound.
o The chest tube is then attached to drainage tubing that leads to a collection device.
o Place the chest tube drainage system below the client’s chest level with the tubing coiled on the bed. Ensure that the tubing from the bed to the drainage system is straight to promote drainage via gravity.
• Monitor the client’s vital signs and response to the procedure.
Respiratory Diagnostic and Therapeutic Procedures: Chest Tube Systems – Chest Tube Insertion: Postprocedure Nursing actions, Part I
Postprocedure
o Nursing actions
• Check the client’s vital signs, breath sounds, 5a02, color, and respiratory effort as indicated by the status of the client and at least every 4 hr.
• Encourage coughing and deep-breathing every 2 hr.
• Keep the drainage system below the client’s chest level, including during ambulation.
• Monitor the chest tube’s placement and function.
o Check the water seal level every 2 hour and add water as needed. The water level should fluctuate with respiratory effort.
o Document the amount and color of drainage hourly for the first 24 hour and then at least every 8 hr. Mark the date, hour, and drainage level on the container at the end of each shift. Report excessive drainage (greater than 70 mL/hr) or drainage that is cloudy or red to the provider. Drainage will often increase with position changes or coughing.
Respiratory Diagnostic and Therapeutic Procedures: Chest Tube Systems – Chest Tube Insertion: Postprocedure Nursing actions, Part II
o Monitor the fluid in the suction control chamber and maintain the fluid level prescribed by the provider.
o Check for expected findings of tidaling in the water seal chamber and continuous bubbling only in the suction chamber.
o Routinely monitor tubing for kinks, occlusions, or loose connections.
o Monitor the chest tube insertion site for redness, pain, infection, and crepitus (air leakage in subcutaneous tissue).
Respiratory Diagnostic and Therapeutic Procedures: Chest Tube Systems – Chest Tube Insertion: Postprocedure Nursing actions, Part III
o Position clients in the semi-Fowler’s to high-Fowler’s position to promote optimal lung expansion and drainage of the fluid from the lungs.
• Administer pain medications as prescribed.
• Obtain a chest x-ray to verify the chest tube’s placement.
• Keep two enclosed hemostats, a bottle of sterile water, and an occlusive dressing located at the bedside at all times.
• Due to the risk of causing a tension pneumothorax, chest tubes are only clamped when ordered by the provider in specific circumstances, such as an air leak, during drainage system change, accidental disconnection of tubing, or damage to
the collection device.
• Do not strip or milk tubing routinely; only perform this action when prescribed by the provider. Stripping creates a high negative pressure and can damage the client’s lung tissue.
Respiratory Diagnostic and Therapeutic Procedures: Chest Tube Systems – Chest Tube Insertion: Complications – Air leaks
Air leaks can result if a connection is not taped securely.
• Nursing Actions
o Monitor the water seal chamber for continuous bubbling (air leak finding). If observed, locate the source of the air leak and intervene accordingly (tighten the connection, replace drainage system).
~ Check all of the connections.
~ Call for assistance.
~ Cross clamp close to client’s chest. If bubbling stops, the leak is at the insertion site or within the thorax. If bubbling doesn’t stop,
methodically move clamps down the drainage tubing toward the
collection device, moving one clamp at a time. When the bubbling
stops, the leak is within the section of tubing or at that connection
distal to the clamp.
Respiratory Diagnostic and Therapeutic Procedures: Chest Tube Systems – Chest Tube Insertion: Complications – Accidental disconnection, system breakage, or removal
• Complications can occur at any time.
• Nursing Actions
o If a chest tube is accidentally dislodged from the client’s chest, the nurse should immediately cover the insertion site with dry sterile gauze and notify the provider. This allows air to escape and reduces the risk for development of a tension pneumothorax.
o If a chest tube disconnects from the drainage system, the nurse should immediately place the end of the tube in sterile water to restore the water seal. It is also important to keep the drainage system below the level of the client’s chest.
Respiratory Diagnostic and Therapeutic Procedures: Chest Tube Systems – Chest Tube Insertion: Complications – Tension pneumothorax
• Sucking chest wounds, prolonged clamping of the tubing, kinks in the tubing, or obstruction may cause a tension pneumothorax.
Respiratory Diagnostic and Therapeutic Procedures: Chest Tube Systems – Chest Tube Removal
Provide pain medication 30 min before removing chest tubes.
• Assist the provider with sutures and chest tube removal.
• The provider will instruct clients to take a deep breath, exhale, and bear down (Valsalva maneuver) or to take a deep breath and hold it (increases intrathoracic pressure and reduces
the risk of air emboli) during chest tube removal.
• Apply airtight sterile petroleum jelly gauze dressing. Secure in place with a heavyweight stretch tape.
• Obtain chest x-rays as prescribed. This is performed to verify continued resolution of the pneumothorax, Hemothorax, or pleural effusion.
• Monitor clients for excessive wound drainage, signs of infection, or recurrent pneumothorax.
Respiratory Disorders: Oxygen Therapy
• Oxygen is a tasteless and colorless gas that accounts for 21 % of atmospheric air.
• Oxygen is administered in an attempt to maintain an SaO2 of at least 950/0 to 1000/0 by using the lowest amount of oxygen without putting the client at risk for complications.
• Indications include – Maintain adequate cellular oxygenation for clients:
o Who have acute and/or chronic respiratory disorders.
o Who have decreased cardiac output.
o Who have disorders that increase oxygen demand, such as sepsis and fever.
o Who cannot spontaneously breathe on their own and require mechanical ventilation
Respiratory Disorders: Oxygen Therapy – Delivery Devices
Supplemental oxygen can be delivered by a variety of methods based on the client’s particular circumstances. The percentage of oxygen delivered to the client is expressed as the fraction of inspired oxygen (FiO2).
Respiratory Disorders: Oxygen Therapy -Low-flow oxygen delivery system – Nasal Cannula
Low-flow oxygen delivery systems deliver varying amounts of oxygen based on the method and the client’s breathing pattern.
o Nasal cannula – A length of tubing with two small prongs for insertion into the nares
• FiO2 – 240/0 to 440/0 at flow rates of 1 to 6 L/min
Respiratory Disorders: Oxygen Therapy -Low-flow oxygen delivery system – Nasal Cannula – • Nursing Interventions
o Check the patency of the nares.
o Ensure that the prongs fit in the nares properly.
o Use water-soluble gel to prevent dry nares.
o Provide humidification for flow rates of 4 L/min and above
Respiratory Disorders: Oxygen Therapy -Low-flow oxygen delivery system – Nasal Cannula – Advantages
• Advantages
– It is safe, easy to apply, comfortable, and well-tolerated. Clients are able to eat, talk, and ambulate
Respiratory Disorders: Oxygen Therapy -Low-flow oxygen delivery system – Nasal Cannula – disadvantages
• Disadvantages
o The Fi02 varies with the flow rate and the client’s rate and depth of breathing.
o Extended use can lead to skin breakdown and dry the mucous membranes.
o The tubing is easily dislodged.
Respiratory Disorders: Oxygen Therapy -Low-flow oxygen delivery system -Simple face mask
Simple face mask (covers the client’s nose and mouth)
• Fi02 – 40% to 60% at flow rates of 5 to 8 L/min (the minimum flow rate is
5 L/min to ensure flushing of CO2 from the mask).
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Respiratory Disorders: Oxygen Therapy -Low-flow oxygen delivery system -Simple face mask – Advantages
o A face mask is easy to apply and may be more comfortable than a nasal cannula
Respiratory Disorders: Oxygen Therapy -Low-flow oxygen delivery system -Simple face mask – Disadvantages
o Flow rates of 5 L/min or lower can result in rebreathing of CO2,
o This device is poorly tolerated by clients who have anxiety or
claustrophobia.
o Eating, drinking, and talking are impaired.
o Use caution with clients who have a high risk of aspiration or airway obstruction.
Respiratory Disorders: Oxygen Therapy -Low-flow oxygen delivery system – Simple face mask – Nursing Interventions
o Check for proper fit to ensure a secure seal over the nose and mouth.
o Ensure that clients wear a nasal cannula during meals.
o Monitor skin and provide skin care to area covered by the mouth.
Respiratory Disorders: Oxygen Therapy -Low-flow oxygen delivery system – Partial rebreather mask
Partial rebreather mask (covers the client’s nose and mouth)
• Fi02 – 60% to 75% at flow rates of 6 to 11 L/min
Respiratory Disorders: Oxygen Therapy -Low-flow oxygen delivery system – Partial rebreather mask -• Advantages
o The mask has a reservoir bag with no flaps, which allows the client to rebreathe up to 1/3 of exhaled air together with room air.
Respiratory Disorders: Oxygen Therapy -Low-flow oxygen delivery system – Partial rebreather mask -• disadvantages
• Disadvantages
o Complete deflation of the reservoir bag during inspiration causes CO2 buildup.
o The Fi02 varies with the client’s breathing pattern
o This device is poorly tolerated by clients who have anxiety or
claustrophobia.
o Eating, drinking, and talking are impaired.
o Use with caution for clients who have a high risk of aspiration or airway obstruction.
Respiratory Disorders: Oxygen Therapy -Low-flow oxygen delivery system – Partial rebreather mask – • Nursing Interventions
o Keep the reservoir bag from deflating by adjusting the oxygen flow rate to keep it inflated.
o Use with caution for clients at high risk of aspiration or airway obstruction.
o The Fi02 varies with the client’s breathing pattern.
o Check for proper fit to ensure a secure seal over the nose and mouth.
o Ensure that clients use a nasal cannula during meals.
o Make sure the reservoir does not twist or kink.
Respiratory Disorders: Oxygen Therapy -Low-flow oxygen delivery system – Nonrebreather mask
Nonrebreather mask (covers the client’s nose and mouth)
FI02 – 80% to 95% at flow rates of 10 to 15 L/min to keep the reservoir bag 2/3 full during inspiration and expiration
Respiratory Disorders: Oxygen Therapy -Low-flow oxygen delivery system – Nonrebreather mask – Advantages
o Delivers the highest 02 concentration possible (except for intubation).
o A one-way valve situated between the mask and reservoir allows clients to inhale maximum 02 from the reservoir bag. The two exhalation ports have flaps covering them that prevent room air from entering the mask.
Respiratory Disorders: Oxygen Therapy -Low-flow oxygen delivery system – Nonrebreather mask – Disadvantages
o The valve and flap on the mask must be intact and functional during each
breath.
o Poorly tolerated by clients who have anxiety or claustrophobia.
o Eating, drinking, and talking are impaired.
Respiratory Disorders: Oxygen Therapy -Low-flow oxygen delivery system – Nonrebreather mask – Nursing Interventions
o Check the valve and flap hourly.
o Check for proper fit to ensure a secure seal over the nose and mouth.
o Use with caution for clients who have a high risk of aspiration or airway obstruction.
o Ensure that clients use a nasal cannula during meals.
Respiratory Disorders: Oxygen Therapy -High flow oxygen delivery system –
High-flow oxygen delivery systems deliver precise amounts of oxygen when properly fitted
Respiratory Disorders: Oxygen Therapy – High flow oxygen delivery system – Venturi mask
Venturi mask (covers the client’s nose and mouth)
• FI02 – 24% to 55% at flow rates of 4 to 10 L/min via different sized adaptors
Respiratory Disorders: Oxygen Therapy – High flow oxygen delivery system – Venturi mask – Advantages
* Delivers the most precise oxygen concentration.
* Humidification is not required.
* Best suited for clients who have chronic lung disease.
Respiratory Disorders: Oxygen Therapy – High flow oxygen delivery system – Venturi mask – Disadvantages
The use of a Venturi mask is expensive.
Respiratory Disorders: Oxygen Therapy – High flow oxygen delivery system – Venturi mask – Nursing Interventions
* Check frequently to ensure an accurate flow rate.
* Make sure the tubing is free of kinks.
* Monitor the client for dry mucous membranes.
* Change to a nasal cannula during meal times.
Respiratory Disorders: Oxygen Therapy – High flow oxygen delivery system – Aerosol mask
Aerosol mask, face tent (fits loosely around the face and neck), and tracheostomy collar (a small mask that covers a surgically created opening in the trachea)
• Fi02 – 24% to 100% at flow rates of at least 10 L/min (they provide high humidification with oxygen delivery)
Respiratory Disorders: Oxygen Therapy – High flow oxygen delivery system – Aerosol mask – Advantages
* Good for clients who do not tolerate masks well.
* Useful for clients who have facial trauma, burns, and/or thick secretions.
Respiratory Disorders: Oxygen Therapy – High flow oxygen delivery system – Aerosol mask – Disadavantages
High humidification requires frequent monitoring.
Respiratory Disorders: Oxygen Therapy – High flow oxygen delivery system – Aerosol mask – Nursing Interventions
* Empty condensation from the tubing often.
* Ensure that there is adequate water in the humidification canister.
* Ensure that the aerosol mist leaves from the vents during inspiration and expiration.
* Make sure the tubing does not pull on the tracheostomy.
Respiratory Disorders: Oxygen Therapy – High flow oxygen delivery system – T-piece
FiO2 – 24% to 100% at flow rates of at least 10 L/min
Respiratory Disorders: Oxygen Therapy – High flow oxygen delivery system – T-piece – Advantages
This device can be used for a client who has a tracheostomy, laryngectomy, or an endotracheal tube (ET).
Respiratory Disorders: Oxygen Therapy – High flow oxygen delivery system – T-piece – Disadvantages
High humidification requires frequent monitoring.
Respiratory Disorders: Oxygen Therapy – High flow oxygen delivery system – T-piece – Nursing Interventions
* Ensure that the exhalation port is open and uncovered.
* Make sure that the T-piece does not pull on the tracheostomy or ET tube.
* Ensure that the mist is evident during inspiration and expiration.
Oxygen Therapy- Hypoxemia
o Hypoxemia is an inadequate level of oxygen in the blood. Hypovolemia, hypoventilation, and interruption of arterial flow can lead to hypoxemia.
Oxygen Therapy- Hypoxemia – Client Presentation – Early Findings
• Tachypnea
• Tachycardia
• Restlessness
• Pale skin and mucous membranes
• Elevated blood pressure
• Symptoms of respiratory distress (use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds)
Oxygen Therapy- Hypoxemia – Client Presentation – Late Findings
• Confusion and stupor
• Cyanotic skin and mucous membranes
• Bradypnea
• Bradycardia
• Hypotension
• Cardiac dysrhythmias
Oxygen Therapy- Hypoxemia – Client Outcomes
o The client maintains an oxygen saturation of 95% to 100%.
o The client maintains a patent airway.
Oxygen Therapy- Hypoxemia – Nursing Actions – Preparation of Client
• Explain all procedures to the client.
• Place the client in semi-Fowler’s or Fowler’s position to facilitate breathing and promote chest expansion.
• Ensure that all equipment is working properly.
Oxygen Therapy- Hypoxemia – Nursing Actions – Ongoing Care, Part I
• Provide oxygen therapy at the lowest flow that will correct hypoxemia.
• Monitor respiratory rate, rhythm and effort, and lung sounds to determine the client’s need for supplemental oxygen.
* Signs and symptoms of hypoxemia are shortness of breath, anxiety, tachypnea, tachycardia, restlessness, pallor, or cyanosis of the skin and/or mucous membranes, adventitious breath sounds, and confusion.
* Signs and symptoms of hypercarbia (elevated levels of CO2) are restlessness, hypertension, and headache.
• Monitor oxygenation status with pulse oximetry and ABGs.
• Apply the oxygen delivery device prescribed.
Oxygen Therapy- Hypoxemia – Nursing Actions – Ongoing Care, Part II
• Check the fit of the mask to ensure a secure seal over the client’s nose and mouth.
• Promote good oral hygiene and provide as needed.
• Promote turning, coughing, deep breathing, use of incentive spirometer, and suctioning.
• Promote rest and decrease environmental stimuli.
• Provide emotional support for clients who appear anxious.
• Monitor nutritional status; provide supplements as prescribed.
• Monitor the client’s skin integrity; provide moisture and pressure-relief devices as indicated.
• Monitor and document the client’s response to oxygen therapy.
• Maintain oxygen flow as prescribed.
• Discontinue supplemental oxygen gradually.
Oxygen Therapy- Hypoxemia – Nursing Actions – Interventions
• Monitor for signs and symptoms of respiratory depression such as decreased respiratory rate and decreased level of consciousness; notify the provider if these findings are present.
