Alteration in Gas Transport:

1
Alteration in Gas Transport

• Care of the Patient with Problems of the
  Respiratory Tract
• Carol Isaac MacKusick, MSN, RN, CNN
• Nursing 2903
• Fall, 2005

2
The Nursing Process and Respiration

• Assessment
• Client History
• Why are you here?
• General overall health
• Any colds or congestion or allergy problems?
• Smoking history
• Pack years number of packs per day times number
  of years
• How much time away from work or school have you
  missed because of this?

3
Assessment

• Client History
• Subjective symptoms
• Dyspnea with ADLs?
• Childhood diseases
• Asthma, pneumonia, allergies, croup
• Adult illnesses
• Pneumonia, sinusitis, TB, HIV, emphysema, DM,
  HTN, cardiac disease
• Vaccine history
• Flu, pneumonia, BCG

4
Assessment

• Client History
• Surgeries of upper or lower respiratory tract
• Injuries to upper or lower respiratory tract
• Hospitalizations
• Date of last
• CXR, PPD, PFT
• Recent weight loss
• Night sweats

5
Assessment

• Client History
• Sleep disturbances
• How many pillows?
• Family history
• Recent travel
• Occupation
• Leisure activities

6
Assessment

• Client History
• Drug use
• Recreational (marijuana, cocaine, crack)
• Prescription
• ACE inhibitors
• Antihistamines
• Bronchodilators
• Chemotherapy
• OTC
• Allergy medications
• Home remedies
• Herbals Elecampane, Hyssop, Mullein, Licorice

7
Assessment

• Client History
• Allergies
• Foods, drugs, substances
• Allergic response?
• Treatment?
• Diet history
• BMI
• Obese? Malnourished?
• Body weight in pounds times 703 divided by height
  in inches squared
• Food intake related to breathing issues?

8
Assessment

• Client History
• Occupation and Home Life
• Environmental factors and exposure
• Type of heat used in the home
• Animals or pets in home
• Hobbies involving chemicals
• Pest infestation at home or work
• Tie to asthma, wheezing related to roaches

9
Assessment

• Major signs and symptoms
• Cough
• Type, duration, length
• Sputum production
• Color, consistency, amount
• Dyspnea
• Rate of perception
• ADLs
• Paroxysmal nocturnal dyspnea
• Orthopnea

10
Assessment

• Major signs and symptoms
• Chest pain
• Wheezing
• Clubbing of fingers / nails
• Hemoptysis
• Cyanosis

11
Gerontologic Considerations

• Vital capacity and respiratory muscle strength
  peak between 20-25 and then decrease
• Age 40 and older surface area in alveoli is
  reduced
• Age 50 alveoli loses elasticity
• Loss of chest wall mobilitydecrease in vital
  capacity

12
Gerontologic Considerations

• Amount of respiratory dead space increases with
  age
• Decreased diffusion capacity with age lower
  oxygen level in arterial circulation

13
Risk Factors for Respiratory Disease

• Smoking
• Personal / family history
• Occupation
• Allergens
• Recreational exposure

14
Physical Assessment

• Nose and Sinuses
• External nose
• Deformities, tumors
• Nostrils symmetry of size, shape
• Nasal flaring
• Inspect for color, swelling, drainage, bleeding
• Mucous membranes
• Nasal septum
• Bleeding, perforation, deviation

15
Physical Assessment

• Air movement
• Occlude one nare
• Sinuses
• Via palpation
• Tenderness, swelling
• Tapping
• Penlight
• Frontal, maxillary

16
Physical Assessment

• Pharnyx, Trachea, and Larynx
• Posterior pharynx
• Tongue depressor
• One side at a time
• Observe rise and fall of palate and uvula (ah)
• Inspect for color, symmetry, discharge, edema,
  ulceration, tonsillar enlargement
• Neck
• Inspect for symmetry, alignment, masses,
  swelling, bruises, use of accessory neck muscles
  in breathing

17
Physical Assessment

• Neck
• Lymph nodes
• Tender, movable inflammation
• Hard, fixed suggest malignancy
• Trachea
• Palpate for position, mobility, tenderness,
  masses
• Larynx
• laryngoscope

