ARDS
What is Acute Respiratory Distress Syndrome (ARDS) & Acute Respiratory Failure (ARF)?
Diffuse inflammatory damage to alveolar capillary memberans, inflammatory exudate builds up in alveoli and causes collapse. Shunting of blood. decreased perfusion, increased capillary pressure. hypoxiema. Imparied gas exchange leads to multisystem organ failure. It is a secondary disorder cause by something such as sepis, trauma or shock.
ARF- Hypoxemic failure (Low O2 and High Co2)
What is Pneumonia?
Inflamation and infection of lung tissue such as alevoli and bronchioles.
Pneumonia influenza most common cause of infectious disease death in US.
Pathogen invades lower resp tract; antigen-antibody response; endotoxins released; inflammatory respones; hypoventilation; ventilation-perfusion mismatch- poor oxygenation, hypoxemia
What do chest tubes do?
Drain fluid, blood, pus or air from pleural space within the lung inorder to re-expand a collapsed lung. To restore negative pressure from the pleural space.
Inserting the CT into the pleural space sucks out the air, fluid blood into a closed 1-way drainage system.
What is Chronic Obstructive Pulmonary Disease?
Not fully reversible and lmited air flow due to chronic bronchitis and or emphysema. Chronic destruction of lung tissue leading to chronic air trapping and high CO2.
3rd leading cause of morbidity in the US.
85-90% due to a history of cigarette smoking.
May also be due to antitrypsin deficiency.
What is Asthma?
A chronic inflammatory disorder in the the bronchi and brochials. Episodic and reversible air flow limitation and reactivity.
Factor which may trigger asthma exacerbations- stress, excercise, cold air, respiratory viruses, allergens, cigarrette smoke, air pollution
What is Tuberulosis (TB)?
Bacterial infection caused by M. Tuberculosis.
Spread by airborne route. Inhaled in the lungs and spread to lymph and blood stream
What are the different types of respiratory inhalers?
Bronchodilators- Beta 2 Agonists= albuterol; Anticholinergics=Ipratropium; Methylxanthines=theophylline
Anti-inflammatory- steroids=fluticasone, beclamethasone; leukotriene inhibitor=montilukast; Mast Cell Stabilizer=cromolyn
Theophylline leverl- 10-20 mg/dl
Asthma Attack priority meds AIM
#1 Albuterol- A
#2 Ipratropium- I
#3 Methylprednisolone- Solu Medrol _m
What is the medical managment for ARDS?
Identify primary disorder. Agressive respiratory support including PEEP (improve alveoli function). increase FiO2 to keep PaO2>60 mm Hg; Spo2>90%
Balance fluid resuscitation. treat shock.
MORTALITY RATE- 35-60%
What are the different types of Pneumonia?
Community Acquired (CAP)- <48 hrs after hosp admission.Pneumoniae most common etiology; increasing age and comobity are risk factors.
Healthcare Acquired (HCAP)- non hosp but extensive healthcare contact; previous hosp in past 90days; family member with multi drug infection.
Hosptial Acquired (HAP)- Diagnosed 48 hrs or more after hospital admission but not prior to admission.Pneumoniae, Enterbactorer, E.Coli, influenxa, Klebsiella infections. risk factors are comorbiity, prolonged hosp, increased exposure, elderly.
Ventilator Associated (VAP)- Endotracheally intubated, ventilated 48 + hrs. Risk factors is length of mechanical ventialation. High mortality rate.
What are the 3 Chest tube chambers and their function?
1. suction
2. water seal and air leak monitor
3. collection chamber
What are the signs, symptoms and lab values for COPD?
Chronic productive cough 3+ months over 2+ years
Bronchial walls thicken d/t chronic inflammation, impedes airflow, cannot maintain oxygen levels
Alveolar walls adjacent to bronchioles become thickened, fibrosed
Impaired Ventilation: increased mucus, obstruction of small airways, chronic productive cough
Viral, bacterial respiratory infections common (alveolar macrophages dysfunctional d/t damage)
Low PaO2- Hypoxemia and High PaCo2-hypercapnic.