• For respiratory distress:
o Position the client for maximum ventilation (Fowler’s or semi-Fowler’s position).
o Complete a focused respiratory assessment.
o Promote deep breathing and use supplemental oxygen as prescribed.
o Stay with the client and provide emotional support to decrease anxiety.
o Promote airway clearance by encouraging coughing and oral/oropharyngeal suctioning if necessary.
Complications and Hazards of Oxygen Therapy – Oxygen Toxicity
• Oxygen toxicity can result from high concentrations of oxygen (typically above 50%), long durations of oxygen therapy (typically more than 24 to 48 hr), and the client’s degree of lung disease.
• Signs and symptoms include a nonproductive cough, substernal chest pain, nasal stuffiness, dyspnea, nausea, vomiting, fatigue, headache, sore throat, and hypoventilation.
Complications and Hazards of Oxygen Therapy – Oxygen Toxicity – Nursing Action
Use the lowest level of oxygen necessary to maintain an adequate Sa02•
o Monitor the ABGs and notify the provider if Pa02 levels are outside of the expected reference range.
o Use an oxygen mask with continuous positive airway pressure (CPAP), hilevel positive airway pressure (BiPAP), or positive end expiratory pressure (PEEP) as prescribed while the client is on a mechanical ventilator to help decrease the amount of needed oxygen.
Complications and Hazards of Oxygen Therapy: Oxygen-induced Hypoventilation
Oxygen-induced hypoventilation can develop in clients who have COPD and chronic hypoxemia and hypercarbia. Clients who have COPD rely on low levels of arterial oxygen as their primary drive for breathing. Providing supplemental oxygen at high levels can decrease or eliminate their respiratory drive.
Complications and Hazards of Oxygen Therapy: Oxygen-induced Hypoventilation – Nursing Actions
Nursing Actions
o Monitor the client’s respiratory rate and pattern, level of consciousness, and Pa02 levels.
o Provide oxygen therapy at the lowest flow that corrects hypoxemia (usually 1 to 3 L/min).
o If the client tolerates it, use a Venturi mask to deliver precise oxygen levels.
o Notify the provider of impending respiratory depression, such as a decreased respiratory rate and a decreased level of consciousness.
Complications and Hazards of Oxygen Therapy: Combustion
Oxygen is combustible.
Complications and Hazards of Oxygen Therapy: Combustion : Nursing Actions
o Post “No Smoking” or “Oxygen in Use” signs to alert others of a fire hazard.
o Know where the closest fire extinguisher is located.
o Educate clients and others about the fire hazard of smoking during oxygen use.
o Have clients wear a cotton gown, because synthetic or wool fabrics can generate static electricity.
o Ensure that all electric devices (razors, hearing aids, radios) are working well.
o Ensure electric machinery (monitors, suction machines) are well-grounded.
o Do not use volatile, flammable materials (alcohol or acetone) near clients who are receiving oxygen
Respiratory Disorders: Oxygen Therapy – Mechanical Ventilation – Breathing
Mechanical ventilation provides breathing support until lung function is restored, delivering warm (body temperature 37° C [98.6° F]), 100% humidified oxygen at FiO2 levels between 21% and 100%.
Respiratory Disorders: Oxygen Therapy – Mechanical Ventilation – Positive pressure ventilators
Positive-pressure ventilators deliver air to the lungs under pressure throughout inspiration and/or expiration to keep the alveoli open during inspiration and to prevent alveolar collapse during expiration.
Respiratory Disorders: Oxygen Therapy – Mechanical Ventilation – Positive pressure ventilators : Benefits
The benefits include:
• Forced/enhanced lung expansion
• Improved gas exchange (oxygenation)
• Decreased work of breathing
Respiratory Disorders: Oxygen Therapy – Mechanical Ventilation – Delivery
Delivery methods via
• An endotracheal tube
• A tracheostomy tube
• A nasal or face mask (noninvasive modes such as CPAP, BiPAP)Mechanical ventilators can be cycled based on pressure, volume, time and or flow.

Respiratory Disorders: Oxygen Therapy – Mechanical Ventilation – Common Modes of Ventilation: Assist-control (AC)
Preset ventilator rate and tidal volume. The client can initiate breaths; however, the ventilator takes over and delivers a preset tidal volume. Hyperventilation can result in respiratory alkalosis. The client may require sedation to decrease respiratory rate.
Respiratory Disorders: Oxygen Therapy – Mechanical Ventilation – Common Modes of Ventilation: Synchronized intermittent mandatory ventilation (SIMV)
Preset ventilator rate and tidal volume. For client-initiated breaths, tidal volume depends on the client’s effort. Ventilator-initiated breaths are synchronized to reduce competition between the ventilator and the client. SIMV is used as a regular mode of ventilation and as a weaning mode (rate decreased to allow more spontaneous ventilation). It can increase the work of
breathing and respiratory muscle fatigue.
Respiratory Disorders: Oxygen Therapy – Mechanical Ventilation – Common Modes of Ventilation: Pressure Support Ventilation (PSV)
Preset pressure delivered during spontaneous inspiration to reduce work of breathing. The client controls rate and tidal volume. Often used as a weaning mode. PSV decreases the work of breathing and promotes respiratory muscle conditioning. No ventilator breaths are delivered. PSV does not guarantee minimal minute ventilation. It is often combined with other modes of ventilation (SIMV, AC).
Respiratory Disorders: Oxygen Therapy – Mechanical Ventilation – Common Modes of Ventilation: Positive end expiratory Pressure (PEEP)
Positive pressure applied at the end of expiration to increase functional residual capacity and improve oxygenation by opening collapsed alveoli. PEEP must be used in conjunction with AC or SIMV; it cannot be used alone. PEEP decreases cardiac output and can cause volutrauma (trauma to lung tissue caused by tidal
volumes that are too high) and increased intracranial pressure (lCP).
Respiratory Disorders: Oxygen Therapy – Mechanical Ventilation – Common Modes of Ventilation: Volume assured pressure support ventilation (VAPSV)
Similar to PSV with a minimal set tidal volume for each breath. VAPSV optimizes pressure support inspiratory flow, reduces the work of breathing, decreases volutrauma, and ensures minimal minute ventilation. VAPSV is used with clients who have severe respiratory disease or those who are having difficulty weaning.
Respiratory Disorders: Oxygen Therapy – Mechanical Ventilation – Common Modes of Ventilation: Independent Lung Ventilation
Double lumen endotracheal tube allows each lung to be ventilated separately. ILV is used in clients who have unilateral lung disease. It requires two ventilators, sedation, and/or neuromuscular blocking agents.
Respiratory Disorders: Oxygen Therapy – Mechanical Ventilation – Common Modes of Ventilation: High-frequency ventilation
Delivers a small amount of gas at very rapid rates (60 to
3,000 cycles/min). High-frequency ventilation is used frequently in children. The client must be sedated and/or receiving neuromuscular blocking agents. Breath sounds are difficult to assess
Respiratory Disorders: Oxygen Therapy – Mechanical Ventilation – Common Modes of Ventilation: Inverse Ration Ventilation (IRV)
Lengthens inspiratory phase of respiration to maximize oxygenation. IRV is used for hypoxemia refractory to PEEP. It is uncomfortable for clients and requires sedation and/or neuromuscular blocking agents. There is a high risk of volutrauma and decreased cardiac output due to air trapping.
Respiratory Disorders: Oxygen Therapy – Mechanical Ventilation – Common Modes of Ventilation: Continuous positive airway pressure (CPAP)
Positive pressure supplied during spontaneous breaths. No ventilator breaths are delivered unless they are in conjunction with SIMI. Risks include volutrauma, decreased cardiac output, and increased ICP. CPAP can be invasive or noninvasive. It is often used for obstructive sleep apnea.
Respiratory Disorders: Oxygen Therapy – Mechanical Ventilation – Common Modes of Ventilation: Bi-Ievel positive airway pressure (BiPAP)
Positive pressure delivered during spontaneous breaths. Different pressures are delivered for inspiration and expiration. No spontaneous breaths are delivered. BiPAP is a noninvasive mode.
Oxygen Therapy Indications
o Diagnoses
• Hypoxemia, hypoventilation with respiratory acidosis
o Airway trauma
o Exacerbation of COPD
o Acute pulmonary edema due to myocardial infarction or heart failure
o Asthma attack
o Head injuries, cerebrovascular accident, or coma
o Neurological disorders (multiple sclerosis, myasthenia gravis, Guillain-Barre)
o Obstructive sleep apnea
• Respiratory support following surgery (decrease workload)
• Respiratory support while under general anesthesia or heavy sedation
Oxygen Therapy Client Outcomes
o The client will maintain an oxygen saturation of 95% to 100%.
o The client will maintain a patent airway.
Oxygen Therapy: Nursing Actions: Preparation of the Client
• Explain the procedure to clients.
• Establish a method for communication, such as asking yes/no questions, providing writing materials, using a dry-erase board and/or a picture communication board, or lip-reading.
Oxygen Therapy: Nursing Actions: Ongoing care
• Maintain a patent airway.
o Check the position and placement of tube.
o Document the tube placement in centimeters at the client’s teeth or lips.
o Use two staff members for repositioning and resecuring the tube.
o Apply protective barriers (soft wrist restraints) according to hospital protocol to prevent self-extubation.
o Use caution when moving clients.
o Suction oral and tracheal secretions to maintain tube patency.
o Support ventilator tubing to prevent mucosal erosion and displacement.
• Check respiratory status every 1 to 2 hr – Breath sounds, respiratory effort, and
spontaneous breaths
Oxygen Therapy: Nursing Actions: Ongoing care: Monitor and document ventilator settings hourly.
o Rate, FiO2 and tidal volume
o Mode of ventilation
o Use of adjuncts (PEEP, CPAP)
o Plateau or peak inspiratory pressure (PIP)
o Alarm settings
Oxygen Therapy: Nursing Actions: Ongoing care:Monitor the ventilator alarms, which signal if the client is not receiving the correct ventilation.
o Never turn off the ventilator alarms.
o There are three types of ventilator alarms – Volume, pressure, and apnea alarms
1) Volume (low pressure) alarms indicate a low exhaled volume due to a disconnection, cuff leak, and/or tube displacement.
2) Pressure (high pressure) alarms indicate excess secretions, client biting the tubing, kinks in the tubing, client coughing, pulmonary edema, bronchospasm, and/or pneumothorax.
3) Apnea alarms indicate that the ventilator does not detect spontaneous respiration in a preset time period.
Oxygen Therapy: Nursing Actions: Ongoing care: Maintain adequate (but not excessive) volume in the cuff of the endotracheal tube.
*Assess the cuff pressure at least every 8 hr. Maintain the cuff pressure below 20 mm Hg to reduce the risk of tracheal necrosis.
* Assess for an air leak around the cuff (client speaking, air hissing, or decreasing SaO2). Inadequate cuff pressure can result in inadequate oxygenation and/or accidental extubation.
Oxygen Therapy: Nursing Actions: Ongoing care: Administer Medication: Analgesics
Morphine and fentanyl (Sublimaze)
Oxygen Therapy: Nursing Actions: Ongoing care: Administer Medication: Sedatives
– Propofol (Diprivan), diazepam (Valium), lorazepam (Ativan),
midazolam (Versed), and haloperidol (Haldol)
~ Clients receiving mechanical ventilation may require sedation or
paralytic agents to prevent competition between extrinsic and intrinsic breathing and the resulting effects of hyperventilation.
Oxygen Therapy: Nursing Actions: Ongoing care: Administer Medication: Neuromuscular blocking agent
Pancuronium bromide (Pavulon), atracurium (Tracrium), and vecuronium (Norcuron)
Oxygen Therapy: Nursing Actions: Ongoing care: Administer Medication: Ulcer-preventing agents
– Famotidine (Pepcid) or lansoprazole (Prevacid)
Oxygen Therapy: Nursing Actions: Ongoing care: Administer Medication: Antibiotics
– For established infections
Oxygen Therapy: Nursing Actions: Ongoing care: Repositioning
Reposition the oral endotracheal tube every 24 hr or according to protocol. Check for skin breakdown.
* Older adult clients have fragile skin and are more prone to skin and mucous membrane breakdown. Older adult clients have decreased oral secretions. They require frequent, gentle skin and oral care.
Oxygen Therapy: Nursing Actions: Ongoing care: Provide adequate nutrition.
* Check gastrointestinal functioning every 8 hr.
* Monitor bowel habits.
* Administer enteral feedings as prescribed
Oxygen Therapy: Nursing Actions: Ongoing care: Continually monitor clients during the weaning process and watch for signs of weaning intolerance
– Respiratory rate greater than 3D/min or less than 8/min
– Blood pressure or heart rate changes more than 20% of baseline
– SaO2 less than 90%
– Dysrhythmias, elevated ST segment
– Significant decrease in tidal volume
– Labored respirations, increased use of accessory muscles, and diaphoresis
– Restlessness, anxiety, and decreased level of consciousness
Oxygen Therapy: Nursing Actions: Ongoing care: Miscellaneous
• Suction the oropharynx and trachea prior to extubation.
• Following extubation, monitor clients for signs of respiratory distress or airway obstruction, such as ineffective cough, dyspnea, and stridor.
• Suction the tracheal tube to clear secretions, as needed. Reposition the client to promote mobility of secretions.
• Older adult clients have decreased respiratory muscle strength and chest wall compliance, which makes them more susceptible to aspiration, atelectasis, and pulmonary infections. The older adult client will require more frequent position
changes to promote mobility of secretions.
Oxygen Therapy: Complications – Fluid retention
• Fluid retention in clients who are receiving mechanical ventilation is due to decreased cardiac output, activation of renin-angiotensin-aldosterone system, and/or ventilator humidification.
• Nursing Actions: Monitor the client’s intake and output and weight.
Oxygen Therapy: Complications – Oxygen toxicity
• Oxygen toxicity can result from high concentrations of oxygen (typically above 50%), long durations of oxygen therapy (typically more than 24 to 48 hr), and/or the client’s degree of lung disease.
• Nursing Actions – Monitor for signs (fatigue, restlessness, severe dyspnea, tachycardia, tachypnea, crackles, and cyanosis).
Oxygen Therapy: Complications – Aspiration
• Keep the head of the bed elevated 30° at all times to decrease the risk of aspiration.
• Nursing Actions: Check residuals every 4 hours if the client is receiving enteral feedings to decrease the risk of aspiration.
Oxygen Therapy: Complications – Gastrointestinal (GI) ulceration (stress ulcer)
• Gastric ulcers can be evident in clients receiving mechanical ventilation.
• Nursing Actions: Monitor GI drainage and stools for occult bleeding. Administer ulcer prevention medications (sucralfate and histamine2 blockers) as prescribed.
RESPIRATORY DISORDERS: Airway Management

1) Maintenance of a patent airway is critical when providing care to clients, and suctioning and tracheostomy care are procedures that nurses must be knowledgeable about to ensure a patent airway.

2) Whenever possible, clients should be encouraged to cough. Coughing is more effective than artificial suctioning at moving secretions into the upper trachea or laryngopharynx.

3) Airway suctioning involves the use of a suction machine and catheter to remove secretions from the airway.

4) A tracheotomy is a sterile surgical incision made into the trachea for the purpose of establishing an airway. A tracheostomy is the stoma/opening that results from a tracheotomy and the insertion and maintenance of a tracheostomy tube.

RESPIRATORY DISORDERS: Airway Management – Suctioning
Suctioning can be accomplished orally, nasally, or endotracheally.
RESPIRATORY DISORDERS: Airway Management – Suctioning – Indications
o Diagnoses
• Hypoxemia
o Client presentation
• Early signs of hypoxemia (restlessness, tachypnea, tachycardia), decreased SaO2 levels, adventitious breath sounds, visualization of secretions, cyanosis, and absence of spontaneous cough.
RESPIRATORY DISORDERS: Airway Management – Suctioning: Client Outcomes
o The client will maintain a patent airway.
o The client will maintain a SaO2 between 95% and 100%.
Measures for all types of suctioning
o Use medical aseptic technique to suction the mouth (oropharyngeal).
o Use surgical aseptic technique for all other types of suctioning.
RESPIRATORY DISORDERS: Airway Management – Suctioning: Nursing Action – Preprocedure:
*Perform hand hygiene, provide privacy, and explain the procedure to clients.