18
Physical Assessment

• Lungs and Thorax
• Inspection
• Palpation
• Fremitus
• 99
• Crepitus
• Bubble wrap
• Chest expansion
• Movement

19
Physical Assessment

• Lungs and Thorax
• Percussion
• Pulmonary resonance
• Air, fluid, solid masses
• Intercostal spaces only
• Diagphragmatic excursion
• Normal 1 -2 inches
• Deep breath / percuss
• No breath / percuss
• Normally higher on the right (liver)

20
Physical Assessment

• Auscultation
• Upright first
• Bare chest
• Open mouth breathing
• Full respiratory cycle
• Observe for dizziness

21
Physical Assessment

• Normal breath sounds
• Bronchial, bronchovesicular, vesicular
• Not heard peripherally
• Adventitious breath sounds
• Additional sounds superimposed on normal sounds
• Indicate pathology
• Crackles, wheezes, rhonchi, pleural friction rub

22
Physical Assessment

• Voice sounds
• Assessed when abnormalities noted
• Increased when sound travels through solid or
  liquid
• Consolidation of lung, pneumonia, atelectasis,
  pleural effusion, tumor, abscess
• Bronchophony 99 loud and clear
• Whispered Pectriloquy 1, 2, 3 loud
• Egophony E heard as an A

23
Physical Assessment

• Skin and Mucous Membranes
• Pallor, cyanosis, nail beds
• General Appearance
• Muscle development, general body build
• Muscles of neck, chest
• Endurance
• How does the client move in 10 20 steps?
• Speaking exertion

24
Diagnostic Assessment

• Need to know
• Normal / abnormal for
• RBC
• Hgb / Hct
• WBC / leukocytes / neutrophils
• Eosinophils
• Basophils
• Lymphocytes
• Monocytes
• ABGs
• Sputum studies
• Skin (PPD) testing

25
Diagnostic Testing

• Chest xrays
• Digital Chest Radiography
• CT
• V/Q Scan
• Pulse Oximetry
• PFTs

26
Diagnostic Testing

• Pulmonary Function Tests (PFTs)
• Used generally in chronic conditions
• Assesses respiratory function
• Determine extent of dysfunction
• Measures lung volumes, ventilatory function, and
  mechanics of breathing, diffusion, and gas
  exchange
• Assesses response to therapy
• Screening test in hazardous industries

27
Diagnostic Testing

• Arterial Blood Gases (ABGs)
• Measures blood pH and arterial oxygen and carbon
  dioxide levels
• Assesses ability of lungs to provide adequate
  oxygen and removal of carbon dioxide
• Assesses ability of kidneys to maintain normal pH

28
Diagnostic Testing

• Pulse Oximetry
• Noninvasive method of monitoring oxygen
  saturation of hemoglobin
• Unreliable in cardiac arrest and shock, dyes or
  vasoconstictor meds used, severe anemia, or high
  carbon monoxide level

29
Diagnostic Testing

• Cultures
• Throat or sputum
• Sputum
• Best to obtain early AM
• Rinse mouth, takes deep breaths, coughs, and
  expectorates
• Deliver specimen to lab within 2 hours

30
Diagnostic Examination

• Endoscopy
• Bronchoscopy, laryngoscopy, mediastinoscopy
• Check for patent airway every 15 minutes post
  procedure for two hours
• Thoracentesis
• Local anesthetic
• Patient must remain still
• Usually at bedside
• Post procedure CXR r/o mediastinal shift,
  monitor VS, auscultate breath sounds
• Lung biopsy

31
Diagnosis

• Upper Airway Medical Diagnosis
• Rhinitis
• Viral rhinitis
• Acute sinusitis
• Chronic sinusitis
• Acute pharyngitis
• Chronic pharyngitis
• Tonsillitis and adenoiditis

32
Diagnosis

• Upper Airway Medical Diagnosis
• Peritonsillar abscess
• Laryngitis
• Upper Airway Nursing Diagnosis
• Ineffective airway clearance
• Acute pain
• Impaired verbal communication
• Fluid volume deficit
• Knowledge deficit

