Scope of practice

RN LPN/LVN UAP

 Clinical  Monitoring RN findings  Activities of daily

assessment  Reinforcing education living
 Initial client  Routine procedures (eg,  Hygiene
education catheterization)  Linen change
 Discharge  Most medication  Routine, stable vital
education administrations signs
 Clinical judgment  Ostomy care  Documenting
 Initiating blood  Tube patency & enteral input/output
transfusion feeding  Positioning
 Specific assessments

Rifapentine (Priftin)
a derivative of rifampin, is an antitubercular agent used with other drugs (eg, isoniazid) as a
combination therapy in active and latent tuberculosis infections. Both rifampin and rifapentine
reduce the efficacy of oral contraceptives by increasing their metabolism
notify the health care provider of any signs or symptoms of hepatotoxicity (eg, jaundice, fatigue,
weakness, nausea, anorexia), and expect red-orange-colored body secretions.

Asthma
Airways are chronically inflamed with varying degrees of airway obstruction that can be
exacerbated by exposure to triggering agents. Common asthma triggers include:
 Allergens: Dander (eg, cat, dog), dust mites, pollen
 Drugs: Beta blockers; nonsteroidal anti-inflammatory agents, including aspirin
 Environmental: Chemicals, sawdust, soaps/detergents
 Infectious: Upper respiratory infections
 Intrinsic: Emotional stress, gastrointestinal reflux disease
 Irritants: Aerosols/perfumes, cigarette smoke (including secondhand smoke),
dry/polluted air
Acute severe asthma exacerbations (status asthmaticus) occur when severe airway obstruction
and lung hyperinflation (air trapping) persist despite aggressive treatment with bronchodilators
and corticosteroid therapy.
Clinical manifestations indicating impending respiratory failure include:
 PaCO2 ≥45 mm Hg (6.0 kPa): Indicates hypercapnia and hypoventilation
resulting from fatigue and labored breathing. As initial tachypnea subsides, and
respiratory rate returns to normal, PaCO2 rises and respiratory acidosis develops
 PaO2 ≤60 mm Hg (8.0 kPa): Indicates hypoxemia resulting from increased work
of breathing, decreased gas exchange (hyperinflation and air trapping), and
inability of the lungs to meet the body's oxygen demand
 Paradoxical breathing (abnormal inward movement of the chest on inspiration
and outward movement on expiration): Indicates diaphragm muscle fatigue and
use of respiratory accessory muscles
 Mental status changes (restlessness, confusion, lethargy, drowsiness):
Sensitive indicators of hypoxemia and hypoxia
 Absence of wheezing and silent chest (no sound of air movement on
auscultation): Ominous signs indicating severe hyperinflation and air trapping in
the lungs
 Single-word dyspnea: Inability to speak >1 word before pausing to breathe due
to shortness of breath
Clients with respiratory failure have respiratory acidosis (low pH and elevated pCO2).

Montelukast (Singulair) is a leukotriene receptor blocker with both bronchodilator and anti-
inflammatory effects; it is used to prevent asthma attacks but is not recommended as an
emergency rescue drug in asthma.
A long-acting beta agonist (Salmeterol) is administered with an inhaled corticosteroid for long-
term control of moderate to severe asthma; it is not used as an emergency rescue drug in asthma.

Pharmacologic treatment for acute asthma includes the following:

1. Oxygen to maintain saturation >90%
2. High-dose inhaled short-acting beta agonist (albuterol or levalbuterol) and anticholinergic
agent (ipratropium) nebulizer treatments every 20 minutes
3. Systemic corticosteroids (Solu-Medrol) to control the underlying inflammation. These
will take some time to show an effect.
Clinical manifestations of an asthma exacerbation include:
 Accessory respiratory muscle use related to increased work of breathing and diaphragm
fatigue
 Chest tightness related to air trapping
 Cough from airway inflammation and increased mucus production
 Diminished breath sounds related to hyperinflation
 High-pitched expiratory wheezing caused by narrowing airways; wheezing may be heard
on both inspiration and expiration as asthma worsens
 Tachypnea related to inability to take a full, deep breath
 prolonged expiratory phase

Interventions to help reduce viscosity of mucus, facilitate secretion removal, and promote
comfort include the following:
 Increasing oral fluids to 2-3 L/day if not contraindicated prevents dehydration and keeps
secretions thin
 Cool mist humidifier increases room humidity of inspired air
  Guaifenesin (Robitussin) is an expectorant that reduces the viscosity of thick secretions
by increasing respiratory tract fluid; drinking a full glass of water after taking the
medication is recommended.
 Abdominal breathing with the huff, a forced expiratory cough technique, is effective in
mobilizing secretions into the large airways so that they can be expectorated
 Chest physiotherapy (postural drainage, percussion, vibration)
 Airway clearance handheld devices, which use the principle of positive expiratory
pressure to help loosen secretions when the client exhales through the mouthpiece

Montelukast (Singulair)
A leukotriene (chemical mediator of inflammation) inhibitor and is not used to treat acute
episodes. It is given orally in combination with beta agonists and corticosteroid inhalers (eg,
fluticasone, budesonide) to provide long-term asthma control.