* Don the required personal protective equipment.
* Assist clients to Fowler’s or high-Fowler’s position for suctioning if possible.
* Encourage clients to breathe deeply and cough in an attempt to clear the secretions without artificial suctioning.
* Obtain baseline breath sounds and vital signs, including SaO by pulse oximeter. SaO2 may be monitored continually during the procedure.
* Check that the suction equipment is working properly.
RESPIRATORY DISORDERS: Airway Management – Suctioning: Nursing Action – Intraprocedure:
o Open the sterile suction package.
* Place a sterile drape or towel on the client’s chest.
* Set up the container, touching only the outside.
* Pour approximately 100 mL of sterile water or 0.9% sodium chloride (NaCl) into the container.* Don sterile gloves.
.. The clean/nondominant hand should hold the connecting tube; this
glove protects the nurse.
.. The sterile/dominant hand should hold the sterile catheter; this glove protects clients.

* Connect the suction catheter to the wall unit’s tubing.
* Set suction pressure to no more than 120 mm Hg.
* Test the suction setup by aspirating sterile water/0.9% NaCl solution from the cup. If the unit is operating properly, continue with the procedure.
* Limit each suction attempt to no longer than 10 to IS seconds to avoid hypoxemia and the vagal response. Limit suctioning to two to three attempts.
* Once suctioning is complete, clear the suction tubing by aspirating sterile water 0.9% NaCI solution.

RESPIRATORY DISORDERS: Airway Management – Suctioning: Nursing Action – Postprocedure
o Postprocedure
• Nursing Actions
* Document data (vital signs, Sp02; breath sound, how clients tolerated the procedure and the color, consistency, and amount of secretions)
RESPIRATORY DISORDERS: Airway Management – Oropharyngeal suctioning – Preprocedure
Nursing Actions
* Obtain baseline breath sounds and vital signs, including Sa02 by pulse oximeter.
* Use a Yankauer or tonsil-tipped rigid suction catheter for oropharyngeal suctioning.
RESPIRATORY DISORDERS: Airway Management – Oropharyngeal suctioning – Intraprocedure
Nursing Actions
* Insert the catheter into the client’s mouth.
* Apply suction and move the catheter around the mouth, gumline, and pharynx.
* Clear the catheter and tubing.
* Repeat as needed.
* Monitor the client’s Sa02 level.
RESPIRATORY DISORDERS: Airway Management – Oropharyngeal suctioning – Postprocedure
Nursing Actions
* Replace the oxygen mask if applicable.
* Store the catheter in a clean, dry place for reuse.
* Allow clients to perform suctioning if possible.
* Document the client’s response.
RESPIRATORY DISORDERS: Airway Management – Nasopharyngeal and nasotracheal suctioning – Preprocedure
Nursing Actions
* Perform suctioning with a flexible catheter.
* Catheter size is based upon the diameter of the client’s nostrils and the thickness of the secretions.
* Hyperoxygenate clients during equipment preparation with 100% Fi02.
* Lubricate the distal 6 to 8 cm (2 to 3 in) of the suction catheter with a water soluble lubricant.
* Remove the oxygen delivery device with the nondominant hand if
applicable
RESPIRATORY DISORDERS: Airway Management – Nasopharyngeal and nasotracheal suctioning – Intraprocedure
Nursing Actions
* Insert the catheter into the nares during inhalation.
* Do not apply suction while inserting the catheter.
* Follow the natural course of the nares and slightly slant the catheter downward as it is advanced.
* Advance the catheter the approximate distance from the nose tip to the base of the earlobe.
* Apply suction intermittently by covering and releasing the suction port with the thumb for 10 to 15 seconds.
* Apply suction only while withdrawing the catheter and rotating it with the thumb and forefinger.
* Clear the catheter and tubing.
* Allow clients time for recovery (20 to 30 seconds) between sessions.
* Hyperoxygenate clients before each suctioning pass.
* Repeat as necessary.
RESPIRATORY DISORDERS: Airway Management – Nasopharyngeal and nasotracheal suctioning – Postprocedure
Nursing Actions
* Document the client’s response.
* Do not reuse the suction catheter
RESPIRATORY DISORDERS: Airway Management – Endotracheal Suctioning (ETS) – Preprocedure
Nursing Actions
* Perform ETS through a tracheostomy or endotracheal tube.
* Ask for assistance if necessary.
* Obtain a suction catheter with an outer diameter of no more than one-half the size of the internal diameter of the endotracheal tube.
* Hyperoxygenate clients using a bag-valve mask (BVM) or specialized ventilator function with a Fi020f 100%.
* Apply a face shield and sterile gloves.
RESPIRATORY DISORDERS: Airway Management – Endotracheal Suctioning (ETS) – Intraprocedure
Nursing Actions
* Insert the catheter into the lumen of the airway. First remove the BVM or ventilator from the tracheostomy or endotracheal tube if indicated. Advance the catheter until resistance is met. The catheter should reach the level of the carina (location of bifurcation into the main stem bronchi).
* Pull the catheter back 1 cm (0.5 inches) prior to applying suction to prevent mucosal damage.
* Apply suction intermittently by covering and releasing the suction port with the thumb for 10 to 15 seconds.
* Apply suction only while withdrawing the catheter and rotating it with the thumb and forefinger.
* Reattach the BVM or ventilator and supply clients with 100% inspired oxygen.
* Clear the catheter and tubing.
* Allow time for client recovery between sessions.
* Repeat as necessary.
RESPIRATORY DISORDERS: Airway Management Endotracheal Suctioning (ETS) – Postprocedure
Nursing Actions
D Document the client’s response.
RESPIRATORY DISORDERS: Airway Management Endotracheal Suctioning (ETS) – Complications: Hypoxemia
Hypoxemia
• A decrease in Sa02 or cyanosis may occur during suctioning, indicating worsening
hypoxemia.
• Nursing Actions
* To reduce the risk of hypoxemia:
~ Limit each suction attempt to no longer than 10 to 15 seconds.
~ Limit suctioning to two to three attempts.
~ Allow clients time for recovery 20 to 30 seconds between sessions.
~ Hyperoxygenate clients before each suctioning pass.
~ Decrease suctioning times for older adult clients.
* If clients shows signs or symptoms of hypoxemia, stop the procedure.
RESPIRATORY DISORDERS: Airway Management Endotracheal Suctioning (ETS) – Complications:
Anxiety
• Clients undergoing suctioning may become anxious during the procedure.
• Nursing Actions
o Explain the procedure to all clients prior to suctioning.
o Provide reassurance before, during, and after the procedure.
o Maintain a calm manner.
RESPIRATORY DISORDERS: Artificial Airways and Tracheotomy Care, Tracheotomy
• A tracheotomy is a sterile surgical incision into the trachea through the skin and muscles made for the purpose of establishing an airway.
• A tracheotomy may be performed as an emergency procedure or as a scheduled surgical procedure; it may be temporary or permanent.
• Artificial airways can be placed in the mouth (orotracheal tube), the nose (nasotracheal tube), or through a tracheostomy.
RESPIRATORY DISORDERS: Artificial Airways and Tracheotomy Care, Tracheostomy
• A tracheostomy is the stoma/opening that results from a tracheotomy to provide and secure a patent airway.
o Tracheostomy tubes vary in composition (plastic or metal), number of parts, size (long versus short), and shape (50 to 90° angles).
o There is no standard tracheostomy sizing system; however, the diameter of the tracheostomy tube must be smaller than the trachea.
o The outside cannula has a flange or neck plate that sits against the skin of the neck and has holes on each side for attaching ties around the client’s neck to stabilize the tracheostomy tube.
RESPIRATORY DISORDERS: Artificial Airways and Tracheotomy Care, Advantages of a tracheostomy for long-term therapy instead of an endotracheal tube
o Less risk of long-term damage to the airway
o Increased client comfort because no tube is present in the mouth
o Decreased incidence of pressure ulcers in the oral cavity and upper airway
o Ability for clients to eat, because the tube enters lower in the airway
o Ability for clients to talk
RESPIRATORY DISORDERS: Artificial Airways and Tracheotomy Care, Tracheostomy
• Air flow in and out of a tracheostomy without air leakage (a cuffed tracheostomy tube) bypasses the vocal cords resulting in an inability to produce sound or speech.
• Uncuffed and fenestrated tubes that are in place or capped allow clients to speak. Clients with a cuffed tube, who can be off mechanical ventilation and breathe around the tube, can use a
special valve to allow for speech. The cuff is deflated and the valve occludes the opening.
• Swallowing is possible with a tracheostomy tube in place; however, laryngeal elevation is affected and it is important to identify the client’s risk for aspiration prior to intake.
RESPIRATORY DISORDERS: Artificial Airways and Tracheotomy Care, Tracheostomy – Indications
o Diagnoses
• Indications for insertion of a tracheostomy
o Upper airway obstruction
o Edema (anaphylaxis, burns, trauma, head/neck surgery)
o Copious secretions
o The need for long-term mechanical ventilation
o The need for reconstruction after laryngeal trauma or laryngeal cancer surgery
o Obstructive sleep apnea refractory to conventional therapy
RESPIRATORY DISORDERS: Artificial Airways and Tracheotomy Care, Tracheostomy – Client Presentation
Client presentation
• Inability to oxygenate through the nasopharynx due to obstruction evidenced by dyspnea, poor Sa02 and poor ABG values
• Inability to wean from mechanical ventilation within 2 weeks
• Sleep apnea not improved by noninvasive mechanical ventilation (CPAP)
RESPIRATORY DISORDERS: Artificial Airways and Tracheotomy Care, Tracheostomy – Client Outcome
o The client will maintain a patent airway.
o The client will maintain a Sa02 between 95% and 100%.
RESPIRATORY DISORDERS: Artificial Airways and Tracheotomy Care, Tracheostomy – Nursing Care
Preparation of the client
• Explain the procedure.
• Place clients in semi-Fowler’s or Fowler’s position.
• Keep the following at the client’s bedside – Two extra tracheostomy tubes (one that is the client’s size and one that is a size smaller, in case of accidental decannulation), the obturator for the existing tube, an oxygen source, suction catheters and a suction source, and a manual resuscitation bag.
• Provide clients with methods to communicate with staff (paper and pen, dry erase board).
• Provide clients with an emergency call system, as well as a call light.
RESPIRATORY DISORDERS: Artificial Airways and Tracheotomy Care, Tracheostomy – Nursing Care – Ongoing care, Part I
Monitor:
o Oxygenation and ventilation (respiratory rate, effort, Sa02) and vital signs hourly
o Thickness, quantity, odor, and color of mucous secretions
o Stoma and skin surrounding the stoma for signs of inflammation or infection (redness, swelling, drainage)
• Provide adequate humidification and hydration to thin secretions and decrease risk of mucus plugging.
• Do not suction routinely, because this may cause mucosal damage, bleeding, and bronchospasm.
RESPIRATORY DISORDERS: Artificial Airways and Tracheotomy Care, Tracheostomy – Nursing Care – Ongoing care, Part II
• Monitor the need for suctioning. Suction on a PRN basis when findings indicate it is needed (audible/noisy secretions, crackles, restlessness, tachypnea, tachycardia, mucus in the airway).
• Maintain surgical aseptic technique when suctioning to prevent infection.
RESPIRATORY DISORDERS: Artificial Airways and Tracheotomy Care, Tracheostomy – Nursing Care – Ongoing care, Part III
Provide emotional support to clients and family.
• Give frequent oral care, usually every 2 hr.
• For cuffed tubes, keep the pressure below 20 mm Hg to reduce the risk of tracheal necrosis due to prolonged compression of tracheal capillaries.
RESPIRATORY DISORDERS: Artificial Airways and Tracheotomy Care, Tracheostomy – Nursing Care – Ongoing care, Part IV
• Provide tracheostomy care every 8 hr.
* Suction the tracheostomy tube if necessary, using sterile suctioning supplies.
* Remove old dressings and excess secretions.
* Apply the oxygen source loosely if clients desaturate during the procedure.
* Use cotton-tipped applicators and gauze pads to clean exposed outer cannula surfaces. Begin with half-strength (mixed with sterile 0.9% sodium chloride) or full-strength hydrogen peroxide followed by 0.9% sodium chloride. Clean in a circular motion from the stoma site outward.
* Use surgical aseptic technique to remove and clean the inner cannula (use half-strength or full-strength hydrogen peroxide solution to clean the cannula and sterile 0.9% sodium chloride to rinse it). Reinsert a multiuse inner cannula or replace the inner cannula with a new one if it is disposable.
RESPIRATORY DISORDERS: Artificial Airways and Tracheotomy Care, Tracheostomy – Nursing Care – Ongoing care, Part V
* Clean the stoma site and then the tracheostomy plate with half-strength or full-strength hydrogen peroxide solution followed by 0.9% NaCI saline.
* Place a split 4 in by 4 in dressing around the tracheostomy.
* Change tracheostomy ties if they are soiled. Secure new ties in place before removing soiled ones to prevent accidental decannulation.
* If a knot is needed, tie a square knot that is visible on the side of the neck. Check that one or two fingers fit between the tie tape and the neck.
* Document the type and amount of secretions, the general condition of the stoma and surrounding skin, the client’s response to the procedure, and any teaching or learning that occurred.
RESPIRATORY DISORDERS: Artificial Airways and Tracheotomy Care, Tracheostomy – Nursing Care – Ongoing care, Part VI
* Change nondisposable tracheostomy tubes every 6 to 8 weeks or per protocol.
* Reposition clients every 2 hr to prevent atelectasis and pneumonia.
* Minimize dust in the client’s room; do not shake bedding.
• If the client is permitted to eat, position the client in an upright position and tip
the client’s chin to her chest to enable swallowing. Check for aspiration.
RESPIRATORY DISORDERS: Artificial Airways and Tracheotomy Care, Tracheostomy – Nursing Care – Ongoing care – Administer Medication
o Anti-inflammatory agents to reduce edema
o Antibiotics as indicated for prophylaxis or infection treatment
o Aerosolized bronchodilators to relieve bronchospasm
o Mucus liquefying agents
RESPIRATORY DISORDERS: Artificial Airways and Tracheotomy Care, Tracheostomy – Nursing Care – Ongoing care – Considerations for older adult clients
o There is an increased risk of respiratory infection and pneumonia in older adult clients due to the decrease in cough effectiveness and secretion clearance. Respiratory infections may be more severe and last longer.
o Older adult clients may be at risk for dehydration (due to limited mobility, decrease in appetite, medications), contributing to thick, dried secretions that can occlude the airways.
o Maintaining good hydration in older adult clients, as well as providing
humidification (as ordered), is important to reduce the viscosity of
secretions.
RESPIRATORY DISORDERS: Artificial Airways and Tracheotomy Care, Tracheostomy – Nursing Care – Ongoing care -Client education
• Reinforce discharge teaching.
o Tracheostomy care
o Signs and symptoms that clients should immediately report to the health care provider (signs of infection, copious secretions)
o Ways to achieve good nutrition
• Consider requesting a referral for clients to a home health care agency and community support groups.
RESPIRATORY DISORDERS: Artificial Airways and Tracheotomy Care, Tracheostomy – Complications
Accidental decannulation
• Accidental decannulation in the first 72 hr after surgery is an emergency because the tracheostomy tract has not matured and replacement may be difficult.
• Nursing Actions
o Keep the tracheostomy obturator and a spare tracheostomy tube at the bedside.
o Call for assistance.
o If accidental decannulation occurs after the first 72 hr, immediately hyperextend the neck, and with the obturator inserted into the tracheostomy tube, quickly and gently replace the tube and remove the obturator.
RESPIRATORY DISORDERS: Asthma
Asthma is a chronic inflammatory disorder of the airways that results in intermittent and reversible airflow obstruction of the bronchioles.
o The obstruction occurs either by inflammation or airway hyperresponsiveness.
o Asthma can occur at any age.
o The cause of asthma is unknown; however, it may have a genetic component.
RESPIRATORY DISORDERS: Manifestations of asthma
o Mucosal edema
o Bronchoconstriction
o Excessive mucus production
RESPIRATORY DISORDERS: ASTHMA: Diagnosis
Asthma diagnoses are based on symptoms and classified into one of the following four categories:
o Mild intermittent – Symptoms occur less than twice a week.
o Mild persistent – Symptoms arise more than twice a week but not daily.
o Moderate persistent – Daily symptoms occur in conjunction with exacerbations twice a week.
o Severe persistent – Symptoms occur continually, along with frequent exacerbations that limit the client’s physical activity and quality of life.