33
Planning and Implementation

• Upper airway
• Maintain patent airway
• Promote comfort
• Promote communication
• Encourage fluid intake
• Teach self care
• Encourage appropriate hand washing

34
Planning and Implementation

• Managing potential complications
• Sepsis
• Sepsis
• Meningitis
• Otitis media

35
Evaluation

• Maintenance of patent airway
• Reports feelings of comfort
• Demonstrates ability to communicate
• Maintains adequate fluid intake
• Identifies strategies to prevent infections
• Becomes free of s/sx of infection
• Demonstrates adequate knowledge

36
Upper Airway Obstruction and Trauma

• Medical Diagnosis
• Sleep apnea
• Obstructive
• Central
• Mixed
• Epistaxis
• Nasal Obstruction
• Fractures of the nose
• Laryngeal Obstruction
• Laryngeal Carcinoma

37
Upper Airway Obstruction and Trauma

• Nursing Diagnosis
• Knowledge deficit
• Anxiety
• Ineffective airway clearance
• Impaired verbal communication
• Nutritional imbalance
• Alteration in body image
• Self care deficit
• Sleep deprivation
• Risk for injury
• Fatigue

38
Planning and Implementation

• Sleep apnea
• Avoid ETOH
• Decrease body mass
• CPAP
• Uvulopalatopharyngoplasty
• Tracheostomy
• Pharmacologic Management
• Low flow O2
• Triptil
• Education

39
Planning and Implementation

• Epistaxis
• Dependent on location of site
• Generally anterior
• Pinch outer portion / sit upright
• Silver nitrate / gelfoam / electrocautery
• Topical vasoconstrictors
• Monitor VS
• Estimate amount of blood loss
• Dont forget standard precautions

40
Planning and Implementation

• Nasal Obstruction
• Deviation of nasal septum
• Submucous resection
• Generally outpatient
• Promote drainage
• Alleviate discomfort
• Frequent oral hygiene

41
Planning and Implementation

• Fractures of the nose
• Bleeding from site
• Bruising
• Clear fluid
• CSF
• Glucose positive
• Surgical reduction one week post injury
• Ice therapy
• Control anxiety
• Oral hygiene

42
Planning and Implementation

• Laryngeal Obstruction
• Often fatal
• Acute laryngitis, urticaria, scarlet fever,
  anaphylaxis, foreign bodies
• Edema SQ Epi 11,000 / corticosteroid
• Abdominal thrust (Heimlich)
• Emergent tracheotomy

43
Planning and Implementation

• Laryngeal Cancer
• Risk factors chart 22-5
• Dependent upon tumor staging (chart 22-6)
• Laryngectomy
• Radiation
• Speech therapy
• Potential complications respiratory distress,
  hemorrhage, infection, wound breakdown

44
Laryngeal Cancer

• Educate preoperatively
• Reduce anxiety
• Maintain patent airway
• Encourage speech therapy
• Maintain adequate nutrition
• Promote positive body image
• Teach self care

45
Evaluation

• Adequate level of knowledge
• Lessened anxiety
• Clear airway
• Acquires effective communication
• Appropriate intake
• Positive self and body image
• Complication free
• Adheres to home therapy

46
Chest and Lower Respiratory Tract

• Medical Diagnosis
• Atelectasis
• Patho figure 23-1
• Acute tracheobronchitis
• Pneumonia
• MUST know table 23-1 and charts 23-2, 23-3
• Review older adult considerations / risk factors
• Assess any older adult with AMS for pneumonia
• May not have cough or fever

47
Nursing Diagnosis

• Ineffective airway clearance
• Activity intolerance
• Fluid volume deficit
• Altered nutrition
• Knowledge deficit
• Impaired gas exchange
• Pain
• Fatigue

48
Planning and Implementation

• Avoid potential complications
• Continuing symptoms
• Shock
• Respiratory failure
• Atelectasis
• Pleural effusion
• Confusion
• Superinfection