Albuterol (Proventil)
Short-acting inhaled beta-2 agonist used to control airway obstruction caused by chronic
obstructive pulmonary disease, asthma, or bronchitis. It also is used to prevent exercise-induced
asthma. The therapeutic effect is relaxation of the smooth muscles of the airways, which results
in immediate bronchodilation. Bronchodilation decreases airway resistance, facilitates mucus
drainage (expectorates mucus plugs), decreases the work of breathing, and increases
oxygenation. As a result of these actions, the respiratory ratewill decrease and peak flow will
be increased (if tested).
side effects (not therapeutic effects): tremor (most frequent), tachycardia and palpitations,
restlessness, and hypokalemia, n/v. can be reduced with the use of a spacer or chamber device.

Fluticasone/salmeterol (Advair)
a combination drug containing a corticosteroid (fluticasone) and a bronchodilator
(salmeterol). Salmeterol is a long-acting inhaled β2-adrenergic agonist that promotes relaxation
of the bronchial smooth muscles over 12 hours. Fluticasone decreases inflammation. This
medication is used as part of the treatment plan for prevention and long-term control of
asthma but not for acute attacks.
Client instructions include:
 After inhalation, rinse the mouth with water without swallowing to reduce the risk of
oral/esophageal candidiasis
 Avoid smoking and using tobacco products
 Receive the pneumococcal and influenza vaccines if there is a risk for infection

Carbon monoxide poisoning

Carbon monoxide (CO) is a colorless, odorless gas produced by burning fuel (eg, oil, kerosene,
coal, wood) in a poorly ventilated setting. CO toxicity (poisoning) is most often associated with
smoke inhalation from structure fires, but is also generated by furnaces/hot water heaters fueled
by natural gas or oil, coal or wood stoves, fireplaces, and engine exhaust.
Clients with CO toxicity often have nonspecific symptoms, and the diagnosis can be missed. It is
important to assess for possible CO exposure to initiate appropriate emergency care and prevent
hypoxic neurologic impairment. To help identify elevated CO levels in the home, the nurse can
ask about the following:
 Similar symptoms in other family members, or an illness in an indoor pet that developed
at the same time
 Fuel-burning heating/cooking appliances; risk of CO toxicity increases in the fall and
winter due to increased used of heat sources in an enclosed space
The purpose of hemoglobin (Hgb) is to pick up oxygen in the lungs and deliver it to the
tissues. It must be able to pick up oxygen and release it in the right places.
Carbon monoxide (CO) has a much stronger bond to Hgb than oxygen does. Consequently, CO
displaces oxygen from Hgb, causing hypoxia that is not reflected by a pulse oximeter reading.
The conventional pulse oximeter is not effective in identifying hypoxia in CO poisoning;
diagnosis requires co-oximetry of a blood gas sample. The nurse's primary action is to administer
highly concentrated (100%) oxygen using a nonrebreather mask at 15 L/min in order to reverse
this displacement of oxygen.
A serum carboxyhemoglobin test is needed to confirm the diagnosis. Normal values are <5% in
nonsmokers and slightly higher (<10%) in smokers

COPD
Chronic obstructive pulmonary disease (COPD) generally refers to 2 conditions, emphysema and
chronic bronchitis. A combination of the 2 is common. It affects about 12 million people and is
the 3rd leading cause of death in the United States. It occurs most commonly in the seventh
decade of life. COPD is categorized by slowly progressive, persistent airflow obstruction that is
closely associated with chronic airway inflammation.
The major risk factor is tobacco smoke (eg, cigarette, pipe, cigar). Although the client quit
smoking cigarettes last year, he smoked a pack a day for 53 years. Working as a car mechanic for
40 years is a major risk factor because of prolonged exposure to carbon monoxide
fumes. Exposure to irritating chemicals, fumes, or vapors in the presence of cigarette smoking
increases the risk of developing COPD.
Some clients with COPD breathe in response to low arterial oxygen levels (hypoxemia). If they
receive more oxygen than they need to maintain an arterial saturation, the increased level can
decrease the drive to breathe. Therefore, supplemental oxygen should be administered in the
lowest concentration possible to maintain a pulse oxygen saturation of 90%-93% or a PaO2 of 60-
70 mm Hg.
Clients with COPD need to report any signs of infection (including change in their normal
sputum) as infection is a primary cause of exacerbation. Any client with COPD should have a
pneumococcal vaccine and an annual influenza virus vaccine.
An exacerbation of COPD is characterized by the acute worsening of a client's baseline
symptoms (dyspnea, cough, sputum color and production). NIPPV is often prescribed short-term
to support gas exchange in clients who have moderate to severe COPD exacerbations and acidosis
(pH <7.3) or hypercapnia (PaCO2 >45 mm Hg). NIPPV can prevent the need for tracheal
intubation and is administered until the underlying cause of the ventilatory failure is reversed with
pharmacologic therapy (corticosteroids, bronchodilators, antibiotics).
BIPAP involves the use of a mechanical device and facemask in a conscious client who is
breathing spontaneously. BIPAP delivers oxygen to the lungs and then removes carbon dioxide
(CO2). CO2 retention causes mental status changes. If the client becomes drowsy or confused, it
is likely that more CO2 is being retained than what BIPAP can remove; this should be reported to
the HCP. Arterial blood gas evaluation should be obtained to determine CO2 level and BIPAP
effectiveness. Altered mental status poses the greatest threat to a client's survival as it can
lead to decreased protective reflexes (gag, swallow, cough), periods of apnea, and airway
compromise

The most common causes of respiratory complications in the immediate postoperative

period include the following:
 Airway obstruction, which can be due to retained secretions or the tongue falling
backward against the soft palate in sedated clients. Suctioning and an artificial oral
airway can be used to prevent obstruction until the client becomes more responsive.
  Hypoxemia, which can be due to atelectasis from increased retained secretions or
hypoventilation, aspiration, or bronchospasm. Pulse oximetry and supplemental oxygen
are used to maintain pulse oximeter readings >92%; placing the client in side-
lying position and administrating antiemetic medications help to decrease aspiration.
 Hypoventilation, which can be due to depression of the respiratory drive as a result of
anesthesia, pain, and opioid analgesia.
The client with severe COPD will have a chronically low oxygen level, hypoxemia. To
compensate, the body produces more red blood cells (RBCs) to carry needed oxygen to the cells.
A high RBC count is called polycythemia.