RESPIRATORY DISORDERS: ASTHMA – Risk Factors
Older adult clients have decreased pulmonary reserves due to physical changes that occur with the aging process.
• Older adult clients are more susceptible to infections.
• The sensitivity of beta-adrenergic receptors decreases with age. As the beta receptors age and lose sensitivity, they are less able to respond to agonists, which can result in bronchospasms.
RESPIRATORY DISORDERS: ASTHMA – Subjective Data
o Dyspnea
o Chest tightness
o Anxiety and/or stress
RESPIRATORY DISORDERS: ASTHMA – Objective Data
Physical assessment findings
• Coughing
• Wheezing
• Diminished lung sounds
• Mucus production
• Use of accessory muscles
• Poor oxygen saturation (low SaO2)
• Barrel chest or increased chest diameter
RESPIRATORY DISORDERS: ASTHMA – Assessment
Obtain the client’s history regarding current and previous asthma exacerbations.
• Onset and duration
• Precipitating factors (stress, exercise, exposure to irritant)
• Changes in medication regimen
• Medications that relieve symptoms
• Other medications taken
• Self-care methods used to relieve symptoms
RESPIRATORY DISORDERS: ASTHMA – Laboratory Tests
Laboratory Tests
• ABGs
o Hypoxemia (decreased Pa02 1ess than 80 mm Hg)
o Hypocarbia (decreased PaC02 less than 35 mm Hg – Early in attack)
o Hypercarbia (increased PaC02 greater than 45 mm Hg – Later in attack)
• Sputum cultures
o Bacteria can indicate infection.
RESPIRATORY DISORDERS: ASTHMA – Diagnostic procedures – Pulmonary function tests (PFTs)
Pulmonary function tests (PFTs) are the most accurate tests for diagnosing asthma and its severity.
o Forced vital capacity (FVC) is the volume of air exhaled from full inhalation to full exhalation.
o Forced expiratory volume in the first second (FEV1) is the volume of air blown out as hard and fast as possible during the first second of the most forceful exhalation after the greatest full inhalation.
o Peak expiratory rate flow (PERF) is the fastest airflow rate reached during exhalation.
o A decrease in FEV1 or PERF by 15% to 20% below the expected value is common in clients who have asthma. An increase in these values by 12% following the administration of bronchodilators is diagnostic for asthma.• Periodic chest x-rays are used to monitor changes in the. client’s chest structure.

RESPIRATORY DISORDERS: ASTHMA – Diagnostic procedures – Pulmonary function tests (PFTs) – Nursing Care
Nursing Care
o Position clients to maximize ventilation (high-Fowler’s = 90·).
o Monitor respiratory status including watching for shortness of breath, dyspnea, and audible wheezing. An absence of wheezing may indicate severe constriction of the alveoli.
o Administer oxygen therapy as prescribed.
o Monitor clients receiving IV therapy.
o Maintain a calm and reassuring demeanor.
o Provide rest periods for older adult clients who have dyspnea. Design room and walkways with opportunities for rest. Incorporate rest into ADLs.
o Encourage prompt medical attention for infections and appropriate vaccinations.
o Administer medications as prescribed.
RESPIRATORY DISORDERS: ASTHMA – Medication Administration – Bronchodilators (inhalers)
• Short-acting beta-agonists, such as albuterol (Proventil, Ventolin), provide rapid relief of acute symptoms and prevent exercise-induced asthma.
• Anticholinergic medications, such as ipratropium (Atrovent), block the parasympathetic nervous system. This allows for the sympathetic nervous system effects of increased bronchodilation and decreased pulmonary secretions.
• Methylxanthines, such as theophylline (Theo-Our), require close monitoring of serum medication levels due to a narrow therapeutic range.
RESPIRATORY DISORDERS: ASTHMA – Medication Administration – Bronchodilators (inhalers) – Nursing Considerations
* Instruct clients in proper use of MOl, OPA, or nebulizer.
* Albuterol- Watch clients for tremors and tachycardia.
* Theophylline – Monitor the client’s serum levels for toxicity. Side effects will include tachycardia, nausea, and diarrhea.
* Ipratropium – Observe clients for dry mouth.
RESPIRATORY DISORDERS: ASTHMA – Medication Administration – Bronchodilators (inhalers) – Client Education
* Instruct clients to use a bronchodilator inhaler 5 min prior to using an anti-inflammatory inhaler to promote bronchodilation and increased absorption of medication.
* Ipratropium – Advise clients to suck on hard candies to help relieve dry mouth.
* Teach clients to monitor heart rate.
* Increase water fluid intake to decrease dry mouth and throat irritation.
RESPIRATORY DISORDERS: ASTHMA – Medication Administration – Anti-inflammatory agents
These are used to decrease airway inflammation, and they include:
* Corticosteroids, such as fluticasone (Flovent) and prednisone (Deltasone)
* Leukotriene antagonists, such as montelukast (Singulair), mast cell stabilizers, such as cromolyn sodium (Intal), and monoclonal antibodies, such as omalizumab (Xolair)
RESPIRATORY DISORDERS: ASTHMA – Medication Administration – Anti-inflammatory agents – Nursing Considerations
– Watch clients for decreased immune function.
– Monitor for hyperglycemia.
– Advise clients to report black, tarry stools.
– Observe clients for fluid retention and weight gain. This can be common.
– Monitor the client’s throat and mouth for aphthous lesions (cold sores).
RESPIRATORY DISORDERS: ASTHMA – Medication Administration – Anti-inflammatory agents – Client Education
o Encourage clients to drink plenty of fluids to promote hydration.
o Encourage clients to take prednisone with food.
o Instruct children to rinse mouth or gargle with warm saltwater after the use of an inhaler.
o Instruct children and their families to watch for redness, sores, or white patches in the mouth, and report them to the provider.
RESPIRATORY DISORDERS: ASTHMA – Medication Administration – Combination agents (bronchodilator and anti-inflammatory)
• Ipratropium and albuterol (Combivent)
• Fluticasone and salmeterol (Advair Diskus)
RESPIRATORY DISORDERS: ASTHMA – Medication Administration – Interdisciplinary Care
o Request respiratory services for inhalers and breathing treatments for airway management.
o Request nutritional services for weight loss or gain related to medications or diagnosis.
o Consider rehabilitation care for clients who have prolonged weakness and need assistance with increasing level of activity.
RESPIRATORY DISORDERS: ASTHMA – Care after discharge, Part I
Client education
• If clients smoke, promote smoking cessation.
• Advise clients to use protective equipment (mask) and ensure proper ventilation while working in environments that contain carcinogens or particles in the air.
• Encourage influenza and pneumonia vaccinations for all clients who have asthma and especially for the older adults.
RESPIRATORY DISORDERS: ASTHMA – Care after discharge, Part II
Teach clients how to recognize and avoid triggering agents, such as:
o Environmental factors, such as changes in temperature (especially warm to cold) and humidity
o Air pollutants
o Strong odors (perfume)
o Seasonal allergens (grass, tree, and weed pollens) and perennial allergens (mold, feathers, dust, roaches, animal dander, foods treated with sulfites)
o Stress and emotional distress
o Medications (aspirin, NSAIDS, beta-blockers, cholinergics)
o Enzymes, including those in laundry detergents
o Chemicals (household cleaners)
o Sinusitis with postnasal drip
o Viral respiratory tract infection
RESPIRATORY DISORDERS: ASTHMA – Care after discharge, Part III
• Instruct clients how to properly self-administer medications (nebulizers and inhalers).
• Educate clients regarding infection prevention techniques.
• Encourage regular exercise as part of asthma therapy. Remind clients to use medication prior to activity if necessary.
o Promotes ventilation and perfusion.
o Maintains cardiac health.
o Enhances skeletal muscle strength.
RESPIRATORY DISORDERS: ASTHMA – Client Outcomes
o The client will maintain adequate gas exchange.
o The client will prevent acute attacks.
o The client will have relief of symptoms.
o The client will adhere to the medication regimen.
RESPIRATORY DISORDERS: ASTHMA – complications: Respiratory Failure
Respiratory failure
o Persistent hypoxemia related to asthma can lead to respiratory failure.
o Nursing Actions
• Monitor oxygenation levels and acid-base balance.
• Assist with intubation and mechanical ventilation as indicated.
RESPIRATORY DISORDERS: ASTHMA – complications: Status asthmaticus
o This is a life-threatening episode of airway obstruction that is often unresponsive to common treatment. It involves extreme wheezing, labored breathing, use of accessory muscles, and distended neck veins, and creates a risk for cardiac and/or respiratory arrest.
RESPIRATORY DISORDERS: ASTHMA – complications: Status asthmaticus – Nursing actions
• Assist with emergency intubation .
• Administer humidified oxygen.
• Monitor IV access, ABGs and serum electrolytes.
• Other therapies may include:
o Bronchodilators, epinephrine, and systemic steroid therapy.
• Prepare clients for admission for continued management.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD)
Chronic obstructive pulmonary disease (COPD) encompasses two diseases – emphysema and chronic bronchitis. Most clients who have emphysema also have chronic bronchitis. COPD is irreversible. COPD typically affects middle age to older adults.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Emphysema
Emphysema is characterized by the loss of lung elasticity and hyperinflation of lung tissue. Emphysema causes destruction of the alveoli, leading to a decreased surface area for gas exchange, carbon dioxide retention, and respiratory acidosis.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Chronic Bronchitis
Chronic bronchitis is an inflammation of the bronchi and bronchioles due to chronic exposure to irritants.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) :Risk Factors
o Advanced age
o Cigarette smoking is the primary risk factor for the development of COPD.
o Second-hand smoke
o Alpha1-antitrypsin (AAT) deficiency
o Exposure to air pollution
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) :Subjective Data
Chronic dyspnea
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Objective Data
Physical Assessment Findings
• Dyspnea upon exertion
• Productive cough that is most severe upon rising in the morning
• Respiratory acidosis and compensatory metabolic alkalosis
• Crackles and wheezes
• Rapid and shallow respirations
• Use of accessory muscles
• Barrel chest or increased chest diameter (with emphysema)
• Hyperresonance on percussion due to “trapped air” (with emphysema)
• Irregular breathing pattern
• Thin extremities and enlarged neck muscles
• Dependent edema secondary to right-sided heart failure
• Clubbing of fingers and toes
• Pallor and cyanosis of nail beds and mucous membranes (late stages of the
disease)
• Decreased oxygen saturation levels (expected reference range is 95% to 100%)
• In clients who have dark-colored skin or in older adults, oxygen saturation levels
can be slightly lower.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Laboratory tests
• An increased hematocrit level is due to low oxygenation levels.
• Use sputum cultures and WBC counts to diagnose acute respiratory infections.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Diagnostic procedures – Pulmonary function tests
* These tests are used for diagnosis, as well as determining the effectiveness of therapy.
* Comparisons of forced expiratory volume (FEV) to forced vital capacity (FVC) are used to classify COPD as mild to very severe.
* As COPD advances, the FEV to FVC ratio decreases. The expected reference range is 100%. For mild COPD, the FEV/FVC ratio is decreased to less than 70%. As the disease progresses to moderate and severe, the ratio decreases to less than 50%.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Diagnostic procedures – Chest X-ray
* Reveals hyperinflation of alveoli and flattened diaphragm in the late stages of emphysema.
* It is often not useful for the diagnosis of early or moderate disease.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Diagnostic procedures – Arterial blood gases (ABGs)
o Hypoxemia (decreased PaO2less than 80 mm Hg)
o Hypercarbia (increased PaCO2 greater than 45 mm Hg)
o Respiratory acidosis, metabolic alkalosis compensation
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Diagnostic procedures – Pulse oximetry
o Clients who have COPD usually have oxygen levels less than the expected reference range of 95% to 100%
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Diagnostic procedures – AAT (alpha! antitrypsin) levels used to assess for AAT deficiency.
o A deficiency in a special enzyme produced by the liver that helps regulate other enzymes (that help breakdown pollutants) from attacking lung tissue.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Nursing Care, Part I
o Position clients to maximize ventilation (high-Fowler’s is 90°).
o Encourage effective coughing, or suction to remove secretions.
o Encourage deep breathing and use of an incentive spirometer.
o Administer breathing treatments and medications as prescribed
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Nursing Care, Part II
o Administer oxygen as prescribed.
• Clients who have COPD may need 2 to 4 L/min of oxygen via nasal cannula or up to 40% via Venturi mask.
• Often clients with COPD usually have chronically increased PaCO2 (hypercarbia) and hypoxia which is their stimulus to breath. Therefore, these clients should only receive 1 to 2 L/min of oxygen via nasal cannula. It is important to recognize that low arterial levels of oxygen serve as the primary drive for breathing.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Nursing Care, Part III
o Monitor for skin breakdown around the nose and mouth from the oxygen device.
o Promote adequate nutrition. Encourage soft, high-calorie foods to conserve energy.
o Encourage clients to consume 2 to 3 L/day of fluid from food and beverage sources.
o Monitor current weight and note any changes.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Nursing Care, Part IV
o Instruct clients to practice breathing techniques to control dyspneic episodes.
• For diaphragmatic, or abdominal, breathing, instruct clients to:
o Take breaths deep from the diaphragm.
o Lie on back with knees bent.
o Rest hand over abdomen to create resistance.
o If the client’s hand rises and lowers upon inhalation and exhalation, the breathing is being performed correctly.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Nursing Care, Part V
• For pursed-lip breathing, instruct clients to:
* Form the mouth as if preparing to whistle.
* Take a breath in through the nose and out through the lips/mouth.
* Not puff the cheeks.
*Take breaths deep and slow.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Nursing Care, Part VI
o Incentive spirometry
• This is used to monitor and promote optimal lung expansion.
• Nursing Actions
* Show clients how to use the incentive spirometry machine.
• Client Education
* Instruct clients to keep a tight mouth seal around mouthpiece and to inhale and hold breath for 3 to 5 seconds. As clients exhale, the needle of the spirometry machine will rise. This promotes lung expansion.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Nursing Care, Part VII
o Determine the client’s physical limitations and structure activity to include periods of rest.
o Provide rest periods for older adult clients who have dyspnea. Design the room and walkways with opportunities for relaxation.
o Provide support to clients and their families.
• Talk about disease and lifestyle changes, including home care services such as portable oxygen.
o Encourage verbalization of feelings.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) :Medications – Bronchodilators
Bronchodilators (inhalers)
• Short-acting beta2 agonists, such as albuterol (Proventil, Ventolin) provide rapid relief.
• Cholinergic antagonists (anticholinergic medications), such as ipratropium (Atrovent), block the parasympathetic nervous system. This allows for the sympathetic nervous system effects of increased bronchodilation and decreased pulmonary secretions.
• Methylxanthines, such as theophylline (Theo-Dur), relax smooth muscles of the bronchi. These medications require close monitoring of serum medication levels due to narrow therapeutic ranges.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) :Medications – Bronchodilators : Nursing Considerations
• Nursing Considerations
* Watch clients for tremors and tachycardia when taking albuterol.
* Observe clients for dry mouth when taking ipratropium.
* Monitor the client’s serum levels for toxicity when taking theophylline. Side effects will include tachycardia, nausea, and diarrhea.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) :Medications – Bronchodilators : Client Education on Ipratropium
* Encourage clients to suck on hard candies to help moisten dry mouth while taking ipratropium
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) :Medications – Anti-Inflammatory Agents
• These medications decrease airway inflammation.
• If corticosteroids, such as fluticasone (Flovent) and prednisone (Deltasone), are given systemically, monitor for side effects (immunosuppression, fluid retention,
hyperglycemia, hypokalemia, poor wound-healing).
• Leukotriene antagonists, such as montelukast (Singulair)i mast cell stabilizers, such as cromolyn sodium (Intal)i and monoclonal antibodies, such as omalizumab (Xolair), can be used.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) :Medications – Anti-Inflammatory Agents : Nursing Considerations
* Watch clients for a decrease in immunity function.
* Monitor clients for hyperglycemia.
* Advise clients to report black, tarry stools.
* Observe clients for fluid retention and weight gain. This is common.
* Check the client’s throat and mouth for aphthous lesions (cold sores).
