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ABG Terms
pH- amount of free hydrogen ions in the arterial
blood. (H+) PaO2- the partial pressure of oxygen PaCO2- the partial pressure of carbon dioxide HCO3- bicarbonate in arterial blood SaO2- % of oxygen bound to Hgb as compared to the total amount that can be possibly carried.
HCO3- 22-26
SaO2- 95-100%
arteries SIMULTANEOUSLY while instructing the patient to form a fist. Then have the client relax hand while RELEASING pressure on the RADIAL ARTERY. HAND SHOULD TURN PINK QUICKLY INDICATING PATENCY OF THE RADIAL ARTERY. REPEAT FOR THIS PROCESS FOR THE ULNAR ARTERY
(20 minutes if pt. is on anticoagulants) Monitor ABG site for bleeding, loss of pulse, swelling, and changes in temp and color
BLOOD CAN ALSO BE DRAWN FROM AN ARTERIAL LINE
Bronchoscopy Uses
Can visualize abnormalities such as tumors,
inflammation, and strictures Biopsy of suspicious tissue (lung tissue) (biopsy can have additional risks for bleeding) Aspiration of deep sputum
lidocaine
Laryngospasm
Uncontrolled muscle contractions of the laryngeal
Pneumothorax
Collapsed lung
S/S- diminished breath sounds
Asthma
Chronic inflammatory disorder of the airways in
intermittent and reversible airflow obstruction of the bronchioles The obstruction occurs either by inflammation or airway hyperresponsiveness Cause is unknown.
Manifestations of Asthma
1. Mucosal edema
2. Bronchoconstriction 3. Excessive mucous production
S/s of Asthma
Coughing, wheezing, mucus production, poor oxygen saturation, barrel chest or increased chest diameter
week 2. Mild persistent- symptoms arise more than 2x a week but not daily 3. Moderate persistent- daily symptoms occur in conjunction with exacerbations 2x a week 4. Severe persistent- symptoms occur continually, along with frequent exacerbations that limit the clients physical activity and quality of life.
Pulmonary function tests (PFT) are the most accurate tests for diagnosing asthma and its severity!
Asthma Therapy
Exercise (promotes ventilation/perfusion)
Medications
Medications
Bronchodilators (inhalers)
Anti-inflammatory agents- used to decrease airway
Bronchodilators
Short acting beta2 agonists such as albuterol (Proventil,
Ventolin)- provide rapid relief of acute symptoms and prevent exercise induced asthma. Watch for tremors and tachycardia
Anticholinergic meds- ipratropium (Atrovent)- increases
bronchodilation and decreased pulmonary secretions. (sympathetic nervous system) (GIVE PATIENT CANDY FOR DRY MOUTH!!!))) Methylxanthines- (Theo-Dur)- requires close monitoring of serum med. Levels due to a narrow therapeutic range. Toxicity =tachycardia, nausea, diarrhea
Anti-inflammatory Agents
Corticosteroids- fluticasone (Flovent), prednisone
(Deltasone)
ENCOURAGE THE PATIENT TO TAKE
Combination Agents
Ipratropium and albuterol (Combivent)
Fluticasone and salmetrol (Advair)
THE SAME TIME, ADMINISTER THE BRONCHODILATOR 1st in order to increase the absorption of the anti-inflammatory agent.