Cystic fibrosis (CF)

a genetic disorder involving the cells that line the respiratory, gastrointestinal (GI), and
reproductive tracts. A defective protein responsible for transporting sodium and chloride causes
the secretions from exocrine glands in these areas to be thicker and stickier than normal. These
abnormal secretions plug smaller airway passages and ducts in the GI tract. Secretions of
impaired digestive enzymes in the GI tract result in ineffective absorption of essential
nutrients. The sticky respiratory secretions lead to an inability to clear the airway and a chronic
cough. The client eventually develops chronic lung disease (bronchiectasis). As a result of these
changes, the client's lifespan is shortened; most affected individuals live only into their 30s.
Chest physiotherapy helps remove sticky secretions that cause ineffective airway
clearance. Clients and parents should receive genetic testing and counseling as CF is transmitted
in an autosomal recessive inheritance pattern. Spiritual support should be offered as clients must
deal with the impact of CF on lifespan and future pregnancies.
Also at risk for rupture of the damaged alveoli, which results in sudden-
onset pneumothorax. Findings of pneumothorax include sudden worsening of dyspnea,
tachypnea, tachycardia, and a drop in oxygen saturation. Because many of these findings can be
seen with lung infection, a sudden drop in oxygen saturation could be the only early clue.
The client with CF will often have a decreased pulse oximetry (reflects oxygen saturation in the
blood) reading due to the chronicity of the disease process and damage to the lungs; however, a
reading of 90% requires urgent intervention.
Clients with CF often cough up blood-streaked sputum (hemoptysis) as a result of damage to
blood vessels in the airway walls secondary to infections. However, this usually resolves with
treatment of the infection. Frank hemoptysis needs urgent assessment.
Fecal retention and impaction are common in CF due to decreased water and salt secretion into
the intestines.
Maintaining weight is a challenge in those with CF due to the malabsorption of carbohydrates,
fats, and proteins caused by the impaired enzyme secretions in the gastrointestinal tract.

Theophylline
a bronchodilator with a low therapeutic index and a narrow therapeutic range (10-20
mcg/mL). The serum level should be monitored frequently to avoid severe adverse
effects. Toxicity is likely to occur at levels >20 mcg/mL. Individual titration is based
on peakserum theophylline levels, so it is necessary to draw a blood level 30 minutes after dosing.
Theophylline can cause seizures and life-threatening arrhythmias. Toxicity is usually due to
intentional overdose or concurrent intake of medications that increase serum theophylline
levels. Cimetidine and ciprofloxacin can dramatically increase serum theophylline levels
(>80%). Therefore, they should not be used in these clients.
Caffeinated products (eg, coffee, cola, chocolate) should be avoided as they would intensify the
adverse effects (eg, tachycardia, insomnia, restlessness) of theophylline.
signs of toxicity that should be reported are anorexia, nausea, vomiting, restlessness, and
insomnia. Seizures, cardiac arrhythmias most serious & lethal
Peak flow meter
hand-held device used to measure peak expiratory flow rate (PEFR) and is most helpful for
clients with moderate to severe asthma. Exhaling as quickly and forcibly as possible through the
mouthpiece of the device evaluates the degree of airway narrowing by measuring the volume of
air that can be exhaled in one breath. Use of the device permits self-management and provides
information to guide and evaluate treatment.
The personal best reading is the highest peak flow reading the client can attain, usually over a 2-
week period, when asthma is in good control.
used after a short-acting bronchodilator rescue MDI to evaluate response, not after a
corticosteroid MDI.
The action plan uses traffic signal colors to categorize into zones degrees of asthma symptom
severity and airway obstruction (peak flow meter readings):
 Green zone indicates asthma is under control and PEF is 80%-100% of personal
best. When in this zone, there is no worsening of cough, wheezing, or trouble breathing
 Yellow zone means caution; even on a return to the green zone after use of rescue
medication, further medication or a change in treatment is needed
 Red zone indicates a medical alert and signals the need for immediate medical treatment
if the level does not return to yellow immediately after taking rescue medications

Nasal cannula
an inexpensive, comfortable, low-flow oxygen delivery device capable of delivering oxygen
concentrations of up to 44%. It can be used in the short term in responsive postoperative clients
to treat hypoventilation and reverse hypoxemia effectively.

Simple face mask

delivers a higher concentration of oxygen (40%–60%), is more uncomfortable and restrictive,
must be removed to eat or drink, and is not appropriate at this time. It can be used if hypoxemia
does not resolve.