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) :Medications – Anti-Inflammatory Agents : Client Education
* Encourage clients to drink adequate fluids to promote hydration.
* Encourage clients to take glucocorticoids (Prednisone) with food.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Interdisciplinary Care
o Request referral for respiratory services to assist with inhalers, breathing treatments, and suctioning for airway management.
o Request a referral for nutritional services to assist with weight loss or gain related to medications or diagnosis. Clients may also need assistance with food preparation and delivery.
o Request a referral for rehabilitative care if clients have prolonged weakness and need assistance with increasing level of activity.
o Request a referral for a home health aide for assistance with ADLs. May also need assistance with obtaining home oxygen.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Therapeutic Procedures
o Chest physiotherapy uses percussion and vibration to mobilize secretions.
o Raising the foot of the bed slightly higher than the head can facilitate optimal drainage and removal of secretions by gravity.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Care after Discharge
Client education
• Promote smoking cessation.
• Instruct clients to use protective equipment, such as a mask, and ensure proper ventilation while working in environments that contain carcinogens or particles in the air.
• Recommend influenza and pneumonia immunizations, especially for the older adult client.
• Encourage clients to eat high-calorie foods to promote energy.
• Encourage rest periods as needed.
• Remind clients to perform frequent hand hygiene to prevent infection.
• Reinforce the importance of taking medications (inhalers, oral medications) as prescribed.
• Reinforce to clients to use oxygen as prescribed. Inform other caregivers not to smoke around the oxygen due to flammability.
• Provide support to the clients and their families.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Client Outcomes
o The client will maintain adequate gas exchange.
o The client will be able to keep a patent airway.
o The client will remain free from infection.
o The client will be able to stay within 10% of ideal body weight.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Complications – Respiratory infection
o Respiratory infections result from increased mucus production and poor oxygenation levels.
o Nursing Actions
• Administer oxygen therapy.
• Monitor oxygenation levels.
• Administer antibiotics and other medications as prescribed
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Complications – Right-sided heart failure (cor pulmonale)
o Air trapping, airway collapse, and stiff alveoli lead to increased pulmonary pressures.
o Blood flow through the lung tissue is difficult. This increased workload leads to enlargement and thickening of the right atrium and ventricle.
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Complications – Right-sided heart failure (cor pulmonale) – Manifestations
• Low oxygenation levels
• Cyanotic lips
• Enlarged and tender liver
• Distended neck veins
• Dependent edema
RESPIRATORY DISORDERS: Chronic Obstructive Pulmonary Disease (COPD) : Complications – Right-sided heart failure (cor pulmonale) – Nursing Actions
• Monitor respiratory status and administer oxygen therapy.
• Monitor heart rate and rhythm.
• Administer medications as prescribed.
• Monitor clients receiving IV fluids and diuretics to maintain fluid balance.
RESPIRATORY DISORDERS: Pneumonia
• Pneumonia is an inflammatory process in the lungs that produces excess fluid. Pneumonia is triggered by infectious organisms or by the aspiration of an irritant, such as fluid or a foreign object.
• The inflammatory process in the lung parenchyma results in edema and exudate that fills the alveoli.
• Pneumonia can be a primary disease or a complication of another disease or condition.
It affects people of all ages, but the young, older adult clients, and clients who are immunocompromised are more susceptible. Immobility can be a contributing factor in the development of pneumonia.
RESPIRATORY DISORDERS: Pneumonia – There are two types of pneumonia.
There are two types of pneumonia.
1) Community acquired pneumonia (CAP) is the most common type and often occurs as a complication of influenza.
2) Hospital acquired pneumonia (HAP) has a higher mortality rate and is more likely to be resistant to antibiotics. It usually takes 24 to 48 hr from the time clients are exposed to acquire HAP.
RESPIRATORY DISORDERS: Pneumonia – Older Adult Considerations
Older adult clients are more susceptible to infections and have decreased pulmonary reserves due to normal lung changes, including decreased lung elasticity and thickening alveoli.
RESPIRATORY DISORDERS: Pneumonia – Risk Factors
o Advanced age
o Recent exposure to viral or influenza infections
o No history of pneumonococcal vaccination
o Tobacco use
o Substance abuse (alcohol, cocaine)
o Chronic lung disease (asthma, emphysema)
o Conditions that increase the risk of aspiration (dysphagia)
o Mechanical ventilation (ventilator acquired pneumonia)
o Impaired ability to mobilize secretions (decreased level of consciousness, immobility, recent abdominal or thoracic surgery)
o Immunocompromised status
o Inactivity and immobility
RESPIRATORY DISORDERS: Pneumonia – Subjective Data
o Anxiety
o Fatigue
o Weakness
o Chest discomfort
o Confusion from hypoxia is the most common manifestations of pneumonia in older adult clients
RESPIRATORY DISORDERS: Pneumonia – Objective Data
Physical assessment findings
• Fever
• Chills
• Flushed face
• Diaphoresis
• Shortness of breath or difficulty breathing
• Tachypnea
• Pleuritic chest pain (sharp)
• Sputum production (yellow-tinged)
• Crackles and wheezes
• Coughing
• Dull chest percussion over all areas of consolidation
• Decreased oxygen saturation levels (expected reference range is 95% to 100%) .
• Fever, cough, and yellow-tinged are often absent in clients who have pneumonia
RESPIRATORY DISORDERS: Pneumonia – Laboratory Test – CBC
– Elevated WBC count (may not be present in older adult clients)
RESPIRATORY DISORDERS: Pneumonia – Laboratory Test – Sputum Culture and Sensitivity
o Obtain specimen before starting antibiotic therapy.
o Obtain specimen by suctioning if clients are unable to cough.
o Older adult clients have a weak cough reflex and decreased muscle strength. Therefore, older adult clients have trouble expectorating, which can lead to difficulty in breathing and make specimen retrieval more difficult.
RESPIRATORY DISORDERS: Pneumonia – Laboratory Test – ABGs
Hypoxemia (decreased PaO2 less than 80 mmHg)
RESPIRATORY DISORDERS: Pneumonia – Laboratory Test – Diagnostic procedures – Chest X-ray
– A chest X-ray will show consolidation (solidification,density) of lung tissue
– A chest X-ray is an important diagnostic tool because the early signs and symptoms of pneumonia are often vague in older adults clients.
RESPIRATORY DISORDERS: Pneumonia – Laboratory Test – Diagnostic procedures – Pulse Oximetry
– Clients who have pneumonia usually have oximetry levels less than the expected reference of 95% to 100%
RESPIRATORY DISORDERS: Pneumonia – Nursing Care, Part I
– Position clients to maximize ventilation (high-Fowler’s = 90%)
– Encourage coughing or suction to remove secretions
– Administer breathing treatments and medications as prescribed
– Administer oxygen therapy as prescribed
– Monitor for skin breakdown around the nose and mouth from the oxygen device
RESPIRATORY DISORDERS: Pneumonia – Nursing Care, Part II
– Encourage deep breathing with an incentive spirometer to prevent alveolar collapse.
– Determine the client’s physical limitations and structure activity to include periods of rest.
– Promote adequate nutrition. Encourage soft, high calorie foods to conserve energy.
RESPIRATORY DISORDERS: Pneumonia – Nursing Care, Part III
– Encourage fluid intake of 2 to 3 L / day from food and beverage sources to promote hydration and thinning of secretions, unless contraindicated due to another condition.
– Provide rest period for older adult clients who have dyspnea
– Reassure client who are experiencing respiratory distress
RESPIRATORY DISORDERS: Pneumonia – Medications: Antibiotics
– Given to destroy infectious pathogens, commonly used antibiotics include penicillin and cephalosporin
– Often initially given via intermittent IV bolus and then switched to an oral form as the client’s condition improves.
– Important to obtain any culture specimens prior to giving the first dose of an antibiotic. Once the specimen has been obtained, the antibiotics can be given while waiting for the results of the ordered culture.
RESPIRATORY DISORDERS: Pneumonia – Medications: Antibiotics : Nursing Considerations
– Observe clients taking cephalosporins for frequent stools.
– Monitor the client’s kidney function, especially older adults who are taking penicillins and cephalosporins.
RESPIRATORY DISORDERS: Pneumonia – Medications: Antibiotics : Client Education
Encourage clients to take penicillins and cephalosporins with food. Some penicillins should be taken 1 hour before meals or 2 hours after.
RESPIRATORY DISORDERS: Pneumonia – Medications: Bronchodilators
Given to reduce bronchospasms and reduce irritation.
– short acting beta2 antagonists, such as albuterol, provide rapid relief.
– cholinergic antagonists (anticholinergic medication) such as IPRATROPIUM (Atrovent), block the parasympathetic nervous system., allowing for increased bronchodilation and decreased pulmonary secretions
– Methylxanthines such as theophylline (Theo-dur), require close monitoring of serum medication levels due to the narrow therapeutic range.
RESPIRATORY DISORDERS: Pneumonia – Medications: Bronchodilators – Nursing Considerations
o Watch for tremors and tachycardia for clients taking albuterol.
o Observe for dry mouth for clients taking Ipratropium
o Monitor serum medication levels for toxicity for clients taking theophylline. Side effects will include tachycardia, nausea, diarrhea
RESPIRATORY DISORDERS: Pneumonia – Medications: Bronchodilators – client education
Encourage clients to suck on hard candies to help moisten dry mouth while taking Ipratropium
RESPIRATORY DISORDERS: Pneumonia – Medications: Anti-inflammatories
– Anti-inflammatories decrease inflammation
– Glucocorticoids such as fluticasone (Flovent) and prednisone (Deltasone), can be prescribed to help with inflammation. Monitor for immunosuppression, fluid retention, hyperglycemia, hypokalemia, and poor wound healing.
RESPIRATORY DISORDERS: Pneumonia – Medications: Anti-inflammatories – Nursing Considerations
o Monitor clients for decreased immune function.
o Monitor clients for hyperglycemia. .
o Advise clients to report black, tarry stools.
o Observe clients for fluid retention and weight gain. This can be common
o Monitor the client’s throat and mouth for aphthous lesions (Cold sores)
RESPIRATORY DISORDERS: Pneumonia – Medications: Anti-inflammatories – Client Education
o Encourage clients to drink adequate fluids to promote hydration.
o Encourage clients to take glucocorticosteroids with food.
RESPIRATORY DISORDERS: Pneumonia – Medications: Interdisciplinary Care
– Recognize the need for referral for respiratory services to assist with inhalers, breathing treatments and suctioning for airway management.
– Recognize the need for nutritional assistance with client’s weight loss or gain related to medication or diagnosis
– Recognize the need for a referral for rehabilitation if clients have prolonged weakness and need assistance with increasing level of activity.
RESPIRATORY DISORDERS: Pneumonia – Medications: Client Education
– Reinforce clients the importance of continuing medications for treatment of pneumonia
– Encourage rest periods as needed
– Encourage clients to maintain hand hygiene to prevent infection
– Remind clients that treatment of and recovery from pneumonia can take time.
– Encourage immunizations for influenza and pneumonia
– Promote smoking cessation if client smokes.
RESPIRATORY DISORDERS: Pneumonia – Medications: Client Outcomes
– Client is able to maintain adequate gas exchange
– Client is able to maintain a patent airway
– Client remains free from infection.
RESPIRATORY DISORDERS: Pneumonia – Medications: Complications – Atelectasis
– Airway inflammation and edema lead to alveolar collapse and increase hypoxemia
– Clients might report shortness of breath and exhibit sings of hypoxemia
– Client might have diminished or absent breath sounds over the affected area.
– A chest X-ray will show an area of density
RESPIRATORY DISORDERS: Pneumonia – Medications: Complications – Bacteremia (sepsis)
– This can occur if pathogens enter the bloodstream from the infection in the lungs.
RESPIRATORY DISORDERS: Tuberculosis
• Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis (a nonmoving, slow-growing, acid-fast rod).
• TB is transmitted through aerosolization (airborne route).
• Once inside the lung, the body encases the TB bacillus with collagen and other cells. This may appear as a Ghon tubercle (primary lesion) on a chest x-ray.
• Only a small percentage of people infected with TB actually develop an active form of the infection. The TB bacillus may lie dormant for many years before producing the disease.
• TB primarily affects the lungs but can spread to any organ in the blood.
• The risk of transmission decreases after 2 to 3 weeks of antibiotic therapy.
• Individuals who have been exposed to TB but have not developed the disease may have latent TB. This means that the mycobacterium tuberculosis is in the body, but the body has been able to fight off the infection. If not treated, it can lie dormant for several years and then become active as the individual becomes older or immunocompromised.
RESPIRATORY DISORDERS: Tuberculosis – Risk Factors
o Frequent and close contact with an untreated individual
o Lower socioeconomic status and homelessness
o Immunocompromised status (HIV, chemotherapy)
o Poorly ventilated, crowded environments (prisons, long-term care facilities)
o Advanced age
o Recent travel outside of the United States to areas where TB is endemic
o Substance abuse including drugs and alcohol
o Health care occupation that involves performance of high-risk activities (respiratory treatments, suctioning, coughing procedures)
RESPIRATORY DISORDERS: Tuberculosis -Subjective Data
o Persistent cough
o Purulent sputum, possibly blood-streaked
o Fatigue and lethargy
o Weight loss and anorexia
o Night sweats and low-grade fever in the afternoon
RESPIRATORY DISORDERS: Tuberculosis -Objective Data
Physical assessment findings
• Older adult clients often present with atypical symptoms of the disease (altered mentation or unusual behavior, fever, anorexia, weight loss).
• Dullness heard with percussion of lungs
• Adventitious breath sounds include bronchial breath sounds and crackles
RESPIRATORY DISORDERS: Tuberculosis -Laboratory tests
• QuantiFERON-TB Gold
* Blood test that detects release of interferon-gamma (IFN-g) in fresh
heparinized whole blood from sensitized people
* Diagnostic for infection, whether it is active or latent
RESPIRATORY DISORDERS: Tuberculosis: Diagnostic procedures
• Mantoux test (should be read in 48 to 72 hr)
– An intradermal injection of an extract of the tubercle bacillus is made.
– An induration (palpable, raised, hardened area) of 10 mm or greater in diameter indicates a positive skin test.
– An induration of 5 mm is considered a positive test for
immunocompromised clients.
– A positive Mantoux test indicates that clients have developed an -immune response to TB. A client’s TB test will be positive within 2 to 10 weeks of exposure to the infection. It does not confirm that active disease is present. Clients who have been treated for TB may retain a positive reaction.
– Individuals who have latent TB may have a positive Mantoux test and may receive treatment to prevent development of an active form of the disease.
– Clients who have received a Bacillus Calmette-Guerin vaccine within the past 10 years may have a false-positive Mantoux test. These clients will need a chest x-ray to evaluate the presence of active TB infection.
RESPIRATORY DISORDERS: Tuberculosis: Client Education
~ Reinforce to clients the importance of returning for a reading of the injection site by a health care provider within 48 to 72 hours.
RESPIRATORY DISORDERS: Tuberculosis: Diagnostics and Laboratory
• A chest x-ray may be ordered to detect active lesions in the lungs.
• Acid-fast bacilli smear and culture
o A positive acid-fast test suggests an active infection.
o The diagnosis is confirmed by a positive culture for Mycobacterium tuberculosis.
o Nursing Actions
~ Three early morning sputum samples are obtained.
~ Wear personal protective equipment when obtaining specimens.
~ Obtain samples in a negative airflow room.
RESPIRATORY DISORDERS: Tuberculosis: Nursing Care
o Prevent infection transmission.
• Wear an N95 or HEPA respirator when caring for clients who are hospitalized with TB.
• Place clients in a negative airflow room and implement airborne precautions.
• Use barrier protection when the risk of hand or clothing contamination exists.
• Have clients wear a mask if transportation to another department is necessary. Clients should be transported using the shortest and least busy route.
• Teach clients to cough and expectorate sputum into tissues that are disposed of by clients into provided sacks.
o Administer medications as prescribed.
o Promote adequate nutrition.
• Encourage fluid intake and a well-balanced diet for adequate caloric intake.
• Encourage foods that are rich in protein, iron, and vitamin C.
o Provide emotional support
RESPIRATORY DISORDERS: Tuberculosis: Medications
o Due to the resistance that is developing against the anti-tuberculin medications, combination therapy of up to four medications at a time is presently recommended.
o The current four-medication regimen includes isoniazid (Nydrazid), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol hydrochloride (Myambutol).