What are signs and symptoms of asthma?
A- accessory muscle use
S- shortness of breath and dyspnea
T- tight chest and tachypnea
H- high pitched wheezing
M- minimal diminished breath sounds
A- Absent breath sounds (silent chest) PRIORITY, acidosis, air trapping (prolonged expiration)
MAY LEAD TO RESPIRATORY FAILURE= High CO2, hypercapnic; Respiratory acidosis- PaOs< 80 Hypoxic
What are the signs and symptoms of TB?
Night sweats, anorexia/ weight loss, cough and hemoptysis- blood tinged sputum
dyspnea and SOB
fever and chills.
What are risk factors for Lung CA? What is the most common Lung CA?
Risk factors include tobacco smokin is the major cause (90%). Second hand smoke or radon gas, asbestos, arsenic, chromium, coal dust, iron oxides, nickel, radioactive dustand uranium
Most common Lung CA- Non-small cell lung cancer.
Adenocarcinoma is a non-small cell lung cancer most frequently in women who are non-smokers
What is a complication of ARDS?
Pneumothorax due to plumonary scarring. May require Chest tube to reinflate.
What is the medical management of Pneumonia?
Broad spectrum antibiotics for bacterial infection.
Supportive care- hydration, rest, antitussive, antihistamine, decongestants.
NOT COUGH SUPPRESSANTS.
What are signs the chest tube is not functioning correctly or need attention?
1. Suction chamber- vigorous bubbling or no bubbling.
2. Water seal/air monitoring- Continuous bubbling may be an air leak. Tidaling has stopped may indicate lung has re-expanded (not necessarily bad but should be reported)
3. Collection Chamber- over 100ml/hr of bright red blood may indicated bleeding and needs to be reported.
What are signs and symptoms of Empysema?
PINK PUFFER- damage to alveloi results in loss of lung elasticity & loss of inflation of lung tissue. results in loss of lung tissue recoil and air trapping.
P-pink skin, pursed lip breathing
I Increased chest- barrel chest
N= Minimal or NO chronic cough
K- Keep tripoding
What are danger signs of an asthma exacerbation?
1. agitation
2. restlessness
3. drowsiness
Status asthmaticus- may require endotracheal intubation
How is TB diagnoses?
Positive INTRADURMAL Mantoux testing over 15mm duration= positive TST AND
Chest x-ray and positive sputum cultures
3 sterile positive sputum cultures in 3 consectutive days
What is pleurisy? What are the priorty nursing interventions for pleurisy?
Pleurisy is inflammation of the pleural membrane causing sharp pain with inspiration.
Nursing interventions focus on avoidance of pneumonia. Need to give opioids for pain management before coaching patient to cougha & deep breathe, use incentive spirometer.
What is the nursing assessment in ARDS?
Assessment- recognize early. May mimic pul edema.
First sign of hypoxemia- Agitation, restlessness, confusion.
Increasing anxiety, SOB, tachypnea, dyspnea.
Decreased breath sounds with crackles. Retractions.
Hypoxemia despite high FiO2. Hypotension, Tachycardia. shock. pulmonary hypertension.
What are the nursing interventions for pneumonia?
Turn cough and deep breathing, avoid cough suppressants, give antitussives- codeine, huff coughing, fluids 2-3L day, high fowler's, truning- good lung down for hypoxia, infected lung up. Early ambulation, Incentive spirometer;
Respiratory assessment- may begin as a URI & progresses to lower resp tract, high fever is typically bacterial pneumonia (101 plus chills), viral is low grade.
Assess respirations for tachypnea, progressive dyspnea, orthopnea, productive cough, pleuritic chest pain with cough, fatigue, malaise, diaphoresis, anorexia.
Anticipate- Chest X-ray, sputume culture, blood culutre, infiltrates, consolidations on chest x-ray. Sputum culture BEFORE antibotics
What do you do if the Chest tube is disconnected or falls out?