49
Planning and Implementation

• Improve airway patency
• Hydration
• Humidification
• Oxygen therapy
• CPT
• Promote rest
• Long recovery periods
• Conserve energy
• Promote fluid intake

50
Planning and Implementation

• Maintain adequate nutrition
• Determine caloric needs with RD help
• Educate client
• Teach self care

51
Evaluation

• Adequate airway patency
• Optimal rest patterns
• Maintains appropriate nutrition and hydration
  status
• Knowledgeable of disease and treatment
• Adheres to treatment strategies
• Complication free

52
Inhalation Injury Smoke and Carbon Monoxide

• Produce local injuries by inflammation,
  irritation, and damage to pulmonary tissues
• Systemic injuries
• S S of CO poisoning
• Mild headache, visual disturbances,
  irritability, nausea
• Severe confusion, hallucinations, ataxia, coma

53
Therapeutic Management

• 100 oxygen
• Artificial ventilation
• Hyberbaric chamber more rapid Tx of CO
  poisoning
• Possible intubation
• Steroids, antibiotics, bronchodilators
• Monitor rate and depth of respirations at least
  every hour

54
Planning and Intervention

• VS assessment / monitoring
• Respiratory assessment
• Pulmonary physiotherapy
• Mechanical ventilation
• Psychological care of child and parents

55
Pulmonary Tuberculosis

• Risk factors (chart 23-4)
• CDC recommendations (chart 23-5)
• Classification of disease
• 0-5 class 3 clinically active
• Older adult
• AMS, fever, anorexia
• Delayed reactivity or recall phenomenon with PPD
• Airborne precautions!!
• Close the door!

56
Nursing Diagnosis

• Ineffective airway clearance
• Knowledge deficit
• Activity intolerance
• Potential for treatment non adherence
• Impaired gas exchange
• Fatigue
• Alteration in nutrition
• Social isolation

57
Planning and Implementation

• Medical Management
• Drug resistance is major problem
• Table 23-2 lists current recommended first line
  drug therapy
• Therapy lasts up to 12 months
• HIV infection has increased prevalence
• Drug therapy should be dispensed in two week
  intervals

58
Planning and Implementation

• Potential Complications
• Malnutrition
• Medication side effects
• Drug resistance
• Determine which clients should participate in
  directly observed therapy (DOT)
• Miliary TB
• Decreased effectiveness with oral contraceptives

59
Planning and Implementation

• Promote airway clearance
• Encourage patient adherence
• Promote adequate nutrition
• Encourage rest
• Educate patient regarding routes of transmission
  and disease manifestations
• More people are infected than have active TB
• Teach self care

60
Evaluation

• Maintain patent airway
• Adequate level of knowledge
• Adheres to treatment regimen
• Participates in self care
• Maintains optimal rest patterns
• Complication free

61
Lung Abscess

• Causative factors
• Bacterial pneumonia
• Oral aspiration / obstruction
• Nursing Diagnosis
• Airway clearance
• Knowledge deficit
• Alteration in nutrition

62
Planning and Implementation

• Administer AB therapy
• Monitor for adverse effects
• CPT
• TCDB
• Appropriate nutritional intake
• Emotional support
• Educate regarding self care

63
Pleural Condition Diagnoses

• Medical Diagnosis
• Pleural Conditions
• Pleurisy
• Pleural effusion
• Empyema
• Nursing Diagnosis
• Anxiety
• Pain
• Knowledge Deficit
• Self Care Deficit
• Alteration in Nutrition
• Airway Clearance

64
Planning and Implementation

• Pleural friction rub, decreased fremitus, absent
  breath sounds
• Pain relief, comfort measures
• TCDB
• Thoracentesis
• Implement medical regimen
• Monitor chest tube drainage
• Empyema long healing process

65
Diagnosis

• Pulmonary Edema
• Life threatening
• Generally, abnormal cardiac function
• flash pulmonary edema post surgery
• Crackles in bases, increasing throughout
• Nursing Diagnosis
• Airway clearance
• Cardiac function
• anxiety

66
Planning and Implementation

• Administer O2
• Assist with ventilation as appropriate
• Medication administration
• Monitor patient response
• Educate and prepare patient and family