Complications of Asthma
Respiratory failure - persistent hypoxemia related to asthma can lead to
respiratory failure -if in respiratory failure, monitor oxygen levels and acidbase balance
Status asthmaticus -LIFE THREATENING! Episode of airway obstruction that
is often unresponsive to common treatment. Extreme wheezing, labored breathing, distended neck veins, use of accessory muscles
COPD
COPD
Encompasses 2 diseases- EMPHYSEMA and
Emphysema
Loss of lung elasticity and hyperinflation of lung
tissue Causes destruction of alveoli leading to a decreased surface area for gas exchange, carbon dioxide retention, and resp. acidosis
Chronic Bronchitis
Inflammation of the bronchi and bronchioles due to
Risk Factors
in the morning, resp. acidosis, and comp. metabolic alkalosis, crackles, wheezes, rapid and shallow resps, use of accessory muscles, barrel chest or increased chest diameter, clubbing, decreased o2 levels,
Laboratory Tests
Increased hematocrit is due to low oxygenation levels
Sputum cultures and WBC counts to diagnose acute
respiratory infections
Diagnostic Procedures
Pulmonary function tests
- 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 <70%. As the disease progresses to moderate and severe, the ratio decreases to <50%
Chest x-ray
Reveals hyperinflation of alveoli and flattened
ABG results.
Will show..
Hypoxemia decreased PaO2- <80 Hypercarbia-increased PaCO2>45
that helps regulate other enzymes (that help breakdown pollutants) from attacking lung tissue.
Nursing Care
Fowlers
Cough and deep breathe Incentive spirometer
Suction secretions
Breathing treatments Adequate nutrition (soft, high calorie foods) (fluids)
Incentive Spirometry
Instruct client to keep a tight seal around mouthpiece and to inhale and hold breath for 3-5 sec.
COPD OXYGEN?
Give pt. 2-4 L/min NC or up to 40% via VENTURI
IMPORTANT!!!
IT IS IMPORTANT TO RECOGNIZE THAT LOW
Medications?
Bronchodilators (inhalers)- Albuterol (Proventil,
Ventolin) (provide RAPID relief) Cholinergic antagonists- ipratropium (Atrovent) Methylxanthines- Theo-Dur which relax smooth muscles of the bronchi. Needs close monitoring of serum levels Anti-inflammatories- fluticasone (Flovent) and prednisone (Deltasone). Monitor for side effects (immunosuppresion, fluid retention, hyperglycemia, poor wound healing)
Therapeutic Procedures
Chest PT
Raising the foot of the bed slightly higher than the
Complications of COPD
Respiratory infections- results from increased mucus
production and poor oxygenation levels Right sided heart failure (COR PULMONALE)- air trapping, airway collapse, and stiff alveoli lead to increased pulmonary pressures.. Blood flow through the lung tissue is difficult= increased workload and enlargment and thickening of the right atrium and ventricle. -s/s= low o2 level, cyanotic lips, enlarged liver, distended neck veins, edema
Pneumonia!
Pneumonia
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 Immunocompromised are more susceptible. Immobility can be a contributing factor
2 Types of Pneumonia
1. Community Acquired (CAP)- most common type.
Occurs as a complication of influenza 2. Hospital acquired pneumonia (HAP)- has a higher mortality rate
**** Older adults are more suspectible to infections
and have DECREASED PULMONARY RESERVES DUE TO NORMAL LUNG CHANGES, including decreased LUNG ELASTICITY and thickening alveoli
S/S
Anxiety, fatigue, weakness, chest discomfort, fever,
chills, diaphoretic, SOB, crackles, wheezes, sputum production (YELLOW), coughing, dull chest percussion over areas of consolidation, decreased O2, pleuritic chest pain
*****CONFUSION!!!!! FROM HYPOXIA IS THE MOST
LAB Results
Elevated WBC count
ABG shows hypoxemia (decreased PaO2 < 80)
Chest X-ray
Will show consolidation (solidification, density) of
Medications
Cephalosporins- observe client for frequent stools, take
with food Penicillin- take with food Monitor kidney function for people taking these medications! Bronchodilators- given to reduce bronchospasms and reduce irritation. (albuterol) Cholinergic antagonists (anticholinergic meds)- Atrovent Methylxanthines- Theo-Dur- requires close monitoring of serum levels
Medications continued
Anti-inflammatories- decrease airway inflammation
Glucocorticosteroids- fluticasone (Flovent) and
prednisone (Deltasone). Help with inflammation. Monitor for immunosuppression, fluid retention, hyperglycemia, hypokalemia, and poor wound healing.