Nonrebreather mask
an oxygen delivery device used in a medical emergency. It consists of a face mask with an
attached reservoir bag and a one-way valve between the bag and mask that prevents exhaled air
from entering the bag and diluting the oxygen concentration. The liter flow must be high enough
(up to 15 L/min) to keep the reservoir bag at least 2/3 inflated during inhalation and to prevent the
buildup of carbon dioxide in the bag.
It can deliver up to 95%–100% oxygen concentration if properly maintained during use

Venturi mask
more expensive device used to deliver a guaranteed oxygen concentration to clients with unstable
chronic obstructive pulmonary disease.

Endoscopic bronchoscopy
bronchi are visualized with a flexible fiberoptic bronchoscope that is passed down through the
nose (or through the mouth, or endotracheal or tracheostomy tube). The client receives mild
sedation (eg, midazolam) to provide relaxation and promote comfort. A topical anesthetic (eg,
lidocaine, benzocaine) is applied to the nares and throat to suppress the gag and cough reflexes,
prevent laryngospasm, and facilitate passage of the scope.
The procedure is done to diagnose, obtain tissue samples for biopsy, lavage, and to remove
secretions (mucus plugs), foreign objects, or abnormal tissue with a laser. Blood-tinged sputum
is common and can occur from inflammation of the airway, but hemoptysis of bright red blood
can indicate hemorrhage, especially if a biopsy was performed.
Other complications include hypoxemia, hypercarbia, hypotension, laryngospasm, bradycardia,
pneumothorax (rare), and adverse effects from medications used before and during the procedure.

Peritonsillar abscess
An emergent complication of tonsillitis that can lead to life-threatening airway
obstruction. Symptoms include fever, trismus (inability to open the mouth), drooling, muffled
voice, and deviation of uvula to one side. can progress to life-threatening airway obstruction (eg,
dysphagia, stridor, restlessness). The nurse should immediately assess the client with symptoms
of peritonsillar abscess and monitor for signs of airway obstruction

Pursed-lip breathing technique

helps to decrease shortness of breath by preventing airway collapse, promoting carbon dioxide
elimination, and reducing air trapping in clients with chronic obstructive pulmonary
disease. Clients are taught to relax the shoulders and neck, inhale through the nose for 2 seconds
with the mouth closed, and exhale through pursed lips for 4 seconds (or twice as long as
inhalation).
Pursed lip breathing prolongs exhalation, reduces air trapping in the lungs, and decreases
dyspnea. It does not help to thin secretions.

Tiotropium (Spiriva)
a long-acting, 24-hour, anticholinergic, inhaled medication used to control (COPD). It is
administered most commonly using a capsule-inhaler system called the HandiHaler. The
powdered medication dose is contained in a capsule. The client places the capsule in the inhaler
device and pushes a button on the side of the device, which pokes a hole in the capsule. As the
client inhales, the powder is dispersed through the hole.
Tiotropium looks like an oral medication because it comes in a capsule. Important to teach the
client proper administration prior to the first dose, emphasizing that the capsule should not be
swallowed and that the button on the inhaler must be pushed to allow for medication dispersion.
The nurse should assess/reassess the client's ability to use this medication correctly.
Rinse the mouth after using tiotropium and inhaled steroids (eg, beclomethasone, budesonide,
fluticasone) to remove any medication remaining in the mouth, which decreases the risk of
developing thrush. A common side effect of tiotropium (Spiriva) and other anticholinergics (eg,
ipratropium, benztropine) is xerostomia (dry mouth) due to the blockade of muscarinic receptors
of the salivary glands, which inhibits salivation. Sugar-free candies or gum may be used to
alleviate dry mouth and throat
peak effect of approximately 1 week; therefore, it should not be used as a rescue
medication. Instead, short-acting bronchodilators (eg, albuterol and/or ipratropium) should be
used for symptom rescue. Clients must discontinue ipratropium before taking tiotropium as both
are anticholinergic.
Tiotropium and umeclidinium are long-acting, 24-hour, anticholinergic medications. Ipratropium
is a short-acting anticholinergic used as a rescue medication for COPD and asthma.

Glucocorticoids
(eg, prednisone), when taken in combination with aspirin or nonsteroidal anti-inflammatory drugs
(NSAIDs) such as naproxen, can increase the risk of gastrointestinal ulceration and bleeding. The
client should report black, tarry stools (ie, melena) to the health care provider as they could
indicate gastrointestinal bleeding

ARDS
involves damage to the alveolar-capillary membrane, the blood-gas barrier across which oxygen
diffuses into the alveoli. When the membrane is damaged, the alveoli collapse and fluid leaks
into the alveolar space and impairs gas exchange.

Clients with Acute Pancreatitis can develop respiratory complications including pleural
effusions, atelectasis, and acute respiratory distress syndrome (ARDS). These complications are
often due to activated pancreatic enzymes and cytokines that are released from the pancreas into
the circulation and cause focal or systemic inflammation. ARDS is the most severe form of these
complications and can rapidly progress to respiratory failure within a few hours. Therefore, the
presence of inspiratory crackles in this client could indicate early ARDS and needs to be assessed
further for progression.

Pleural friction rub is auscultated in the lateral lung fields over the area of inflammation. The
sound is produced by the 2 layers rubbing together and can indicate pleurisy, a complication of
pneumonia. It is characterized by squeaking, crackling, or the sound heard when the palm is
placed over the ear and the back of the hand is rubbed with the fingers. Complications of
pneumonia are more prevalent in elderly clients with underlying chronic disease.

