Nursing Management of Patients with Respiratory Disorders

1. Nursing Management of Patients with Respiratory Disorders NURS 2140 Winter Quarter 2012 Teresa M. Champion, RN MSN

2. ASSESSMENT OF PATIENTS WITH RESPIRATORY DISORDERS

3. Anatomy Physiology of Pulmonary System • Ventilation – movement of air in and out of lungs • Respiration – consists of diffusion of oxygen across alveolar-capillary membrane into pulmonary circulation and release of carbon dioxide molecules across the alveolar- capillary membrane through the airways out into the environment

4. Exchange of Gases during Respiration • Respiration Perfusion – the exchange of O2 and CO2 across the alveolar membrane • Alveoli – place in lungs where exchange occurs and must be adequately expanded by air to have adequate contact with hemoglobin • If alveoli are expanded adequately but unable to exchange due to edema or secretions – a ventilation(V)/perfusion(Q) mismatch occurs • If alveoli are not expanded adequately despite blood flow – Ventilation (V) and Perfusion (Q) mismatch will also occur

5. Mechanisms of Respiration • Ventilation – dependent on neuromuscular and musculoskeletal integrity • CNS – medulla and Pons respond to changes to carbon dioxide and oxygen levels in the blood by increasing or decreasing rate and depth of respiration • Musculoskeletal – assist and influence respiration - intercostal muscles, diaphragm, abdominal muscles, thoracic muscles (scalene, sternomastoid and trapezius)

6. Inspiration and Expiration • Influenced by intrapleural pressures • When the pressure of air in the lungs reaches capacity during inspiration, expiration begins • Inspiration is active • Expiration is passive • Movement of air in one breath is the tidal volume • Movement of air over one minute is minute ventilation • Normal tidal volume at rest is ~500ml, but can increase if more is demanded by the body (i.e. exercise and stress)

7. Collection of Patient Data • History • Biographic and demographic data • Chief complaint - dyspnea • Past medical history, allergies • Family history • Risk factors • Social history, Cultures • Medications • Nutrition • Travel and Areas of Residence

8. PHYSICAL EXAMINATION • Inspection • General Appearance • Mentation • Rate, Depth and Rhythm of Respirations • Tachypenea, Bradypnea, Orthopnea, Apnea, Hyperpnea • Thoracic Size and Shape • Thoracic Expansion and Symmetry • Use of Accessory Muscles • Color and Appearance of Skin and Extremities • Pallor • Cyanosis • Neck Inspection – Tracheal Deviation

10. ABNORMAL BREATHING PATTERNS • Cheyenne Stokes • Breaths are deep than become shallow followed by periods of apnea • Causes: severe brain pathology - brain stem herniation, Increased ICP, compression on Brain Stem • Kussmal’s • Breaths are deep, rapid and labored • Rates are >20 bpm • Causes: metabolic acidosis, renal failure, diabetic ketoacidosis

11. PHYSICAL EXAMINATION • Palpatation of Skin and Extremities • Edema – Caused by Pulmonary HTN • 8mm – 4+, 6mm – 3+, 4mm – 2+, 2 mm – 1+ • Skin Temperature & Moisture • warm moist skin r/t increased effort of breathing, possible fever from pulmonary infection • Dry skin-moisture lost from increased respirations • Clinical Reference Points – landmarks • Trachea, nipple line, sternum, intercostals, axillary line, midaxillary line, midclavicular line • Chest Excursion – should be equal and up to 5-10 cm • Tactile Fremitus – palpations of vibration in thorax • Tenderness • Crepitus – also called “subcutaneous emphysema – air trapped under the subcutaneous tissue

13. PHYSICAL EXAMINATION • Auscultation of the lungs – 4 types of breath sounds • Tracheal Breath Sounds – • loud and high pitched – over the largest airway and are the loudest – length of time heard is equal during expiration and inspiration • Bronchial Breath Sounds – • loud and high pitch, harsh and less turbulent and lower in frequency than tracheal – Expiration is heard longer than inspiration • Bronchovesicular – • Midway in pitch between Bronchial and Vesicular and are heard during inspiration and expiration • Vesicular • Soft and low pitched – heard longer during expiration, heard over most of thorax

16. ADVENTITIOUS BREATH SOUNDS • Crackles (Rales) • Indicate fluid, inflammation in airways – snapping sound when airways open – can be heard when airways close too but softer sounding than on inspiration • Intermittent or discontinuous. • Fine or Course • Wheezes • High-pitched musical sounds caused by inflammation in narrowing airways or bronchospasms • Rhonchi– indicate mucus secretions in the airways • Caused by air passing through mucus strands • Can be heard on inspiration and expiration • Continuous/ discontinuous (intermittent), • Mild/moderate/severe

17. ADVENTITIOUS BREATH SOUNDS • Stridor • Heard only during inspiration as air attempts to flow though an obstruction, high pitched crowing sound – needs immediate intervention • Pleural Friction Rub • Indicate inflamed pleural surfaces – easily heard on inspiration – hold breath to determine it is not pericardial

19. USING THE STEHASCOPE • Diaphragm - best for higher pitched sounds, like breath sounds and normal heart sounds. • Bell - is best for detecting lower pitch sounds, like some heart murmurs, and some bowel sounds. It is used for the detection of bruits, and for heart sounds (for a cardiac exam, listen with the diaphragm, and repeat with the bell).