Complications of Pneumonia
Atelectasis
- airway inflammation and edema lead to alveolar
collapse and increase the risk of hypoxemia SOB, diminished or absent breath sounds, chest xray will show an area of density
Complications of Pneumonia
Bacteremia (SEPSIS!!!)
- this can occur if pathogens enter the bloodstream
TB
Infectious disease caused by MYOBACTERIUM
TUBERCULOSIS AIRBOURNE Primary affects the LUNGS, but can spread to any organ Risk of transmission decreases after 2-3 weeks of antibiotics Slow onset
Mantoux test
Intradermal injection of tubercle bacillus Should be read in 48-72 hrs Will be positive within 2-10 weeks of exposure An induration (palpable, raised, hardened area) of 10 mm or greater in diameter indicates a + skin test An induration of 5 mm is considered + for immunocompromised clients A + Mantoux test indicates that the client has developed an immune response to TB. It doesnt confirm that active disease is present. Clients who have been treated for TB may retain a positive reaction.
S/S
Persistent cough
Night sweats Anorexia
Fever
Chills Weight loss
Latent TB
People may have been exposed to TB, but havent
developed the disease. Mycobacterium TB is in the body, but body was able to fight it. If not treated, it can lie dormant for several years and then become active as the individual becomes older or immunocompromised. Individuals who have latent TB may have a + mantoux test and may receive tx to prevent development of an active form of the disease
may have a false positive mantoux test. These clients will need a chest xray to evaluate for the presence of active TB infection.
Risk Factors
Close contact with an untreated person
Low economic status Homelessness
Age
Substance abuse Recent travel outside of US
Lab Test
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
myobacterium tuberculosis
Nursing Actions 1. 3 morning sputum samples are obtained 2. Wear PPE when obtaining specimen 3. Samples should be obtained in a negative airflow
room
Nursing Care
Wear an N95 or HEPA respirator
Place the pt. in a negative airflow room Airborne precautions
TB medications
4 meds @ a time is recommended
MEDS MUST BE TAKEN FOR 6-12 MONTHS.
THE 4 MEDICATIONS
1. ISONIAZID- (INH)
2. RIFAMPIN (RIF) 3. PYRAZINAMIDE (PZA)
4. ETHAMBUTOL (EMB)
5. MAY CONTAIN STREPTOMYCIN SULFATE
(STREPTOMYCIN). DUE TO ITS HIGH LEVEL OF TOXICITY, THIS MED. SHOULD ONLY BE USED IN PTS WHO HAVE MULTI DRUG RESISTANCE TB
ISONIAZID
Bactericidal. Inhibits the growth of mycobacteria by
preventing synthesis of mycolic acid in the cell wall Take on an empty stomach Monitor for hepatotoxicity and neurotoxicity such as tingling of the hands and feet Vitamin b6 (pyridoxine) is used to prevent neurotoxicity from isoniazid
Rifampin
Bacteriostatic and bactericidal antibiotic that inhibits
DNA-dependent RNA polymerase activity in susceptible cells Observe for hepatotoxicity Urine and other secretions will be orange Advice client to report yellowing of the skin, pain or swelling of joints, loss of appetite, or malaise immediately. May interfere with contraceptives
pyrazinamide
Bacteriostatic and bactericidal and its exact
mechanism of action is not known Observe for hepatotoxicity Increase fluids Advise client to report yellowing of skin, pain or swelling of joints, loss of appetite, or malaise immediately. Avoid alcohol
Ethambutol
Bacteriostatic and works by supressing RNA synthesis,
VISION IMMEDIATELY
macrophages during phagocytosis Highly toxic Should only be used in clients who have multi-drug resistant TB Can cause ototoxicity (notify doctor!!!) Report significant changes in urine output and renal function studies Advise pt to drink at least 2-3 L of fluid daily
Client Education
Instruct client to continue with follow up care for 1 full
year Inform the client that sputum samples are needed every 2-4 weeks to monitor therapy effectiveness. Clients are no longer considered infectious after 3 negative sputum cultures
