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Respiratory N415

Respiratory N415

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Respiratory N415

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  1. RespiratoryN415 Linda Winn, RN, MSN Ed., BA Ed.

  2. Respiratory Assessment

  3. Resp Assessment • Breathing Pattern • I:E ratio • Kussmaul • Rate • Dyspnea • Orthopnea • PND – Paroxysmal nocturnal dyspnea • Cough and Sputum • Frequency • Dry / moist • Amount • Color • Thickness • Odor

  4. Assessment (Cont.) • Inspection • Symmetry • Skin color – lip color / finger clubbing • WOB – accessory muscles • Auscultation • Adventitious sounds • Chest pain • History • Diagnoses • Smoking • Quick, Focused Assessment

  5. Breath Sounds Link • Normal and Adventitious breath sounds http://faculty.etsu.edu/arnall/www/public_html/heartlung/breathsounds/contents.html

  6. Diagnostics & Labs

  7. Labs • H/H • Sputum Analysis • C&S • Gram Stain • Acid-Fast smear (AFB) • Cytology • ABG’s • O2 Sats

  8. Diagnostic Tests • CXR • CT Chest • MRI • V/Q Scan • Bronchoscopy http://www.nlm.nih.gov/medlineplus/tutorials/bronchoscopy/htm/_no_50_no_0.htm • Thoracentesis • PFTs – Pulmonary Function Tests • Spirometry

  9. COPD

  10. Chronic Obstructive Pulmonary Disease • Obstruction to expiratory air flow • 15 million Americans have COPD • 4th leading cause of death • Women approaching men in incidence and surpassed men in number of deaths

  11. COPD • 2 Types of COPD • Emphysema • Chronic Bronchitis (most common) • can have either or both • Asthma no longer considered a type of COPD

  12. Etiology smoking: 90% of people with COPD only15% of smokers get COPD smokers 10 x more likely to die from COPD environmental: Pollution Toxins second hand smoke develops slowly Common Signs and Symptoms Dyspnea and Wheezing Video Clip http://www.nlm.nih.gov/medlineplus/tutorials/copd/htm/_no_50_no_0.htm COPD

  13. Impact of Smoking

  14. COPD

  15. COPD video clips http://video.about.com/copd/COPD.htm (skip through the ads  )

  16. Emphysema - Pathophysiology • Abnormal permanent enlargement of the gas exchange airways with destruction of alveolar walls • bronchioles too narrow or collapse • slows air movement during exhalation & traps air in lungs • increases work of breathing •  surface area for gas exchange • Blebs, Bulla

  17. Chronic Bronchitis • Definition • chronic productive cough for 3 months in each of the last 2 years • Pathophysiology • hypertrophy of mucous secreting glands & chronic inflammation of small airways  excessive sputum production • impaired ciliary movement & excessive sputum can increase risk of infection • bronchial walls can become narrowed or obstructed • Thicker mucus

  18. Assessment Findings • Early • SOB • Dyspnea • Activity intolerance • Hypoxemia • Chronic cough with sputum • Prolonged expiration • Wheezing on forced expiration • Altered Breathing Techniques • Pursed-lip breathing • Tripod breathing position • Later • Hyperinflation of lungs  barrel chest • Diminished lung & heart sounds • Central cyanosis (chronic hypoxemia) • CO2 retention

  19. Asthma

  20. Asthma Videos http://www.mayoclinic.com/health/asthma/MM00001 http://www.nlm.nih.gov/medlineplus/tutorials/asthma/htm/_no_50_no_0.htm

  21. Asthma

  22. Exaggerated bronchoconstriction response to stimuli • Airways overreact to triggers causing narrowing • Chronic inflammatory disorder of airways • 1 in 20 Americans; 5000 deaths/year • Common triggers: • allergies: dust, mold, sulfites, dander • cold, dry air • exercise • stress