20. PHYSICAL EXAMINATION • Percussion • Dull - Abnormal Finding • Heard over solid tissue, occurs when air is absent, can be heard over consolidation areas with pneumonia, pleural effusion, hemothorax, solid tumors • Dull thumping sound without vibration • Resonant – Normal Finding • heard over lung fields during inspiration while lungs are full of air • low pitched clear sounds – Normal Finding • Hyperresonant – Abnormal Finding • Very loud, lower pitched longer sound than resonance • Drum like sound with vibration • indicates hyperinflamation – emphysema, pneumothorax

21. PAIN • Pain in association with breathing may be related to Pulmonary Embolism, Pneumothorax, Pleural Disease, Pericarditis, Musculoskeletal Disease or Pneumonia • Sudden onset shortness of breath may be related to Pulmonary Embolism or pneumothorax • Pain during respiration may decrease tidal volumes • Pain management enables participation in rehabilitative activities and promotes deep breathing to prevent pneumonia and atelectasis • Use cough suppressants with caution

22. GERONTOLOGICAL CONSIDERATIONS • Aging decreases respiratory function • Osteoporosis – stooped posture, decreased rib expansion • Anterior to posterior diameter increases • Alveolar surface decreases • Decreased elasticity • Increased atelectisis • Lower arterial oxygen values – decreased exchange of O2/CO2 • Increase risk of pneumonia – Decreased tidal volumes, ineffective cough • Risk of aspiration may increase with aging • Aging may affect patient comfort needs during the examination

23. HEALTH PROMOTION • Smoking cessation • Decrease exposure to second-hand smoke • Hand Hygiene • Flu and Pneumonia Vaccines • Instruction and use of Personal Protective Equipment (PPE) especially in the workplace for workers exposed to allergens, mold, bird, bat and rat feces and other toxins like asbestos

24. STANDARD OF CARE • For patients with cardiac and respiratory illness, standard is: • Continuous or intermittent observation of the patient’s oxygen saturation (most cost effective) • End-tidal carbon dioxide levels (being used more, but is more costly but most accurate). • Monitoring Peak Flow results is utilized to trend treatment effectiveness in patients with asthma

25. RESPIRATORY MONITORING • Pulse Oximetry • Measures saturation of hemoglobin • May NOT be accurate with patients with low Hgb, hypovolemia and shock states • Nail polish, ambient light may interfere with reading • Wave forms should match pulse rate and should not be dampened

26. RESPIRATORY MONITORING • Peak Flow Meters • Evaluate air movement to determine severity of asthma exacerbation • Measure Peak Expiratory Flow Rate • Measurements are based on age and body size • Red Zone (Dangerous) – less than 50% of the normal value • Yellow Zone (caution) – Between 50% to 80% below normal value • Green Zone (Good) – meets 80% to 100% of normal value

27. RESPIRATORY MONITORING • Arterial Blood Gases • Determine Respiratory Acidosis and Alkalosis • PaO2 levels below 80mmHg and/or SaO2 <95% indicate hypoxemia • Cost $800 to $1500.00 per draw • Invasive procedure

28. RESPIRATORY MONITORING • Capnography • Measures exhaled carbon dioxide or End Tidal CO2 (ETCO2) • Small disposable capnographers are used to check ET Tube placement after intubation and/or continuous monitoring of tube placement • Capnography monitoring has been added to the 2010 – 2015 ACLS Guidelines for Compression Effectiveness. • Normal ETCO2 values are 35mmHg to 45mmHg. • ETCO2 values between 10-20mmHg indicate high quality compressions • ETCO2 less than 10mmHg – quality of chest compressions need improvement

29. MONITOR SHOWING ETCO2 WAVEFORM

30. RESPIRATORY PATHWAY DISORDERS • SLEEP APNEA • AIRWAY OBSTRUCTION • TRACHEOSTOMY

31. ANATOMY OF RESPIRATORY TRACT

32. SLEEP APNEA • Defined – a person stops breathing for more than 10 seconds, more that 20-30 times in an hour • 3 types – • Central • Brain fails to send signal to the breathing muscles to initiate respirations (less common) • Obstructive • Physical obstruction from tissues in upper airway • Combination of both or Mixed Sleep Apnea