Tracheostomy
immediate postoperative priority goal is to prevent accidental dislodgement of the tube and loss
of the airway. If dislodgement occurs during the first postoperative week, reinsertion of the tube
is difficult as it takes the tract about 1 week to heal. For this reason, dislodgement is a medical
emergency. The priority nursing action is to ensure the tube is placed securely by checking the
tightness of ties and allowing for 1 finger to fit under these ties.

Pleural effusion
An abnormal collection of fluid (>15-20 mL) in the pleural space between the parietal and
visceral pleurae that prevents the lung from expanding fully, resulting in decreased lung volume,
atelectasis, and ineffective gas exchange. Clients commonly have dyspnea on exertion and non-
productive cough. Examination shows diminished breath sounds, dullness to percussion, and
decreased tactile fremitus.
Palpable vibration felt on the chest wall is known as fremitus. Sound travels faster in solids
(consolidation) than in an aerated lung, resulting in increased fremitus in pneumonia. The
presence of egophony, bronchophony, or whispered pectoriloquy also suggests a consolidative
process. Fluid or air outside the lung interrupts the transmission of sound, resulting in decreased
fremitus in pleural effusion and pneumothorax

Mechanical Ventilation
Risks associated with suctioning include hypoxemia, microatelectasis, and cardiac
dysrhythmias. Suctioning removes secretions and oxygen. To minimize both the amount of
oxygen removed and mucosal trauma, suction is applied when removing, not inserting, the
catheter into the artificial airway. If secretions are thick and difficult to remove, increasing
hydration, not suctioning time, is indicated. Aerosols of sterile normal saline or mucolytics such
as acetylcysteine (Mucomyst) administered by nebulizer can also be used to thin the thick
secretions, but water should not be used. Aerosol therapy may induce bronchospasm in certain
individuals and can be relieved by use of a bronchodilator (albuterol).
Preoxygenation with 100% oxygen for 30 seconds before suctioning, limit suction time to 10-15
seconds.
appropriate to suction the client when the high-pressure alarm on the MV sounds, saturations
drop, rhonchi are auscultated, and secretions are audible or visible. These manifestations can
indicate excessive secretions impairing airway patency.
Ventilator-associated pneumonia (VAP)
The second most common health care-associated infection (HAI) in the United States and is
associated with increased mortality, hospital cost, and length of stay.
Because it is a nosocomial infection, signs and symptoms associated with VAP usually present
within ≥2-3 days after initiation of mechanical ventilation (MV). Characteristic clinical
manifestations of VAP include purulent sputum, positive sputum culture, leukocytosis (12,000
mm3), elevated temperature (>100.4 F [38 C]), and new or progressive pulmonary infiltrates
suggestive of pneumonia on chest x-ray.

Traumatic, or "open," pneumothorax,

Air rushes in through the wound with each inspiration, creating a sucking sound, and fills the
pleural space. The lungs cannot expand, so the client develops respiratory distress and air
hunger. Tachycardia and hypotension result from impaired venous return, as the heart and great
vessels shift with each breath. A tension pneumothorax may also develop if air cannot escape the
pleural space. The priority action in this medical emergency is to apply a sterile occlusive
dressing (eg, petroleum gauze) taped on three sides, preventing inward air flow while allowing air
to escape the pleural space.

Strategies to prevent postoperative pneumonia include the following:

 Adequate pain control is a priority so that the client can move, deep breathe, and cough
more effectively and comfortably. Opioids are effective for relieving postoperative pain,
but because they depress respirations and the cough reflex, assessing the client's response
to the medication and level of sedation is important.
 Ambulate within 8 hours after surgery, if possible. Mobilization/early ambulation
decreases atelectasis and hypoventilation, and promotes coughing, deep breathing, and
lung expansion. Usually, it can be initiated within 4-8 hours after surgery.
 Coughing with splinting every hour. Splinting of the incision and adequate pain
management are useful for promoting an effective cough (huff, cascade) that clears the
airway of secretions.
 Deep breathing and use of the incentive spirometer every hour. Deep breathing in
conjunction with the use of the incentive spirometer promotes ventilation and
oxygenation. It opens the pores of Kohn that permit air from well-ventilated alveoli to
move into collapsed alveoli, and it helps to prevent/decrease atelectasis and
hypoventilation caused by the effects of anesthesia, analgesia, and pain.
 Place in Fowler's position. Elevating the head of the bed 45-60 degrees helps to promote
oxygenation and prevent aspiration. Turn and reposition the client at least every 2 hours.
 Swab mouth with chlorhexidine swabs every 12 hours. Mouth care prevents ventilator-
associated and postoperative pneumonia.
 Use hand hygiene (all personnel) to decrease transmission of microorganisms.

moderate to severe asthma exacerbations

Clinical manifestations- include tachycardia (>120/min), tachypnea (>30/min), saturation <90%
on room air, use of accessory muscles to breathe, and peak expiratory flow (PEF) <40% of
predicted or best (<150 L/min)
Pharmacologic treatment to correct hypoxemia, improve ventilation, and promote bronchodilation
include the following:
1. Oxygen to maintain saturation >90%
2. High-dose inhaled short-acting beta agonist (SABA) (albuterol) and anticholinergic agent
(ipratropium) nebulizer treatments every 20 minutes
3. Systemic corticosteroids (Solu-Medrol)
Interventions to facilitate airway clearance include the following:
 Hydration - IV fluids, oral intake (2-3 L/day), and respiratory humidification help thin
secretions, maintain moisture of mucous membranes, and promote mucociliary clearance.
 Huff coughing technique - the most effective way to raise secretions from the lower to
the upper airway for expectoration. If pain limits deep breathing and coughing, analgesia
can be prescribed
 Chest physiotherapy (percussion, vibration, and postural drainage) to open airways and
break up thickened secretions
 Fowler's position - Sitting upright with the head of the bed at 45-60 degrees promotes
lung expansion and facilitates coughing and secretion removal