RESPIRATORY DISORDERS: Tuberculosis: Medications – Isoniazid
• Isoniazid, commonly referred to as INR, is bactericidal and inhibits growth of mycobacteria by preventing synthesis of mycolic acid in the cell wall.
• Nursing considerations
o Monitor for hepatotoxicity and neurotoxicity, such as tingling of the hands and feet.
o Administer vitamin B6 (pyridoxine) to prevent neurotoxicity from isoniazid
• Client education
o Instruct clients to take medication on an empty stomach.
o Advise clients not to drink alcohol while taking isoniazid, because it may increase the risk for hepatotoxicity.
RESPIRATORY DISORDERS: Tuberculosis: Medications – Rifampin
• Rifampin, commonly referred to as RIF, is a bacteriostatic and bactericidal antibiotic that inhibits DNA-dependent RNA polymerase activity in susceptible cells.
• Nursing considerations
o Observe for hepatotoxicity.
• Client education
o Inform clients that urine and other secretions will be orange.
o Advise clients to report yellowing of the skin, pain or swelling of joints, loss of appetite, or malaise immediately.
o Inform clients that this medication may interfere with the efficacy of oral contraceptives.
RESPIRATORY DISORDERS: Tuberculosis: Medications – Pyrazinamide
• Pyrazinamide, commonly referred to as PZA, is a bacteriostatic and bactericidal, and its exact mechanism of action is unknown.
• Nursing considerations
o Observe for hepatotoxicity.
• Client education
o Instruct clients to drink a glass of water with each dose and increase fluids during the day.
o Advise clients to report yellowing of the skin, pain or swelling of joints, loss
of appetite, or malaise immediately.
o Advise clients to avoid using alcohol while taking pyrazinamide.
RESPIRATORY DISORDERS: Tuberculosis: Medications – Ethambutol
• Ethambutol, commonly referred to as EMB, is a bacteriostatic and works by suppressing RNA synthesis, subsequently inhibiting protein synthesis.
• Nursing considerations
o Obtain baseline visual acuity tests.
o Determine color discrimination ability.
• Client education
o Instruct clients to report changes in vision immediately.
RESPIRATORY DISORDERS: Tuberculosis: Medications – Streptomycin
• Streptomycin is an aminoglycoside antibiotic. It potentiates the efficacy of macrophages during phagocytosis. It is administered either 1M or IV.
• Nursing considerations
o Recognize that due to its high level of toxicity, this medication should only be used in clients who have multi-drug resistance TB.
o Monitor hearing function to detect ototoxicity.
o Report significant changes in urine output and renal function studies.
o Administer 1M or assist with intermittent IV bolus administration.
• Client education
o Advise clients to consume at least 2 to 3 L of fluid from food and beverage sources daily.
o Advise clients to notify the provider if hearing declines.
RESPIRATORY DISORDERS: Tuberculosis: Interdisciplinary Care
o Request a referral for social services if clients need assistance in obtaining prescribed medications.
o Request a referral to a community clinic as necessary for follow-up appointments to monitor medication regimen and status of disease.
o Request a referral to a nutritionist for specialized needs.
RESPIRATORY DISORDERS: Tuberculosis: Care After Discharge
o Client education
• Inform family members of the need to be tested for TB.
• Educate clients to continue medication therapy for its full duration of 6 to 12 months. Emphasize that failure to take the medications may lead to a resistant strain of TB.
• Instruct clients to continue with follow-up care for 1 full year.
• Inform clients that sputum samples are needed every 2 to 4 weeks to monitor therapy effectiveness. Clients are no longer considered infectious after three negative sputum cultures.
• Encourage proper hand hygiene.
• Inform clients that contaminated tissues should be disposed of in plastic bags.
• Advise clients with active TB to wear masks when in public places.
o Client outcomes
• The client will adhere with the medication regimen.
• The client’s sputum will test negative for TB.
RESPIRATORY DISORDERS: Tuberculosis: Complications
• Miliary TB
o The organism invades the blood stream and can spread to multiple body organs with complications including:
• Headaches, neck stiffness, and drowsiness (can be life-threatening)
• Pericarditis
o Dyspnea, swollen neck veins, Pleuritic pain, and hypotension due to an accumulation of fluid in pericardial sac that inhibits the heart’s ability to pump effectively
o Nursing actions
• Treatment is the same as for pulmonary TB.
RESPIRATORY DISORDERS: Respiratory Cancers
Cancers of the respiratory system include laryngeal cancer and lung cancer. Exposure to smoke, both first and secondhand, is a major risk factor. Treatment includes surgery, radiation and/or chemotherapy.
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER
Men are three times more likely to be affected than women, and most cancers occur after 60 years of age.
• Most laryngeal cancers are slow-growing squamous cell carcinomas.
• Treatment includes laryngectomy, radiation, and/or chemotherapy.
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Risk Factors
o Tobacco and alcohol use are the primary risk factors. Their effects are synergistic when used in combination.
o Poor oral hygiene
o Chronic exposure to harmful chemicals (asbestos, metals, wood, paint fumes, tar products) also increases risk.
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Subjective Data
– Persistent or recurrent hoarseness or sore throat
– Lump in throat, mouth, or neck
– Dysphagia
– Persistent, unilateral ear pain
– Weight loss and anorexia
– Foul breath
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Objective Data – Physical Assessment Findings
– Hard, immobile lymph nodes in the neck (if metastasis has occurred)
– Hoarse, raspy voice
– Dyspnea (if tumor is in an advanced stage)
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Laboratory Tests
– Tumor mapping may be done by taking multiple biopsy samples
– Mapping verifies where the tumor is located, its margin, and type
– Staging is done using this information
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Diagnostic Procedures
– X-rays of skull, sinuses, neck and chest; CT scan; magnetic resonance imaging (MRI) scan, single photon emissions computed tomography and positron emissions tomography scans:
These help to determine the extent and exact location of the tumor and level of soft tissue invasion
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Diagnostic Procedures – Indirect laryngoscopy
* An indirect laryngoscopy is initially done to see if the tumor can be visualized. Clients are awake and a topical anesthetic is applied to the tongue and throat. Visualization is done using a laryngeal mirror or fiberoptic laryngoscope
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Diagnostic Procedures – Direct laryngoscopy
Used to visualize the tumor more closely and to obtain biopsy, which will definitively determine cell type and staging
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Diagnostic Procedures – Direct and Indirect laryngoscopy – Nursing Actions
1) Prepare clients for the procedure as appropriate (informed consent NPO)
2) Monitor clients and maintain clients safety following the procedure (vital signs, return of gag reflex). A small amount of bloody sputum is normal.
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Diagnostic Procedures – Direct and Indirect laryngoscopy – Client Education
Inform clients that after the topical anesthetic is applied, they may feel like they cannot swallow. Encourage clients to relax and spit out secretions if they cannot be swallowed.
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Diagnostic Procedures : Nursing Care – Maintain a patent airway
– Suction the client’s mouth, throat, and airway as needed. Use aseptic technique when suctioning the airway.
– Position clients upright to facilitate ventilation.
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Nursing Care – Administer medications as prescribed
– Crush pills to aid in swallowing
– Obtain elixirs when possible
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Nursing Care – Provide pain relief
– Administer analgesics as prescribed
– Consider alternative/adjunctive pain relief methods, such as humidifier, cough and throat lozenges and salt water or antiseptic/anesthetic gargles or throat sprays
– Provide oral care
– Provide emotional support
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Interdisciplinary care
– Request referral for speech therapy to discuss communication options.
– Suggest clients and their families attend a support group
– Request a referral for social services if outpatient radiation or chemotherapy is ordered.
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Surgical Interventions – Laryngectomy
1. May be a partial (removal of one or part of one vocal cord) or total (removal of both vocal cords)
2. Temporary tracheostomies may be established for clients who require only a partial laryngectomy. Permanent tracheal stomas are created for clients who have undergone total laryngectomies
3. A laryngectomy tube is inserted into the stoma immediately after the surgery. This prevents contractures from forming while the stoma is healing. Care is the same as caring for any other type of tracheostomy tube.
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Surgical Interventions – Laryngectomy – Preoperative nursing care
• provide preoperative teaching.
• Determine the preferred alternate form of communication (dry-erase board, pen and paper, alphabet board, picture board).
Inform clients about care of the airway, including tracheostomy care
and suctioning techniques.
• Discuss pain control methods that will be used postoperatively.
• Determine the client’s anxiety level and provide psychological support.
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Surgical Interventions – Laryngectomy – Postoperative nursing care
• Elevate the head of the bed.
• Monitor airway patency, vital signs and signs of bleeding.
• Provide frequent suctioning, but suction gently to prevent trauma to fragile tissue. Allow clients to perform oral suctioning.
• Place the call light within easy reach of clients.
• Monitor the client’s pain level and administer analgesics as prescribed.
• Cleanse and dress wounds as prescribed.
• Initiate nutritional intake as ordered. Nasogastric feedings are usually provided for the first few days until the surgical site has had a chance to heal.
• If a nodal neck dissection (“radical neck”) is done, monitor
eleventh cranial nerve damage, which may be evident as shoulder
drop.
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Surgical Interventions – Laryngectomy – Client Education
* Inform clients undergoing total laryngectomies that they will lose their natural voice.
* Tracheoesophageal fistula, esophageal speech, and electrolarynx devices are methods of speech communication that may be explored and developed following a total laryngectomy. These will allow clients to speak, but the quality of the client’s speech will always sound different.
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Surgical Interventions – Cordectomy or hemilaryngectomy (excision of one vocal cord) may be performed: Nursing Actions
1. An EPIGLOTTIDECTOMY (excision of epiglottis) involves the removal of the epiglottis, leaving the trachea open to swallowed fluids.
2. If clients had all or part of the epiglottis removed, reinforce to clients how to swallow without aspirating. Instruct clients to tuck the chin under when swallowing to prevent aspiration. Arching the tongue in the back of the mouth when swallowing may also be effective
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Surgical Interventions – Care after discharge
Client education:
– Instruct clients about the importance of smoking cessation if applicable. Provide nicotine replacement as prescribed.
– Instruct clients about appropriate techniques for stoma care and suctioning.
Instruct clients to:
o Use saline and cotton-tipped swabs to cleanse the stoma.
o Use a humidifier and/or saline atomizer to moisten the environment and stoma frequently during the day.
o Wear a buttoned cotton shirt or a stoma covering (crocheted bib, scarf or bandana) to keep dust and other particles out of the lungs.
o Wear a shower shield over the stoma when taking a shower.
o Report any signs of incisional or lung infection (fever, purulent drainage, redness, four odor, swelling).
o Consume a diet high in protein and calories.
o Avoid water sports. All other activities are allowed, but lifting may be more difficult because clients will be unable to perform the Valsalva maneuver with an open airway.
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Surgical Interventions – Client Outcomes
o The client will maintain a patent airway.
o The client will be able to swallow food and fluids without choking.
o The client will relearn how to speak using an alternate method of vocalization.
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Surgical Interventions – Complications – Airway Obstruction
o Following a laryngectomy, clients may have copious amounts of secretions. If secretions are not removed, mucous plugs may form and can occlude a client’s airway.
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Surgical Interventions – Complications – Airway Obstruction – Nursing actions
• Monitor respiratory status (Sa02 , breath sounds).
• Maintain humidity in the form of aerosolized oxygen or room air. Supplement with a saline atomizer as needed to keep secretions thin.
• Suction clients when needed and be sure to oxygenate prior to suctioning.
• Encourage deep breathing and coughing to aid in secretion removal.
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Surgical Interventions – Complications – Aspiration
o Clients who have had one vocal cord or the epiglottis removed are at an increased risk for aspiration.
o Aspiration may lead to the development of pneumonia.
o Clients who have had total laryngectomies (removal of both vocal cords) will not be able to aspirate due to the surgical separation of the trachea from the esophagus.
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Surgical Interventions – Complications – Aspiration – Nursing Actions
• Maintain clients in an upright position. Have clients duck their chin down when swallowing.
• Use thickened liquids.
• Cut food into small pieces, and instruct clients to chew well before swallowing. Mechanical soft/pureed diets may be better tolerated than full liquid or soft diets.
• Provide foods that can be formed into a bolus before swallowing (meats, bread).
• Notify the provider if aspiration is suspected. Place clients on NPO status until swallowing ability can be determined
RESPIRATORY DISORDERS: Respiratory Cancers: LARYNGEAL CANCER : Surgical Interventions – Complications – Aspiration – Client Education
• Have clients follow previously described methods of swallowing.
• Instruct clients to notify the provider if symptoms of aspiration or pneumonia develop (fever, shortness of breath, fatigue).
RESPIRATORY DISORDERS: Respiratory Cancers: LUNG CANCER – Overview
• Lung cancer most commonly occurs between the ages of 45 and 70.
• Prognosis of lung cancer is poor because it is often diagnosed in an advanced stage, when metastasis has occurred. Palliative care or treatment geared toward relieving symptoms is often the focus at the advanced stage.
• Bronchogenic carcinomas (arising from the bronchial epithelium) account for 90% of primary lung cancers.
RESPIRATORY DISORDERS: LUNG CANCER – Histologic cell types
• Histologic cell type determines lung cancer classification. Categories include:
o Non-small cell lung cancer (NSCLC)
• Most lung cancers are from this category.
• They include squamous, adeno, and large cell carcinomas.
o Small cell lung cancer (SCLC)
• Fast-growing
• Almost always associated with a history of cigarette smoking
RESPIRATORY DISORDERS: LUNG CANCER – Staging
• Staging of lung cancer is defined with the TMN system.
o T = Tumor
o N = Nodes
o M = Metastasis
RESPIRATORY DISORDERS: LUNG CANCER – Chemotherapy
Chemotherapy is the primary choice of treatment for lung cancers. It is often used in combination with radiation and/or surgery.
RESPIRATORY DISORDERS: LUNG CANCER – Risk Factors
o Cigarette smoking (both first and secondhand smoke)
o Radiation exposure
o Chronic exposure to inhaled environmental irritants (air pollution, asbestos, other talc dusts)
o Older adult clients have decreased pulmonary reserves due to normal lung changes, including decreased lung elasticity and thickening alveoli. This contributes to impaired gas exchange.
o Structural changes in the skeletal system decrease diaphragmatic expansion, thereby restricting ventilation.
RESPIRATORY DISORDERS: LUNG CANCER – Subjective Data
o Determine the client’s history regarding use of tobacco products (cigarettes, Cigars, pipes, and chewing tobacco) .
o Determine the pack-year history, which is the number of packs of Cigarettes smoked per day times the number of years smoked.
o Determine amount of exposure to secondhand smoke.
o Chronic cough
o Chronic dyspnea
RESPIRATORY DISORDERS: LUNG CANCER – Objective Data
Clients who have lung cancer may experience few symptoms early in the disease. Monitor for signs and symptoms that often appear late in the disease.
– Persistent cough, with or without hemoptysis (rust colored or blood tinged sputum)
– Hoarseness
– Dyspnea
– Unilateral wheezing (if airway is obstructed)
– Chest wall pain and chest wall masses
– Muffled heart sounds
– Fatigue, weight loss or anorexia
– Fever
– Clubbing of fingers
RESPIRATORY DISORDERS: LUNG CANCER – Diagnostic Procedures
– Chest X-ray: provides initial identification of the tumor
– Fiberoptic bronchoscopy:
* Can provide direct visibility of the tumor
* Allows for specimen and biopsy collection
RESPIRATORY DISORDERS: LUNG CANCER – Diagnostic Procedures – Nursing Procedures
Prepare clients for the procedure as appropriate (informed consent, NPO), monitor clients, and maintain client safety following the procedure (vital signs, return of gag reflex, sedatives, and supplemental oxygen as needed).
RESPIRATORY DISORDERS: LUNG CANCER – Diagnostic Procedures – Client Education
– Inform clients to have nothing to eat or drink after the procedure until the gag reflex returns.
– Inform clients that the throat may be sore after the procedure.
RESPIRATORY DISORDERS: LUNG CANCER – Diagnostic Procedures – Nursing Care- Nutritional Status
.Monitor nutritional status, weight loss, and anorexia.
* Promote adequate nutrition to provide needed calories for increased work of breathing and prevention of infection.