67
Diagnosis

• Acute Respiratory Failure
• Difference between acute and chronic
• Chronic COPD / neuromuscular dx
• Acute VP mismatch, alveolar hypoventilation,
  PaO2
• Nursing Diagnosis
• Similar to other airway constrictive disease
  states

68
Planning and Implementation

• Assist with intubation / mechanical ventilation
• Monitor response
• Prevent complication
• Enable communication
• Educate family and patient

69
Diagnosis

• Acute Respiratory Distress Syndrome
• Inflammatory trigger
• Nursing Diagnosis
• Airway clearance
• Anxiety
• Pain
• Nutritional alterations

70
Planning and Implementation

• Close monitoring
• Ventilator support
• CPT
• Frequent assessment
• Education
• Rest and comfort measures

71
Pulmonary Hypertension

• Causes Chart 23-7
• Nursing Management
• Identify high risk patients
• Educate regarding s/sx
• Oxygen therapy

72
Cor Pulmonale

• Right ventricle enlargement
• Generally, from COPD
• S/ Sx generally r/t underlying disease state
• Treatment related to addressing underlying
  disorder

73
Pulmonary Embolism

• Risk factors Chart 23-8
• Home care Chart 23-9
• Diagnosis CXR, ECG, V/P scan, ABGs
• Nursing diagnosis
• Knowledge deficit
• Anxiety
• Airway clearance
• Pain
• Decreased cardiac output
• Risk for injury (bleeding)

74
Planning and Intervention

• Improve respiratory and vascular status
• Anticoagulation therapy
• Thrombolytic therapy
• Surgical intervention
• Rare
• Minimizing risk most important step
• Monitor therapy
• Manage pain

75
Sarcoidosis

• Hypersensitivity response
• Biopsy required for diagnosis
• Corticosteroid therapy
• May involve other body systems

76
Occupational Lung Diseases

• Medical Diagnosis
• Silicosis
• Coal workers pneumoconiosis
• Asbestosis
• Prevention is key
• Educate clients to wear a mask
• Consider also hobbies

77
Diagnosis

• Lung and Chest Carcinoma to be covered in
  oncology section
• Chest Trauma to be covered during trauma
  seminar
• Aspiration similar to pneumonia and obstructive
  disorders
• High risk in patients with altered LOC
• Do not force feed clients!

78
Chronic Obstructive Pulmonary Disease

• Airflow limitation
• Irreversible
• Chronic bronchitis, emphysema
• Risk factors Chart 24-1
• Three primary symptoms
• Cough
• Sputum production
• Dyspnea

79
Assessment

• Spirometry evaluation of airflow obstruction
• Ratio of FEV FVC
• Less than 70
• Health history overview chart 24-2
• Assessment chart 24-3
• Stages of COPD table 24-1
• Crackles

80
Nursing Diagnosis

• Impaired gas exchange
• Ineffective airway clearance
• Ineffective breathing pattern
• Activity intolerance
• Knowledge deficit
• Ineffective coping
• Anxiety
• Alteration in nutrition
• Fatigue

81
Planning and Implementation

• Potential complications
• Respiratory insufficiency
• Chronic respiratory failure
• Acute respiratory failure
• Atelectasis
• Pulmonary infection
• Pneumonia
• Pneumothorax
• Pulmonary hypertension

82
Planning and Implementation

• Promote smoking cessation
• Improve gas exchange
• Medication administration
• Measure improve in flow rates
• Airway clearance
• CPT
• Controlled coughing
• Huff coughing
• Increased fluids

83
Planning and Implementation

• Improving breathing patterns
• Inspiratory muscle training
• Diaphragmatic breathing
• Pursed lip breathing
• Standing against wall
• Over bedside table with pillows
• Improving activity tolerance
• Determine limitations
• Determine client preferences
• Pacing activities
• Exercise training

84
Planning and Implementation

• Self care strategies
• Realistic goal setting
• Heat / cold extremes
• Heat increases oxygen demands
• Cold promotes bronchospasms
• Lifestyle modification
• Coping strategies
• Self care teaching