CHEST TUBE IS OUT- 1. Instruct patient to cough and exhale immediatedly
2. Apply occlusive (petroleum gauze) dressing secured on only 3 sides.
CHEST TUBE DISCONNECTED- place distal end into 250ml of sterile saline
CHEST TUBE REMOVAL- tell pt to deep breathe, hold and bear down.
NEVER- milk or strip chest tubes. clamp a chest tube.
What are signs and symptoms of Chronic Bronchitis?
Inflammation of the bronchi and excessive mucus production resulting in a chronic hacking cough and recurrent infection.
B- big and blue skin- cyanosis (hypoxia)
L- long term chronic cough and sputum
U- Unusual lung sounds- crackles and wheezes
E- Edema peripherally due to cor pulmonale
What are the key points of asthma teaching?
Asthma action plan based on Peak Expiratory FLow Rate.
Green zone- Asthma is 80-100% and under control
Yellow Zone- Asthma is NOT in good control. Avoid triggers. need to take rescue inhaler every 4 to 6 hrs for 1-2 days and call HCP for more treatment if necessary.
Red Zone- Really Bad@ Emergency treatment is needed immediately if the peak flow doesnt' return to yellow zone after taking rescue inhaler.
What are priority nursing action if a patient is suspected to have TB?
Airborne precautions; private room
Proper PPE everytime you enter the patient's room.
What are priority Nursing interventions for rib fractures and flail chest?
Assess for paradoxial chest wall movement; extreme chest pain and shallow respirations.
These patients are high risk for pneumonia and respiratory failure due to Co2 retention- hypercapnic
Nursing priorities- pain control and pulmonary hygiene- TCDB and incentive spirometer to expand lungs and prevent atelectasis.
What are the nursing diagnoses for ARDS?
Impaired Breathing Pattern- impaired respiratory function, inflammatory response, pain.
GOAL- Restore regular rate, rhythm, deep ventilation
What is a complicaiton of Pneumonia?
Pleural Effusion- fluid fills pleural space prevention of full expansion of lungs, decreased gas exchange.
Asymetrical chest expansion, decreased breath sounds, diminished breath sounds. dull resonance on percussion, refractory hypoxemia- low PaO2.
Septic Shock- infection in the blood; may lead to multisytem organ failure; look for severly low BP and perufsion. BP<90 systolic MAP,65 mm Hg, cap refill more than 3-4 seconds, tachcardia, fever, hypothermia
What are your priority assessments and equipment for a patient with a chest tube?
Every 2 hours listen to breath sounds, check dressing around chest tube for blood or pus.
Check for subcutaneous emphysema- (air trapped under the skin). Normal to be present immediately following a CT insertion. Assess/palpate for the crepitus to spread by marking the skin after insertion. If crepitus is growing, call HCP.
ASSESS PATIENT FIRST then chest tube!
Chest tubes should be no more than chest level or lower for proper draiange and maintaining neg pressure.
Always have a sterile connector, padded clamp and pertroleum gauze at the bedside!
What are the nursing priorities and interventions for patient with COPD?
Proper positioning- sit patient upright/high fowler's
May need BiPAP- to decrease hypercapnea
Avoid opioids & benzodiazepenes because the decrease breathing which may worsen oxygenation status/respiratory acidosis.
Anxiety- COPD patients are frequently anxious due to the inability to breathe. Assist with relaxation techniques and pursed lip breathing to prevent air trapping and airway collapse during expiration
What is the correct Metered Dose Inhaler technique?
Remove cap. Shake for 10 seconds. Prime inhaler if it is the first use or not used for 2 weeks. Gently exhale all air from the lungs. Place the inhaler mouth piece around lips and avoid tongue from blocking opening. As you press the inhaler, take a deep slow inhalation. Hold breath for at least 10 seconds. Repeat as directed.
If patient can't coordinate the correct inhalation technique or coughing which is a sign the medicine is hitting the back of the throat, they may need a spacer or holding chamber to enhance their inhaler technique.
What are the 4 TB meds and their precautions with administration and monitoring?
RIPE
Rifampin- RED-FAMPIN- normal to see red, orange in tears urine and sweat. Pts should not wear contacts due to discoloration of tears; oral contraceptives are NOT effective; use back up birth control, monitor for jaundice; heptotoxic!