* Encourage intake of soft, high-calorie foods
* Encourage fluids to promote adequate hydration
RESPIRATORY DISORDERS: LUNG CANCER – Diagnostic Procedures – Nursing Care – Airway, Ventilation, Rest and Support
* Maintain a patent airway and suction as needed.
* Position clients in Fowler’ Position to maximize ventilation
* Determine the client’s physical limitations and provide periods of rest
* Provide emotional support to clients and their families. Encourage verbalization of feelings about the disease.
* Discuss the topic of death and dying with clients (if cancer is terminal) and encourage clients to express feelings.
RESPIRATORY DISORDERS: LUNG CANCER – Medication – Chemotherapy agents
Chemotherapy is the treatment of choice for lung cancer. The purpose of these medications is to destroy lung cancer cells, as well as healthy cells, to prevent DNA formation. Platinum compounds such as cisplatin (Platinol AG) are commonly used.
RESPIRATORY DISORDERS: LUNG CANCER – Medication – Chemotherapy agents – Nursing Considerations
o Watch clients for a decrease in immune function.
o Observe clients for nausea and vomiting.
o Monitor clients for fatigue and shortness of breath.
o Observe the client’s throat and mouth for aphthous (cold sore)
RESPIRATORY DISORDERS: LUNG CANCER – Medication – Chemotherapy agents – Client education
o Encourage clients to inform the nurse if nausea and vomiting persists
o Encourage clients to use frequent oral hygiene and use a soft-bristle toothbrush. Advise clients to avoid alcohol-based mouthwashes.
o Inform clients that hair loss (alopecia) occurs 7 to 10 days after treatment begins. Encourage clients to select a hairpiece before treatment starts.
RESPIRATORY DISORDERS: LUNG CANCER – Medication – Opioid agonists (pain medication)
o Morphine sulfate (MS Contin), oxycodone (OxyContin), and fentanyl (Duragesic) are opioid agents used to treat moderate to severe pain.
o Use cautiously with clients who have asthma or emphysema due to the risk of respiratory depression.
RESPIRATORY DISORDERS: LUNG CANCER – Medication – Opioid agonists (pain medication) – Nursing Considerations
o Check the client’s pain level every 4 hr.
o Remind clients receiving the fentanyl patch that the initial patch takes several hours to take effect. A short-acting pain medication will be administered for breakthrough pain.
o Watch clients for signs of respiratory depression, especially in older adult clients. If respirations are 12/min or less, stop the medication and notify the health care provider immediately.
o Observe clients for nausea and vomiting.
o Encourage fluid intake and activity related to a decrease in gastric motility.
o Administer bronchodilators and corticosteroids to help decrease
inflammation and to dry secretions
RESPIRATORY DISORDERS: LUNG CANCER – Medication – Opioid agonists (pain medication) – Client Education
o Encourage clients to suck on hard candies to help with dry mouth.
o Encourage clients to drink adequate fluids to help prevent constipation.
o Advise clients to increase fiber intake to help with constipation.
o Advise clients to notify the nurse if nausea and vomiting persists.
o Advise clients to avoid driving while taking the medication
RESPIRATORY DISORDERS: LUNG CANCER – Interdisciplinary Care
o Request a referral for respiratory services to assist with inhalers, breathing treatments, and suctioning for airway management.
o Request a referral for nutritional services to assist with weight loss related to medications or diagnosis.
o Request a referral for rehabilitation care if clients have prolonged weakness and need assistance with increasing the level of activity
o Recommend clients attend a support group.
o Request a referral for hospice care if indic4ed.
RESPIRATORY DISORDERS: LUNG CANCER – Therapeutic Procedures
Palliative care
o Includes medication, radiation and laser therapy; Thoracentesis; pain management; and hospice referral and care
RESPIRATORY DISORDERS: LUNG CANCER – Surgical Interventions
o The goal of surgery is to remove all tumor Cells, including involved lymph nodes.
• Often involves removal of a lung (pneumonectomy), lobe (lobectomy), segment (segmentectomy), or peripheral lung Tissue(wedge resection)
RESPIRATORY DISORDERS: LUNG CANCER – Surgical Interventions: Nursing Actions and Client Education
o Nursing actions
• Provide preoperative care.
o Client education
• Reinforce to clients about the surgical procedure and chest tube placement.
• Relieve client anxiety and encourage verbalization of feelings.
RESPIRATORY DISORDERS: LUNG CANCER – Surgical Interventions: Care after discharge
Client education
• Encourage clients to take rest periods as needed.
• Encourage clients to eat high-calorie foods to promote energy.
• Encourage clients to perform hand hygiene to prevent infection.
• Encourage clients b avoid crowded areas to reduce the risk of infection.
• Promote smoking cessation if clients smoke.
• Discuss the topic of death and dying (if the cancer is terminal) with clients, and encourage clients to express their feelings.
RESPIRATORY DISORDERS: LUNG CANCER – Surgical Interventions: Client Outcomes
o The client will be able to keep a patent airway.
o The client will remain free from pain.
o The client will remain free from infection.
o The client will be able to stay within 10% of ideal body weight.
RESPIRATORY DISORDERS: Respiratory Cancers: LUNG CANCER – Surgical Interventions: Complications – Superior Vena Cava Syndrome
o Superior vena cava syndrome results from pressure placed on the vena cava by a tumor. It is a medical emergency.
o Nursing actions
• Monitor for signs.
o Early signs include facial edema, edema in neck, nosebleeds, peripheral edema, and dyspnea.
o Late signs include mental status changes, cyanosis, hemorrhage, and hypotension.
• Notify the provider immediately.
• Radiation and stent placement provide temporary relief. Prepare clients for the procedure (informed consent, NPO if possible, client transport).
• Monitor the client’s status (vital signs, oxygenation) during and after the procedure.
RESPIRATORY DISORDERS: Respiratory Cancers: LUNG CANCER – Surgical Interventions: Complications – Metastasis
o Metastasis to the bones can cause bone pain and increase the risk of pathologic fractures.
o Metastasis to the central nervous system can lead to changes in mentation, lethargy, and bowel and bladder malfunction.
o Nursing Actions
– Encourage clients to ambulate carefully
– Reorient clients as needed
– Provide pain management
Clients with Respiratory Disorders: Respiratory Emergencies – Overview
Respiratory emergencies place clients at risk for decreased cardiac output. Respiratory emergencies include pulmonary embolism, spontaneous and tension pneumothorax, Hemothorax, acute respiratory failure and respiratory distress syndrome.
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM: Overview
• A pulmonary embolism (PE) occurs when a substance (solid, gaseous, or liquid) enters venous circulation and forms a blockage in the pulmonary vasculature.
• Emboli originating from deep vein thrombosis (DVT) are the most common cause. Tumors, bone marrow, amniotic fluid, and foreign matter can also become emboli.
• Increased hypoxia to pulmonary tissue and impaired blood flow can result from a large embolus. A PE is a medical emergency.
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM: Risk Factors, Part I
o Long-term immobility
o Oral contraceptive use and estrogen therapy
o Pregnancy
o Tobacco use
o Hypercoagulability (elevated platelet count)
o Obesity
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM: Risk Factors, Part II
o Surgery (especially orthopedic surgery of the lower extremities or pelvis)
o Heart failure or chronic atrial fibrillation
o Autoimmune hemolytic anemia (sickle cell)
o Long bone fractures
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM: Risk Factors, Advanced Age
o Older adult clients have decreased pulmonary reserves due to normal lung changes, including decreased lung elasticity and thickening alveoli. Older adult clients can decompensate more quickly.
o Certain pathological conditions and procedures that predispose clients to DVT formation (peripheral vascular disease, hypertension, hip and knee orthoplasty) are more prevalent in older adults
o Many older adult clients experience decreased physical activity levels, thus predisposing them to DVT formation and pulmonary emboli.
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM: Subjective Data
– anxiety
– feelings of impending doom
– pressure in chest
– pain upon inspiration
– dyspnea and air hunger
– cough
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM: Objective Data
Physical Assessment findings:
– pleurisy
– tachycardia
– hypotension
– tachypnea
– adventitious breath sounds (crackles) and cough
– heart murmur in S3 and S4
– diaphoresis
– decreased oxygen saturation levels (the expected reference range is 95% to 100%) low SaO2.
– petechiae (red dots under the skin) and cyanosis
– pleural effusion (fluid in the lungs)
– low grade fever
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM: Laboratory Tests – ABG Analysis
– PaCo2 levels are low (the expected reference range is 35 to 45 mm Hg) due to initial hyperventilation (respiratory alkalosis)
– As hypoxemia progresses, respiratory acidosis occurs.
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM: Laboratory Tests – CBC Analysis
D-dimer
– Is elevated above expected reference range in response to clot formation and release of fibrin degradation products (the expected reference range is 0.43 to 2.33 mcg / mL).
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM: Diagnostic procedures – Chest x-ray and computed tomography (CT) Scan
– These provide initial identification of a PE. A CT scan is most commonly used. A chest x-ray can show a large PE.
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM: Diagnostic procedures – Ventilation and perfusion scan (V/Q scan)
– images show the circulation of air and blood in the lungs and can detect a PE.
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM: Diagnostic procedures – Pulmonary Angiography
– This is the most thorough test to detect a PE, but it is invasive and costly. A catheter is inserted into the vena cava to visually see a PE.
– Pulmonary angiography is a higher risk procedure than a V/Q scan.
– Nursing actions:
* Verify that informed consent has been obtained
* Monitor that client’s status (vital signs, SaO2, anxiety, bleeding with angiography) after the procedure.
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM: Nursing Care
* Administer oxygen therapy as prescribed to relieve hypoxemia and dyspnea (position clients to maximize ventilation high Fowler’s = 90%)
* Monitor clients receiving IV fluids
* Administer medications as prescribed
* Provide emotional support and comfort to control client anxiety
* Monitor changes in level of consciousness and mental status.
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM: Medication – Anticoagulants
Enoxaparin (Lovenox), heparin and warfarin (Coumadin)
– Anticoagulants are used to prevent clots from getting larger or other clots from forming.
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM: Medication – Anticoagulants – NURSING CONSIDERATIONS
– Check for contraindications (active bleeding, peptic ulcer disease, history of stroke, recent trauma)
– Monitor bleeding times – Prothrombin time (PT) and international normalized ratio (INR) for warfarin, partial thromboplastin time (aPTT) for heparin, and complete blood count (CBC)
– Monitor for side effects of anticoagulants (thrombocytopenia, anemia, hemorrhage)
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM: Medication – Thrombolytic Therapy
Alteplase (Activase) and streptokinase (Streptase)
– Used to dissolve blood clots and restore a pulmonary blood flow
– Similar side effects and contraindications as anticoagulants
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM: Medication – Thrombolytic Therapy – Nursing Considerations
– Check for contraindications (known bleeding disorders, uncontrolled hypertension, active bleeding, peptic ulcer disease, history of stroke, recent trauma or surgery, pregnancy).
– Monitor for evidence of bleeding, thrombocytopenia, and anemia.
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM: Interdisciplinary Care
Request a referral for respiratory services for oxygen therapy, breathing treatments, and ABG’s
– If clients are homebound, set up home care services to perform weekly blood draws.
– Request a referral for social services to supply portable oxygen for clients who have severe dyspnea.
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM: Surgical Interventions – Embolectomy
– Surgical removal of embolus
– Nursing Actions
* Prepare clients for the procedure (NPO status, informed consent)
* Monitor postoperatively (vital signs, SaO2, incision drainage, pain management)
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM: Surgical Interventions – Vena cava filter
– Insertion of a filter in the vena cava to prevent further emboli from reaching the pulmonary vasculature
NURSING ACTIONS
– Prepare clients for the procedure (NPO status, informed consent)
– Monitor postoperatively (vital signs, SaO2, incision drainage, pain management)
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM: Care after discharge
Client education
– promote smoking cessation if clients smoke
– encourage clients to avoid long periods of immobility
– encourage physical activity such as walking
– encourage clients to wear compression stocking to promote circulation
– encourage clients to avoid crossing legs
– advise clients to adhere to a schedule for monitoring PT and INR, follow instructions regarding medication dosage adjustments (for clients on warfarin), and adhere with the need for weekly blood draws.
– remind clients of the increased risk for bruising and bleeding.
* instruct clients to avoid taking aspiring products, unless specified by health care provider.
* encourage clients to check mouth and skin daily for bleeding and bruising
*encourage clients to use electric shavers and soft-bristled toothbrushes.
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM – Client Outcomes
– The client will adhere with anticoagulant therapy
– The client will maintain adequate gas exchange
– The client will be free from severe bleeding incidences
– The client will be pain free
– The client will maintain an appropriate weight for height and body frame.
Clients with Respiratory Disorders: Respiratory Emergencies – PULMONARY EMBOLISM – Complications – Hemorrhage
Nursing Actions:
• Check for oozing, bleeding, or bruising from injection and surgical sites.
• Monitor for internal bleeding (measure abdominal girth and abdominal or flank pain).
• Monitor cardiovascular status (blood pressure, heart rate and rhythm).
• Monitor CBC (hemoglobin, hematocrit, platelets) and bleeding times (PT, aPTT, INR).
• Provide care for clients receiving IV fluids and blood products.
• Test stools, urine, and vomit for occult blood.
Clients with Respiratory Disorders: Respiratory Emergencies – PNEUMOTHORAX
A pneumothorax is the presence of air or gas in the pleural space that causes lung collapse.
• A tension pneumothorax occurs when air enters the pleural space during inspiration through a one-way valve and is not able to exit upon expiration. The trapped air causes pressure on the heart and the lung. As a result, the increase in pressure compresses blood
vessels and limits venous return, leading to a decrease in cardiac output. Death can be a result if not treated immediately.
o As a result of a tension pneumothorax, air and pressure continue to rise in the pleural cavity, which cause a mediastinal shift.
• A spontaneous pneumothorax can occur when there has been no trauma. A small bleb on the lung ruptures and air enters the pleural space.
Clients with Respiratory Disorders: Respiratory Emergencies – HEMOTHORAX
A hemothorax is an accumulation of blood in the pleural space.
Clients with Respiratory Disorders: Respiratory Emergencies – PNEUMOTHORAX and HEMOTHORAX – Risk Factors
o Blunt chest trauma
o Penetrating chest wounds
o Closed/occluded chest tube
o Older adult clients have decreased pulmonary reserves due to normal lung changes, including decreased lung elasticity and thickening alveoli.
o Older adult clients are more susceptible to infections.
Clients with Respiratory Disorders: Respiratory Emergencies – PNEUMOTHORAX and HEMOTHORAX – Subjective Data
o Anxiety
o Pleuritic pain
Clients with Respiratory Disorders: Respiratory Emergencies – PNEUMOTHORAX and HEMOTHORAX – Objective Data
Physical assessment findings
• Signs of respiratory distress (tachypnea, tachycardia, hypoxia, cyanosis, dyspnea, and use of accessory muscles)
• Tracheal deviation to the unaffected side (tension pneumothorax)
• Reduced or absent breath sounds on the affected side
• Asymmetrical chest wall movement
• Hyperresonance on percussion due to trapped air (pneumothorax)
• Dull percussion (hemothorax)
• Subcutaneous emphysema (air accumulating in subcutaneous tissue)
Clients with Respiratory Disorders: Respiratory Emergencies – PNEUMOTHORAX and HEMOTHORAX – Laboratory Tests
• ABGs – Hypoxemia (Pa02 less than 80 mm Hg)
Clients with Respiratory Disorders: Respiratory Emergencies – Diagnostic Test
Chest x-ray – Used to confirm pneumothorax or hemothorax
Clients with Respiratory Disorders: Respiratory Emergencies – Diagnostic Test – Thoracentesis
Thoracentesis may be used to confirm hemothorax. Thoracentesis is the surgical perforation of the chest wall and pleural
space with a large-bore needle
Clients with Respiratory Disorders: Respiratory Emergencies – Diagnostic Test – Thoracentesis – Nursing Actions
~ Verify that informed consent has been obtained.
~ Make sure clients understand the importance of remaining still during the procedure.
~ Assist with client positioning and specimen transport. Monitor the
client’s status (vital signs, Sa02 , injection site). Assist the client to the edge of the bed and to lean over a bedside table.
~ Inform clients they will feel discomfort when the local anesthetic
solution is injected, and when the needle is inserted into the lung,
some pressure may be felt, but no pain.