Military TB
Organism invades the blood stream and can spread to
multiple body organs with complications including: - headaches, stiff neck, drowsiness Pericarditis -dyspnea, swollen neck veins, pleuritic pain, hypotension due to an accumulation of fluid in pericardial sac that inhibits the hearts ability to pump effectively
Larngeal Cancer
More common in men
Greatest risk factors is tobacco and alcohol use
dysphagia, persistent or unilateral ear pain, weight loss, foul breath Hard, immobile lymph nodes in the neck (if metastasis has occurred) Dyspnea (if tumor is an advanced stage)
Laboratory Tests
Tumor mapping may be done by taking multiple
biopsy samples Mapping verifies where the tumor is located, its margins, and type Staging is done using this info
Diagnostic Procedures
X-rays of skull, sinuses, neck and chest CT and MRI scan These help to determine the extent and exact location of the
Indirect and direct laryngoscopy - indirect is done to see if the tumor can be visualized - direct is used to visualize the tumor more closely and to obtain
a biopsy which will determine cell type and staging Before procedure, pt must be NPO. Post procedure assess for return of GAG reflex Inform clients after topical anesthetic is applied, they may feel like they cannot swallow.
Interdisciplinary Care
If surgical removal of the larynx is done, initiate a
speech therapy consult. Social work consult for the client if outpatient radiation or chemotherapy is ordered
Laryngectomy
May be a partial (removal of one or part of 1 larynx) or total
laryngectomy (removal of both larynx) * if cancer is advanced, all or part of the epiglottis may need to be removed ** temp. tracheostomies may be established for clients who required only a partial laryngectomy Permanent tracheal stomas are created for clients who have undergone total laryngectomies A laryngectomy tube is inserted into the stoma immediately after the surgery. This prevents contractures from forming while the stoma is healing. The 11th cranial nerve may be cut resulting in drop following surgery
Total laryngectomy
Pts will lose their natural voice
Cordectomy/hemilaryngectomy
Excision of 1 vocal cord
Risk for aspiration (tuck chin under when swallowing)
Client Education
Use saline and cotton-tipped swabs to cleanse the stoma Humidifier/ saline atomizer to moisten the environment
and stoma frequently during the day Wear a bib, scarf, bandana, etc to cover stoma Instruct patient to avoid lifting. Client unable to lift because the client cannot perform the valsalva maneuver with an open airway Oxygenate prior to suctioning Aspiration may lead to the development of pneumonia Those with a total larygenectomy will not be able to aspirate due to the surgical seperation of the trachea from the esophagus.
Lung Cancer
One of the leading causes of cancer-related deaths
Prognosis is often poor because of late diagnosis Bronchogenic carcinomas account for 90% of primary
lung cancers Histolic cell type determines lung cancer classification: Non small cell lung cancer (NSCLC) - most lung cancers - includes squamous, adeno, and large cell carcinomas
Staging
T= tumor
N=nodes M=metastasis
Chemotherapy
Primary choice of treatment
Cistplatin (Platinol AQ)
S/S
Persistent cough with or without hemoptysis,
hoarseness, dyspnea, unilateral wheezing, chest wall pain, muffled heart sounds, fatigue, weight loss, clubbing of fingers
Bronchoscopy
Can provide direct visibility of the tumor
Allows for specimen and biopsy NPO before and after scope
Hair loss
-Will occur 7-10 days after chemotherapy treatment
begins
Opioid agonists
Morphine sulfate (MS Contin)
Oxycodone (OxyContin) Fentanyl (Duragesic) (PATCH takes several hrs to take
Act on the mu and kappa receptors that help to alleviate pain Assess pain q4 hrs
Surgical Intervention
Goal is to remove all tumor cells, including lymph
nodes Often involves removal of a lung, lobe, segment, or peripheral lung tissue