85
Evaluation

• Knowledgeable of smoking dangers
• Improved gas exchange
• Achieves maximal airway clearance
• Improves breathing pattern
• Demonstrates strategies for activity tolerance
  and self care
• Effective coping
• Avoids complications

86
Bronchiectasis

• Separate from COPD now
• Management similar to COPD
• CPT
• Smoking cessation
• Postural drainage
• Energy conservation measures

87
Asthma

• Chronic inflammatory disease
• Sxs cough, chest tightness, wheezing, dyspnea
• Is reversible
• Most common chronic disease of childhood
• Predisposing factors
• Allergens
• Airway irritants
• Exercise
• Stress
• Sinusitis
• Medications
• Viral respiratory tract infections
• GERD

88
Asthma

• Nursing Diagnosis
• Anxiety
• Airway clearance
• Breathing patterns
• Fluid volume deficit
• Knowledge deficit

89
Assessment

• Health history
• Comorbid conditions
• Sputum cultures / serum samples
• Elevated levels of eosinophils
• ABG / pulse ox
• Hypoxemia during attacks
• Hypocapnia and respiratory alkalosis
• PaCO2
• May rise initially
• Return to baseline indicative of impending
  respiratory failure

90
Planning and Intervention

• Prevention is key
• Pharmacology
• Long acting corticosteroids, anti-inflammatory
  agents
• Quick relief relief of acute symptoms,
  bronchodilators
• Table 24-4 details medications
• Oxygen therapy is often indicated during acute
  attacks
• Can be mixed with helium (Heliox) to improve
  delivery to the alveoli

91
Planning and Intervention

• Peak flow monitoring
• Daily is recommended
• Monitor respiratory status
• Thorough history of allergens
• Medication administration
• Fluid administration
• Intake and output recording
• Preparation for mechanical ventilation

92
Planning and Intervention

• Prevention of complications
• Status asthmaticus
• Respiratory failure
• Pneumonia
• Atelectasis
• Airway obstruction
• Dehydration

93
Status Asthmaticus

• Attack that does not respond to conventional
  therapy
• Close monitoring first 12-24 hours
• Volume status closely monitored
• Energy conservation
• No respiratory irritants
• Nonallergenic pillow

94
Cystic Fibrosis

• Airflow obstructive disease with genetic
  component
• Elevated sweat chloride
• 60 mEq/L
• Steatorrhea
• Control of infections key
• Nursing interventions similar to other
  obstructive diseases
• Lung transplantation small number
• End of life care important

95
Respiratory Procedures

• Inhalation therapy
• Oxygen therapy
• Humidification
• Aerosol therapy
• Artificial ventilation
• Continuous positive airway pressure (C-PAP)

96
Oxygen Therapy

• Nasal cannula / mask / tent
• Apply to anyone who is hypoxic or with stridor
• Considerations
• Avoid open flames and electrical appliances
• Monitor response
• Adverse effects to premature infants retina
• Caution with COPD
• Oxygen toxicity
• Use humidification
• Check skin integrity

97
Aerosol Therapy

• Used to deposit medications directly into airways
• Types
• Hand-held nebulizers
• Metered-dose inhaler (MDI)
• Spacer device
• Close the door when administering

98
Chest Physiotherapy (CPT)

• Postural drainage in conjunction with adjunctive
  techniques
• Manual percussion, vibration, squeezing the
  chest, cough, forceful expiration, and breathing
  exercises
• Considerations
• Percuss over rib cage
• Used in increased sputum production

99
CPT

• Contraindications
• Pulmonary hemorrhage
• Pulmonary embolus
• ESRD
• Increased intracranial pressure
• Minimal cardiac reserves

100
Artificial Ventilation

• Nasotracheal
• Orotracheal
• Tracheostomy
• Considerations
• In children, tubes have more acute angle and are
  softer to mold to contours of trachea

101
Smoking Cessation

• Anyone who smokes is an increased risk for
  pulmonary problems
• Assist clients interested in smoking cessation
  programs
• Teach all clients who smoke the warning signs of
  lung cancer

102
Thats All, Folks!

• Any questions or comments?