INH Isoniazid- interferes with Vit B6 so monitor for peripheral neuropathy- new numbness, tiingling extremities, ataxia. Pts may be on Vit B6 25-50mg daily for supplementation. Hepatotoxic- report jaundice, dark urine, elevated liver enzymes (HOLD MEDS); NO ETOH
Pyrazinamide- 3rd TB drug; hepatotoxic
Ethambutol= EYE; May cause blurred vision, color changes!
How is CF Diagnosed?
What is nursing inteventions for CF?
Sweat test, DNA and stool test.
Normal findings for CF- recurrent lung infections, blood tinged sputum, weight loss, loss of appetite, loos fatty stool or steatorrhea= mucus build up and lack of enzymest to help breakdown fat.
Nursing care- High calorie diet, pancreatic enzymes with all meals, increase fluid intake, excercise, chest physiotherapy, postural drainage, financial counseling for expensive treatments
What are the nursing interventions for ARDS?
HOLY- High fowler's, oxygen and suctioning, listent ot lung sounts, yell for help (notify HCP)
Monitor respiratory status. Positioning to optimize inhalation and chest expansion.
Freq turning to improve ventilation and perfusion
**Prone positioning may be utilized to max oxygenation.
Promote comfort.
Monitor for complications- pneumothorax, PE/blood clots
What are important discharge instructions for a patient with pneumonia?
Discharge instructions- avoid cough suppressants, cool mist humidifier, increase fluids, incentive spirometer, ambulation; finish oral antibiotics, pneumonia vaccine, smoking cessation, handwashing, follow up chest x-ray, report increasing or worsening symptoms.
What are the good signs of the CT chambers to demonstrate proper functioning?
1. Suction chamber- continuous suctioning with a gentle and steady continuous bubbling.
2. Water seal/air leak- Tidaling (rise and fall). Demonstrates the lung has not yet re-expanded.
3. Collection Chamber- Dark blood =document.
Promote health eating- small frequent meals with rest periods, high calorie and high protien.
Avoid- high carbs, exercise 1 hour before/after meals to conserve energy. Avoid gassy foods.
Increase fluid intake (8 glasses or 2-3L daily) to thin mucous. Avoid drinking fluids with meals.
Report increase in sputum, fever or worsening dyspnea.
Prevention- pneumococcal every 5 years, flu vaccine every year.
Meds- good inhaler technique. Always have albuterol to lessen cough and wheezing.
Bronchitis- guaifensesin and cool mist humidifier to mobilize secretions.
Pursed lip breathing- inhale 2 seconds, exhale 4 seconds.
Hugg coughing technique- sit upright in chair, deep slow inhalation, hold breath for 2-3 seconds and then forcefully exhale.
What can you teach your asthma patient about avoiding triggers?
Avoid animal dander, dust, pollen, cigarrette smoke, poor air quality days. Stress reduction. May need to pretreat with albuterol inhaler 30 mins prior to excercise.
Drugs to avoid- NSAIDs- Naproxen, asipirin, ibuprofen, indomethacin and ketorolac
TB Treatment NCLEX tips
Medication treatment 6-12 months
You must weark N-95 mask with patient care at all times.
Family must be tested for TB because of exposure.
Sputum samples are collected every 2-4 weeks.
Pt is no longer infected if they have 3 negative cultures on 3 different days.
What is a Pulmonary Embolism? What are the signs and symptoms? What is the diagnostic test for determining a possible PE?
PE is a clot (blood, fat) that obstructs the pulmonary artery which prevents blood flow, deadly hypoxemia and possible death.
Priorty- Impaired gas exchange related to imbalance of ventilation and perfusion mismatch
Risk factors- obesity, immobility, heart valve issues or afibrillation, estrogen birth control.
Signs and symptoms- hypoxemia- restlessness, aggitation, mental status changes, chest pain, SOB, dyspnea, tachypnea, tachycardia and anxiety.
High D-Dimer blood test indicates high risk for blood clotting disorder or blood clots somewhere in the body.