Clients with Respiratory Disorders: Respiratory Emergencies – Nursing Care
o Administer oxygen therapy.
o Check ABGs, SaO2, CBC, and chest x-ray results.
o Position clients to maximize ventilation (high-Fowler’s = 90%).
o Provide emotional support to clients and their families.
o Monitor chest tube drainage.
o Administer medications as prescribed.
o Encourage prompt medical attention when signs of infection occur.
Clients with Respiratory Disorders: Respiratory Emergencies – Medication – Benzodiazepines
• Lorazepam (Ativan) or midazolam (Versed) may be used to decrease the client’s anxiety.
• Nursing considerations
o Monitor the client’s vital signs (benzodiazepines may cause hypotension and respiratory distress).
• Client education
o Remind clients that medications may cause drowsiness.
Clients with Respiratory Disorders: Respiratory Emergencies – Medication – Opioid agonists
Morphine sulfate and fentanyl (Duragesic) are opioid agents used to treat moderate to severe pain.
Clients with Respiratory Disorders: Respiratory Emergencies – Medication – Opioid agonists – Nursing Considerations
o Use cautiously with clients who have asthma or emphysema, due to the risk
of respiratory depression.
o Check the client’s pain level every 4 hr.
o Remind clients who are receiving the fentanyl patch that the initial patch takes several hours to take effect. A short-acting pain medication will be administered for breakthrough pain.
o Watch clients, especially older adults, for signs of respiratory depression. If respirations are 12/min or less, stop the medication and notify the provider immediately.
o Monitor the client’s vital signs closely for signs of hypotension and
decreased respirations.
Clients with Respiratory Disorders: Respiratory Emergencies – Medication – Opioid agonists – Client Education
Remind clients that medication may cause drowsiness.
Clients with Respiratory Disorders: Respiratory Emergencies – Interdisciplinary Care
o Request a referral for respiratory services to assist with inhalers, breathing treatments,
suctioning for airway management and chest tube management.
o Request a referral for social services and home health care to assist with ADLs and home portable oxygen.
o Request a referral for rehabilitation care if clients have prolonged weakness and need assistance with an increasing level of activity
Clients with Respiratory Disorders: Respiratory Emergencies – Surgical Interventions – Chest tube insertion
• Chest tubes are inserted in the pleural space to drain fluid, blood, or air; reestablish a negative pressure; facilitate lung expansion; and restore normal intrapleural pressure.
Clients with Respiratory Disorders: Respiratory Emergencies – Surgical Interventions – Nursing actions
o Verify informed consent, gather supplies, monitor the client’s status (vital signs, Sa02, chest tube drainage), report abnormalities to the health care provider, and administer pain medications.
o Continually monitor vital signs and the client’s response to the procedure.
o Monitor chest tube placement and function.
Clients with Respiratory Disorders: Respiratory Emergencies – Client Education after Discharge
• Encourage clients to take rest periods as needed.
• Remind clients to use proper hand hygiene to prevent infection.
• Encourage immunizations for influenza as well as pneumonia.
• Remind clients that recovery from a pneumothorax/hemothorax may be lengthy.
• Encourage smoking cessation if clients currently smoke.
• Stress the importance of follow-up care and instruct clients to report the following to the provider:
0 Upper respiratory infection
0 Fever
0 Cough
0 Difficulty breathing
0 Sharp chest pain
Clients with Respiratory Disorders: Respiratory Emergencies -• Client Outcomes
o The client will maintain a patent airway.
o The client will maintain adequate gas exchange.
o The client will remain free from pain.
o The client will remain free from infection.
o The client will remain free from anxiety.
o The client will gradually increase exercise and activity to previous levels.
Clients with Respiratory Disorders: Respiratory Emergencies – Decreased Cardiac Output
o The amount of blood pumped by the heart is decreased.
o This is a result of intrathoracic pressures rising.
o Hypotension develops.
o Nursing actions
• Assist with care of clients receiving IV fluids and blood products.
• Monitor heart rate and rhythm.
• Monitor intake and output (chest tube drainage).
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Acute respiratory failure (ARF)
o ARF is caused by failure to adequately ventilate and/or oxygenate.
o Ventilatory failure is due to a mechanical abnormality of the lungs or chest wall, impaired muscle function (the diaphragm), or a malfunction in the respiratory control center of the brain.
o Oxygenation failure can result from a lack of perfusion to the pulmonary capillary bed (a pulmonary embolism) or a condition that alters the gas exchange medium (pulmonary edema, pneumonia).
o Both inadequate ventilation and oxygenation can occur in individuals with diseased lungs (asthma, emphysema). Diseased lung tissue can cause oxygenation failure and increased work of breathing, eventually resulting in respiratory muscle fatigue and ventilatory failure.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Acute respiratory distress syndrome (ARDS)
o ARDS is a state of acute respiratory failure with a high mortality rate.
o A systemic inflammatory response injures the alveolar-capillary membrane. It becomes permeable to large molecules, and the lung space is filled with fluid.
o A reduction in surfactant weakens the alveoli, which causes collapse or filling of fluid, leading to worsening edema.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Severe acute respiratory syndrome (SARS)
o SARS is the result of a viral infection from a mutated strain of the corona viruses, a group of viruses that also cause the common cold.
o The virus invades the pulmonary tissue, which leads to an inflammatory response.
o The virus is spread easily through airborne droplets from sneezing, coughing, or talking.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Risk Factors – ARF – Ventillatory Failure
• Pulmonary embolism and pneumothorax
• ARDS
• Asthma
• Pulmonary edema
• Fibrosis of lung tissue
• Neuromuscular disorders, (multiple sclerosis, Guillain-Barre syndrome), spinal cord injuries, and cerebrovascular accident that impair the client’s rate and depth of respiration
• Elevated intracranial pressure (closed-head injuries, cerebral edema, hemorrhagic stroke)
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Risk Factors – ARF -Oxygen Failure
• Pneumonia
• Hypoventilation
• Hypovolemic shock
• Pulmonary edema
• Low hemoglobin
• Low concentrations of oxygen (carbon monoxide poisoning, high altitude, smoke
inhalation
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Risk Factors – ARDS
• May result from localized lung damage or from the effects of other systemic problems:
o Aspiration
o Pulmonary emboli (fat, amniotic fluid)
o Pneumonia and other pulmonary infections
o Sepsis
o Near-drowning accident
o Trauma
o Damage to the CNS
o Smoke or toxic gas inhalation
o Drug ingestion/overdose (heroin, opioids, salicylates)
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Risk Factors – SARS
• Exposure to an infected individual
• Immunocompromised individuals (chemotherapy, AIDS)
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE –
• Shortness of breath
• Dyspnea with or without exertion
• Orthopnea (difficulty breathing while laying flat)
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Objective data
• Physical assessment findings
o Dyspnea
o Rapid, shallow breathing
o Cyanotic, mottled, dusky skin
o Tachycardia
o Hypotension
o Substernal or suprasternal retractions
o Decreased SaO2 (less than 90%), may be despite administration of 100% oxygen
o Adventitious breath sounds (wheezing, rales)
o Cardiac arrhythmias
o Confusion
o Lethargy
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Laboratory Tests
• ABG sample
• Room air, PaO2 less than 60 mm Hg, SaO2 less than 90%
• PaCO2 greater than 50 mm Hg and pH less than 7.30 (hypoxemia, hypercarbia)
• Sputum culture (used to rule out or diagnose an infection)
• CBC (elevated WBC count may indicate infection or inflammation)
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Diagnostic Procedures – Chest X-ray
Results may include:
~ Pulmonary edema (ARF, ARDS) Cardiomegaly (ARF)
~ Diffuse infiltrates and white-out or ground-glass appearance (ARDS) Infiltrates (SARS)
o Nursing actions
~ Assist with client positioning before and after the x-ray.
~ Interpret and communicate the results to the appropriate personnel in a timely manner.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Diagnostic Procedures – Electrocardiogram (ECG)
Used to rule out cardiac involvement
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Nursing Care, Part I
o Maintain a patent airway and monitor respiratory status every hour as needed.
o Continually monitor vital signs, including Sa02•
o Suction clients as needed. Oxygenate before suctioning secretions to prevent further hypoxemia.
o Observe and document sputum color, amount, and consistency.
o Mechanical ventilation is often required. Use positive-end expiratory pressure (PEEP) to prevent alveolar collapse during expiration. Follow facility protocol for monitoring and documenting ventilator settings.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Nursing Care, Part II
o Monitor for pneumothorax (a high PEEP may cause the lungs to collapse).
o Obtain ABGs as prescribed and following each ventilator setting adjustment.
o Maintain continuous ECG monitoring for changes that may indicate increased hypoxemia, especially when repositioning and applying suction.
o Position clients to facilitate ventilation and perfusion.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Nursing Care, Part III
o Prevent infection
• Perform frequent hand hygiene.
• Use appropriate suctioning technique.
• Provide oral care every 2 hr and as needed.
• Wear protective clothing (gown, gloves, mask) when appropriate.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Nursing Care, Part IV
Promote Nutrition
– Monitor bowel sounds and elimination patterns
– Obtain daily weights
– Record urine output
– Administer enteral feedings as prescribed.
– Elevate the head of the bed 30 ro 45 degrees
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Nursing Care, Part V
Provide emotional support to clients and their families
– encourage verbalization of feelings
– provide alternative communication means (dry-erase board, pen and paper)
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Medication: Benzodiazepines – Lorazepam (Ativan), Midazolam (Versed) – Actions
Reduce anxiety and resistance to ventilation and decreases oxygen consumption.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Medication: Benzodiazepines – Lorazepam (Ativan) – Nursing considerations
– Monitor respirations on clients who are not ventilated
– Monitor blood pressure and SaO2
– use cautiously in conjunction with opioid narcotiacs
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Medication: General Anesthesia: Propofol (Diprivan) – Actions
– Used to induce and maintain anesthesia
– May be used to sedate clients who are to be placed on mechanical ventilation
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Medication: General Anesthesia: Propofol (Diprivan) – Nursing Considerations
– Contraindicated for clients with hyperlipidemia and egg allergies
– Monitor clients who are intubated and receiving mechanical ventilation.
– Monitor ECG, blood pressure, and sedation levels.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Medication: Opioid analgesics: Morphine Sulfate, Fentanyl citrate (Submlimaze) – Actions
– Provides Pain Management
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Medication: Opioid analgesics: Morphine Sulfate, Fentanyl citrate (Submlimaze) – Nursing Considerations
– Monitor respirations on clients who are not ventilated
– Monitor blood pressure, heart rate, and SaO2
– Monitor ABGs (hypercapnia can result from depressed respiration)
– Use cautiously in conjunction with hypnotic sedatives
– Check the client’s pain level and response to medication
– Document’s client’s pain level
– Have naloxone hydrocholoride (Narcan) and resuscitation equipment available for severe respiratory depression in clients who are not receiving ventilation.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Medication: Neuromuscular blocking agents: Vecuronium (Norcuron) – Actions
– Facilitate ventilation and decrease oxygen consumption
– Often used with painful ventilatory modes (inverse ration ventilation and PEEP)
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Medication: Neuromuscular blocking agents: Vecuronium (Norcuron) – Nursing Considerations
– Given only to clients that are intubated and ventilated
– Monitor ECG, blood pressure and muscle strength
– Give pain medication and sedatives with neuromuscular blocking agents
– Neuromuscular blocking agents do not sedate or relieve pain (clients may be awake and frightened)
– Have neostigmine methylsulfate (Prostigmin) and atropine sulfate (Atropair) available to reverse the effects of the neuromuscular blocking agent
– Have resuscitation equipment available.
– Reassure clients that paralysis is medication-induced
– Explain all procedures to clients.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Medication: Corticosteroids: Cortisone Acetate (Cortistan), Methylprednisolone sodium succinate (Solu-medrol), Dexamethasone sodium phosphate (Decadron) – Actions
– Reduce WBC migration, decrease inflammation, and help stabilize the alveolar-capillary membrane during ARDS
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Medication: Corticosteroids: Cortisone Acetate (Cortistan), Methylprednisolone sodium succinate (Solu-medrol), Dexamethasone sodium phosphate (Decadron) – Nursing Considerations
– Discontinue the medication gradually.
– Administer with an anti-ulcer medication to prevent peptic ulcer formation
– Monitor weight and blood pressure
– Monitor glucose and electrolytes
– Advise clients to take oral doses with food and avoid stopping the medication suddenly
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Medication: Antibiotics sensitive to cultured organisms – Vancomycin – Actions
Treats identified organisms
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Medication: Antibiotics sensitive to cultured organisms – Vancomycin – Nursing Considerations
– Culture sputum prior to administration of first dose
– Monitor for a hypersensitivity reaction
– Advise client to take oral doses with food and finish the prescribed dose.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Interdisciplinary care – Respiratory Therapy
– Typically manages the ventilator, adjusts settings, and provides chest physical therapy to improve ventilation and chest expansion
– May also suction the endotracheal tube and administer inhalation medications, such as bronchodilators
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Interdisciplinary care – Physical Therapy
Indicated for extended ventilatory support and rehabilitation
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Interdisciplinary care – Nutritional therapy
• Enteral or parenteral feeding
• Nutritional support following extubation
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Interdisciplinary care – Therapeutic Procedures – Intubation and mechanical ventilation – Nursing actions
• Artificial airway insertion with mechanical ventilation
o Monitor ECG, SaO2′ breath sounds, and color.
o Sedate as needed.
o Provide reassurance to calm clients.
o Have suction equipment, manual resuscitation bag, and facemask available at all times.
o Suction secretions as needed.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Interdisciplinary care – Therapeutic Procedures – Intubation and mechanical ventilation – Nursing actions – Preintubation
~ Oxygenate with 100% oxygen.
~ Assist ventilation with manual resuscitation bag and facemask.
~ Have emergency resuscitation equipment readily available.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Interdisciplinary care – Therapeutic Procedures – Intubation and mechanical ventilation – Nursing actions – Postintubation
~ Check bilateral breath sounds, symmetrical chest movement, and chest x-ray to confirm placement of the endotracheal tube.
~ Secure the endotracheal tube per institutional guidelines.
~ Periodically check the balloon cuff for air leaks.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Interdisciplinary care – Therapeutic Procedures – Intubation and mechanical ventilation – Nursing actions – PEEP
~ Positive pressure is applied at the end of expiration to keep the alveoli expanded.
~ PEEP is added to the ventilator setting to increase oxygenation and improve lung expansion.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Interdisciplinary care – Therapeutic Procedures – Intubation and mechanical ventilation – Client Education
o Explain all procedures to clients.
o Reassure and calm clients.
o Explain to clients and their families that clients will be unable to speak while the endotracheal tube is in place.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Interdisciplinary care – Therapeutic Procedures – Kinetic Therapy
• A special kinetic bed that rotates laterally and alters client positioning to reduce
atelectasis and improve ventilation.
• Nursing actions
– Begin slowly and gradually increase the degree of rotation as tolerated.
– Monitor ECG, Sa02, breath sounds, and blood pressure.
– Stop rotation if clients become distressed.
– Provide routine skin care to prevent breakdown.
– Sedate as needed.
• Client education
– Explain all procedures to clients.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Interdisciplinary care – Client Outcomes
o The client will be able to breathe independently with no respiratory assistance.
o The client will be able to maintain an Sa02 greater than 90% on room air.
o The client will be free of infection.
o The client will maintain optimal physical and mental functioning.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Complications – Aspiration Pneumonia
• Nursing actions
– Check the cuff on the endotracheal tube for leaks.
– Check suction contents for gastric secretions.
– Verify NG tube placement
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Complications – Infection
Nursing actions
– Prevent infection by using proper hand hygiene and suctioning technique.
– Monitor color, amount, and consistency of secretions.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Complications – Blocked endotracheal tube
• The high-pressure alarm on the ventilator may indicate a blocked endotracheal tube.
• Nursing Actions
– Suction secretions to relieve a mucous plug or insert an oral airway to prevent biting on the tube.
Clients with Respiratory Disorders: Respiratory Emergencies – RESPIRATORY FAILURE – Complications – Immobilization
• Can result in muscle atrophy, pneumonia, and pressure sores
• Nursing Actions
– Reposition and suction every 2 hr.
– Provide routine skin care.
– Implement range-of-motion exercises to prevent muscle atrophy.

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