Chest tubes
When the lung has reexpanded or fluid drainage is no longer needed, the chest tube can be
discontinued. The client should be given an analgesic 30-60 minutes prior to the procedure. A
suture removal kit, petroleum gauze, and occlusive dressing supplies will be needed. The client
should be instructed to take a deep breath, hold it, and bear down (Valsalva maneuver) while the
tube is being removed. This will prevent air from being pulled back into the pleural space and
possibly causing a pneumothorax. A post-procedure chest x-ray must be performed to ensure
there is no reaccumulation of air or fluid in the pleural space.
If the chest tube disconnects from the drainage tubing without contamination, wipe the end of the
chest tube with an antiseptic and immediately reconnect it. To prevent accidental disconnection
of the chest tube from the tubing, secure all connections with tape or bands, according to hospital
policy and procedure.
If the chest tube is disconnected with contamination and cannot be immediately reattached, or if
the chest drainage unit breaks, cracks, or malfunctions, submerge the distal end of the chest tube
1-2 in (2-4 cm) below the surface of a 250 mL bottle of sterile water or saline. This creates an
immediate water seal and prevents air from entering into the pleural space as the new chest
drainage system is established

Thoracentesis
Complications from insertion of the needle and removal of large amounts of fluid include
iatrogenic pneumothorax, hemothorax, pulmonary edema, and infection.
After the procedure, the nurse assesses for pain and difficulty breathing; monitors vital signs and
oxygen saturation; and observes for changes in respiratory rate and depth, symmetry of chest
expansion, and breath sounds. If any abnormalities are noted, a post-procedure chest x-ray is
obtained.
Decreased chest expansion with inspiration and breath sounds on the affected side, tachypnea,
tracheal deviation to the opposite side, and hyperresonance (air) on the affected side are
manifestations of a pneumothorax. These should be reported immediately.

Codeine
An opioid drug prescribed as an analgesic to treat mild to moderate pain and as an antitussive to
suppress the cough reflex. Although the antitussive dose (10-20 mg orally every 4-6 hours) is
lower than the analgesic dose, clients can still experience the common adverse effects (eg,
constipation, nausea, vomiting, orthostatic hypotension, dizziness) associated with the drug.
Codeine decreases gastric motility, resulting in constipation. Increasing fluid intake and fiber in
the diet and taking laxatives are effective measures to prevent constipation
Changing position slowly is effective in preventing the orthostatic hypotension associated with
codeine, especially in the elderly
Taking the medication with food is effective in preventing the gastrointestinal irritation
(eg, nausea, vomiting) associated with codeine
An elevated carbon dioxide (CO2) level (normal: 35-45 mm Hg [4.7-6.0 kPa]) is usually an
indicator of hypercapneic respiratory failure. The bilevel positive airway pressure (BIPAP)
machine will provide positive pressure oxygen and expel CO2 from the lungs. Signs of lethargy
and confusion are usually a late indicator of respiratory decline. The nurse's priority should be to
get the client on the BIPAP machine as soon as possible.

Obstructive sleep apnea (OSA)

the most common type of breathing disorder during sleep and is characterized by repeated periods
of apnea (>10 seconds) and diminished airflow (hypopnea).
Experience repeated periods of apnea, loud snoring, and interrupted sleep. During the day,
morning headaches, irritability, and excessive sleepiness are common.
Interventions include:
 Continuous positive airway pressure device at night to keep the structures of the pharynx
and tongue from collapsing backward
 Limiting alcohol intake at bedtime as it can cause muscles of the oral airway to relax and
lead to airway obstruction
 Weight loss and exercise can reduce snoring and sleep apnea-associated airway
obstruction. Obesity contributes to the development of OSA
 Avoiding sedating medications (eg, benzodiazepines, sedating antidepressants,
antihistamines, opiates) as they may exacerbate OSA and worsen daytime sleepiness

Refractory hypoxemia
is the inability to improve oxygenation with increases in oxygen concentration. It is the hallmark
of ARDS, a progressive form of acute respiratory failure that has a high mortality rate.

The "death rattle"

A noisy rattling sound with breathing commonly seen in a dying client who is unresponsive and
no longer able to manage airway secretions. Anticholinergic medications such as transdermal
scopolamine or atropine sublingual drops effectively treat this symptom by drying up the excess
secretions.