  23. Common Triggers • Allergens: dust, mold, sulfites, dander • Cold, dry air • Exercise • Stress • Environmental

  24. Assessment Findings • Wheezing after exposure to triggers, coughing, chest tightness • Rapid, shallow respirations, dyspnea,  or absent breath sounds, accessory muscle use • Postural changes to aid breathing • Activity intolerance • Anxiety • Severity of symptoms vary • Changes in peak expiratory flow rate

  25. In the Zone • Green Zone • PEFR  80% of baseline • no sx; meds may be  by MD • Yellow Zone • PEFR 50-80% baseline • may have Ø to mod sx • having attack or meds adjusted • Red Zone •  50% baseline • severe sx • medical alert; call MD

  26. Ineffective Airway Clearance Impaired Gas Exchange Ineffective Breathing Pattern Activity Intolerance Altered Nutrition Aspiration, risk for Pain Anxiety Fear High risk for infection Pneumonia Potential Nursing Diagnoses

  27. Monitor VS LOC lung sounds sputum amount and character Maintain airway Pursed-lip breathing cough routines positioning for max lung expansion Suctioning avoid cough suppressants unless cough frequent & non-productive Nursing Management

  28. Nursing Management • Monitor activity tolerance • help pt conserve energy • plan rest periods • O2 prn • Good oral hygiene • Decrease anxiety • remain with patient during anxious episodes, relaxation techniques, O2 prn • Nutrition • Hydration

  29. Collaborative Treatment • Immunizations • flu & pneumonia vaccinations • Bronchodilators • Inhaled steroids • Antibiotics • Oxygen therapy • Pulmonary Rehabilitation • Smoking Cessation

  30. Patient Education • Monitor color, amount, thickness of sputum • Self care: at-home meds & treatments; avoid triggers • Prevention • Pneumococcal vaccine, flu shot • Frequent oral hygiene • Encourage fluids • Environmental hazards • altitude, smog, allergies, smoke • Follow up medical care • American Lung Association • www.lungusa.org

  31. COPD – Cor Pulmonale • Long-term complication

  32. Respiratory RN Diagnoses • Impaired Gas Exchange • Ineffective Airway Clearance • Others

  33. Pulmonary Tuberculosis

  34. Tuberculosis • Incidence • Risk Factors • Mode of Transmission • Mycobacterium tuberculosis • Development of TB http://www.nhs.uk/Conditions/Tuberculosis/Pages/Introduction.aspx http://www.nlm.nih.gov/medlineplus/tutorials/tuberculosis/htm/_no_50_no_0.htm Text copy: http://www.nlm.nih.gov/medlineplus/tutorials/tuberculosis/id359106.pdf

  35. Diagnostic Tests • PPD • CXR • AFB • Bronchoscopy • WBC

  36. Assessment Findings • Classic Sx: • Weight Loss • Low-grade fever • Night sweats • Productive Cough

  37. Treatment • Medications • INH – Isoniazid • Rifampin (Rifadin) • Ethambutol (Myambutol) • Pyrazinamide (PZA) • Multi-drug approach • Not transmittable after 2-3 weeks of treatment

  38. Nursing Care • In-hospital Care • Negative pressure Room • Respiratory isolation • N-95 mask • Fit testing • Transporting Patient • Public Health Nurse • DOT

  39. O2 Levels PaO2SaO2 • Needs O2 <55 <88% • May be OK 40 75% Short-term With COPD • Critical <40 <75%

  40. ABG’s • Acid – Base Balance • Nursing Considerations in drawing ABG’s • Allen’s Test • Ice • Pressure

  41. ABG Normal Values • pH 7.35-7.45 • pCO2 35-45 • HCO3 22-26 • PaO2 80-100 mm Hg SaO2 >95%

  42. ABG Evaluation • Step 1 – pO2 • Step 2 – pH • Acidotic or Alkalotic? • Step 3 – pCO2 • Respiratory cause? • Step 4 – HCO3 • Metabolic cause? • Step 5 – Compensated or Uncompensated

  43. ABG examples • pH 7.39 • pO2 59 • pCO2 59 • HCO3 31 • Diagnosis? • What is this typical of?