33. RISK FOR SLEEP APNEA • Overweight/Obesity • High Blood Pressure • Decreased Airway Size – congestion, inflammation (allergies), anatomical abnormalities • Family History

34. MEDICAL MANAGEMENT FOR SLEEP APNEA • Weight loss • Avoid alcohol, tobacco and sleeping pills (sedatives) • Use side-lying positions when sleeping • Dental devises that move tongue or mandible forward • Continuous Positive Airway Pressure (CPAP) Machines • Surgical Interventions – UVPPP – resection of the uvula and soft palate, Tracheotomy • Focus is on airway patency

35. AIRWAY OBSTRUCTION • Potentially life threatening – requires immediate intervention • Types: foreign object, allergy, lesions, stenosis, swelling • Causes: • Viral and Bacterial Infections, fire or inhalation burns, allergic reactions (foods/medications/bee stings) • Infections after dental extractions • Laryngeal trauma-MVA, Strangulation or surgical procedures • Large tumors • Aspiration of foreign objects

36. Clinical Manifestations of Airway Obstruction • STRIDOR • Inability to speak (partial or complete) • Labored breathing and use of accessory muscles • Air Hunger (mild) • Cyanosis (severe)

37. Medical Management of Airway Obstruction • Diagnosis and treat the cause • Provide Oxygenation Support!! • Sit in upright position • Keep patient’s airway patent (if partial or mild obstructions get worse – need immediate intervention) • Secure and protect airway – Endotracheal Intubation, Cricothyroidotomy or tracheotomy – bag/mask ventilation will not work with obstruction!

38. Tracheotomy • Insertion of artificial airway in the trachea • Recommended for oral/nasal endotracheal intubations lasting longer than 1 – 2 weeks. (book says 7 – 10 days) • Usually is temporary to protect airway until underlying cause can be fixed or corrected

39. Tracheotomy • Incision is below the prominent thyroid cartilage (Adam’s Apple) and below the cricoid cartilage – between 2 – 3 OR 3 – 4 tracheal cartilages • A tube is placed and secured (Sutured) to keep the tracheal stoma open • The tube is also secured with ties • The tube remains in place until the tracheal stoma is well established and won’t close back up • A post tracheotomy kit is kept at bedside or on the nursing unit if accidental decannulation occurs • An Obturator is kept at bedside to prevent stoma closure if decannulation occurs until new tracheotomy tube can be put in immediately

41. TYPES OF TRACHEAL TUBES • Made of silicone, plastic, stainless steel or silver • With or without an inner cannula • With or with out a cuff • Mechanical ventilation requires cuffed tubes to seal the airway to maintain pressures for ventilation • Cuffed tracheal tubes decrease aspiration risk • Inner cannulas prevent tube obstructions from thick crusted secretions • Average adult size are 7 to 8 • Shiley or Bivona are most common

44. Assessment of New Tracheal Artificial Airway • Auscultation of the lungs • Monitoring Oxygenation saturations • Assessment of increased amount of blood in the sputum and around site • Subcutaneous emphysema (crepitis) around the neck • Respiratory distress • Patency of tracheal tube • Postoperative pulmonary edema (POPE)

45. Interventions following Tracheostomy • Encourage cough and deep breathing • Suction as necessary, but keep to a minimum • Provide supplemental oxygen • Pre-oxygenate with 100% Oxygen when suctioning • Hyperventilate (bag – suction) when necessary • Suction limited to 5-10 seconds with each pass • Insert catheter till patient starts to cough or meet slight resistance – do not use force

46. Tracheostomy Cares • Tracheotomy cares should be done every 8 to 12 hours with cleaning the inner cannula or changing the disposable cannula • Most medical institutions no longer use Hydrogen peroxide to clean around tracheostomy site (book says use half-strength) • Aseptic technique is used when cleaning the inner cannula (sterile gloves)

47. Laryngectomy • Trachea is sutured to the stoma • Oral airway is permanently bypassed • Patients lose the ability to speak because the vocal cords are bypassed permanently • Patient only breath out of their stoma • The esophagus still follows the normal pathway and patients can still eat normally

48. LOWER AIRWAY DISORDERS

49. Restrictive lung diseases (interstitial lung diseases) • Result in reduced lung volumes • Alteration in lung parenchyma (alveolar tissue w/ terminal bronchioles, respiratory bronchioles, alveolar ducts) • Disease of pleura, chest wall or neuromuscular apparatus • Characterized by reduced total lung capacity, vital capacity, or resting lung volume

50. Obstructive lung diseases • Common characteristic – chronic and recurring blockage of airways • Limit airflow through the airways and out of the lungs