Respiratory depression
the most serious side effect of narcotic medication. Sedation precedes respiratory depression
Level of Sedation
S- Sleeping, east to rouse: no action necessary
1- Awake, alert: no action necessary, may increase sedation
2- Slightly drowsy but easy to rouse: Acceptable, no action necessary
3- Falls asleep during conversation: Unacceptable, monitor respiratory status, Notify HCP to
decrease sedation by 25-50%
4- Somnolent, minimal or no response to verbal & physical stimuli: Stop sedation, Consider using
naloxone, Notify HCP, Monitor respiratory status

Acute respiratory failure

ARF is defined as inadequate gas exchange that is intrapulmonary (pneumonia, pulmonary
embolism) or extrapulmonary (head injury, opioid overdose) in origin. ARF is a potential
complication of major surgical procedures, especially those involving the thorax and
abdomen. ABG values that indicate the presence of ARF are PaO2 ≤60 mm Hg (8.0 kPa) or
PaCO2 ≥50 mm Hg (6.67 kPa). ARF occurs quickly over time (minutes to hours), and so
there is no physiologic compensation and pH is ≤7.30. Immediate intervention with high O2
concentrations is indicated, and noninvasive or invasive, positive-pressure mechanical ventilation
may be necessary.
antihistamines
(eg, diphenhydramine [Benadryl], loratadine [Claritin], promethazine [Phenergan])

Palliative care
Appropriate for clients who wish to focus on quality of life and symptom management rather than
life-prolonging treatments
client with an advanced, terminal disease (eg, chronic obstructive pulmonary disease) is often an
appropriate candidate

respiratory failure Clinical manifestations include:

 PaCO2 ≥45 mm Hg (6.0 kPa): Indicates hypercapnia and hypoventilation resulting from
fatigue and labored breathing. As initial tachypnea subsides and respiratory rate returns
to normal, PaCO2 rises and respiratory acidosis develops
 PaO2 ≤60 mm Hg (8.0 kPa): Indicates hypoxemia resulting from increased work of
breathing, decreased gas exchange (hyperinflation and air trapping), and inability of the
lungs to meet the body's oxygen demand
 Paradoxical breathing (ie, abnormal inward movement of the chest on inspiration and
outward movement on expiration): Indicates diaphragm muscle fatigue and use of
respiratory accessory muscles
 Mental status changes (eg, restlessness, confusion, lethargy, drowsiness): Sensitive
indicators of hypoxemia and hypoxia
 Absence of wheezing and silent chest (ie, no sound of air movement on
auscultation): Ominous signs indicating severe hyperinflation and air trapping in the
lungs
 Single-word dyspnea: Inability to speak >1 word before pausing to breathe due to
shortness of breath

Pulmonary embolism (PE)

a blood clot that usually originates from the deep veins of the legs (>90%), travels to the
pulmonary circulation, and obstructs a pulmonary artery or one of its branches, resulting in
decreased perfusion in relation to ventilation and impaired gas exchange (hypoxemia).
Clients are at risk for formation of venous thromboembolism (VTE) when the conditions detailed
in Virchow's Triad (hypercoagulability, venous stasis, and endothelial damage) are
present. Clients at risk for PE include those with prolonged immobilization (during
hospitalization if not ambulatory), obesity, recent surgery, varicose veins, smoking, heart failure,
advanced age, or history of VTE.
The assessment data most characteristic of PE include:
 Dyspnea (85%)
 Pleuritic chest pain (60%)
 Tachycardia
 Tachypnea
 Hypoxemia (impaired gas exchange, decreased perfusion with normal alveolar
ventilation, shunting)
 Apprehension and anxiety
A more atypical presentation can be associated with a larger sized PE, and may include
manifestations of cardiopulmonary compromise and hemodynamic instability (eg, right
ventricular dysfunction, pulmonary hypertension, systemic hypotension, syncope, loss of
consciousness, distended neck veins).
Ineffective breathing pattern
A change in rate, rhythm, timing, depth, or chest and abdominal wall excursion during inspiration
and/or expiration that affects a client's ability to maintain adequate ventilation. Characteristic
manifestations include dyspnea, tachypnea, bradypnea, altered chest excursion, respiratory depth
(shallow) and rhythm changes (2-3-second periods of apnea), use of accessory muscles,
paradoxical breathing, orthopnea, and use of the tripod position.

Impaired gas exchange

An alteration in the normal exchange of oxygen and carbon dioxide at the alveolar capillary
membrane. Characteristic manifestations include restlessness, irritability, hypoxemia, hypoxia,
confusion, somnolence, dyspnea, abnormal arterial blood gases, tachycardia, and pale and dusky
skin (cyanosis).

Pneumonia
an acute infection of the lungs. Findings in a client with pneumonia include:
 Crackles - Fine or coarse crackling sounds caused by air passing through alveoli and
small airways obstructed with mucus
 Fever, chills, productive cough, dyspnea, and pleuritic chest pain
 Increased vocal/tactile fremitus - Transmission of palpable vibrations (fremitus) is
increased when transmitted through consolidated versus normal lung tissue.
 Bronchial breath sounds in peripheral lung fields - High-pitched, harsh sounds conducted
through consolidated lung tissue, which are abnormal when heard in an area distant from
where normally heard (ie, trachea); this finding can be an early sign of pneumonia.
 Unequal chest expansion - Decreased expansion of affected lung on palpation
 Dullness - Percussion of medium-pitched sounds over consolidated lung tissue
(pneumonia) or fluid-filled space (eg, pleural effusion, a complication of pneumonia)
Discharge instructions for a client recovering from pneumonia focus on proper medication
regimen, lung expansion and coughing techniques, activity level, hydration, nutrition, avoidance
of tobacco products, reportable manifestations (eg, respiratory distress, chest pain, fever, cough,
change in mucus), follow-up care, influenza and pneumonia vaccinations, and respiratory and
hand hygiene.

Measures to prevent aspiration pneumonia include administering medications to prevent

vomiting, avoiding mealtime sedation, maintaining head-of-bed elevation at 30 degrees or more
(90 degrees during and 30 minutes after meals), and encouraging neck flexion while
swallowing. Clients with dysphagia should receive thickened liquids and be monitored for
coughing, gagging, and pocketing food.

Strategies to prevent postoperative pneumonia

 Adequate pain control is a priority so that the client can move, deep breathe, and cough
more effectively and comfortably. Opioids are effective for relieving postoperative pain,
but because they depress respirations and the cough reflex, assessing the client's response
to the medication and level of sedation is important.
 Ambulate within 8 hours after surgery, if possible. Mobilization/early ambulation
decreases atelectasis and hypoventilation, and promotes coughing, deep breathing, and
lung expansion.
  Coughing with splinting every hour. Splinting of the incision and adequate pain
management are useful for promoting an effective cough (huff, cascade) that clears the
airway of secretions.
 Deep breathing and use of the incentive spirometer every hour. Deep breathing in
conjunction with the use of the incentive spirometer promotes ventilation and
oxygenation. It opens the pores of Kohn that permit air from well-ventilated alveoli to
move into collapsed alveoli, and it helps to prevent/decrease atelectasis and
hypoventilation caused by the effects of anesthesia, analgesia, and pain.
 Place in Fowler's position. Elevating the head of the bed 45-60 degrees helps to promote
oxygenation and prevent aspiration. Turn and reposition the client at least every 2 hours.
 Swab mouth with chlorhexidine swabs every 12 hours. Mouth care prevents ventilator-
associated and postoperative pneumonia.
 Use hand hygiene (all personnel) to decrease transmission of microorganisms.

** Two groups of commonly used drugs, nonsteroidal anti-inflammatory drugs and beta-
adrenergic antagonists (beta blockers), have the potential to cause problems for clients
with asthma.

** Elevating the head and chest in the Fowler's, high Fowler's, orthopneic, and tripod positions
allows for maximum lung expansion and promotes oxygenation, especially in clients with
dyspnea. priority nursing action to help relieve shortness of breath, facilitate oxygenation
(breathing), and promote lung expansion (airway).

** Placing a client with a decreased level of consciousness in a position that uses gravity to help
drain oropharyngeal and gastric secretions can be effective in preventing aspiration and reducing
the risk for aspiration pneumonia.

** Furosemide (Lasix) is a diuretic and is not appropriate for treating the fine crackles associated
with pneumonia. The crackles result from alveolar filling and atelectasis, not from heart failure or
pulmonary edema.

**Cephalexin is a cephalosporin, which is chemically similar to penicillin. If a client has had a

severe allergic reaction to penicillin, there is a 1%-4% chance of an allergic reaction (cross-
sensitivity) to a cephalosporin
**Clients with nasal polyps often have sensitivity to nonsteroidal anti-inflammatory drugs
(NSAIDS), including aspirin. In addition, NSAIDs can exacerbate asthma symptoms. Therefore,
acetaminophen may be a better choice for these clients

**The selective beta blockers (eg, metoprolol, atenolol, bisoprolol) are generally given for heart
failure and hypertension control due to their beta1-blocking effect. The nonselective beta
blockers (eg, propranolol, nadolol), in addition, have a beta2-blocking effect that results in
bronchial smooth muscle constriction. Therefore, nonselective beta blockers are generally
contraindicated in clients with asthma

**H1 receptor antagonists (eg, fexofenadine, cetirizine, levocetirizine, loratadine) decrease the
inflammatory response by blocking histamine receptors. Histamine is released from mast cells
during a type I (immediate) hypersensitivity reaction (ie, allergic rhinitis, allergic conjunctivitis,
and hives).
**Angiotensin-converting (ACE) inhibitors (ending in "pril") are the drugs of choice in diabetic
clients with hypertension or proteinuria. This would be an appropriate administration.

** Morphine and other medications (eg, benzodiazepines) that can depress the respiratory center
should not be used in clients with COPD exacerbation as they can further worsen CO2 retention.

** Hyperresonance is percussed over a hyperinflated lung (eg, asthma, emphysema) or air in the
pleural space

** An elevated eosinophil count in the complete blood count is associated with allergy. Allergies
are frequently triggers of asthma exacerbation. Normal eosinophil count is 1%-2%

** Reticulocytes are immature red blood cells. Normal reticulocyte count is 0.5%-2.0%. Levels
are elevated in hemolytic anemia or hemorrhage when the marrow is attempting to compensate
for lost blood.

** Normal neutrophils are 55%-70%. Elevated neutrophils indicate infection.

** Lymphocytes form the major part of immune system. Elevated levels are seen with viral
infections and hematologic malignancies.

near-drowning victim
 The initial management of a near-drowning victim focuses on airway management due
to potential aspiration (leading to acute respiratory distress syndrome), pulmonary edema,
or bronchospasm (leading to airway obstruction). Hypoxia is managed and prevented by
ensuring a patent airway via intubation and mechanical ventilation as necessary
 Careful handling of the hypothermic client is important because as the core temperature
decreases, the cold myocardium becomes extremely irritable. Frequent turning could
cause spontaneous ventricular fibrillation and should not be performed during the acute
stage of hypothermia. Continuous cardiac monitoring should be initiated
 There are passive, active external, and active internal rewarming methods. Passive
rewarming methods include removing the client's wet clothing, providing dry clothing,
and applying warm blankets. Active external rewarming involves using heating devices
or a warm water immersion. Active internal rewarming is used for moderate to severe
hypothermia and involves administering warmed IV fluids and warm humidified oxygen