ARDS
What is Acute Respiratory Distress Syndrome (ARDS) & Acute Respiratory Failure (ARF)?
Diffuse inflammatory damage to alveolar capillary membranes, inflammatory exudate builds up in alveoli and causes collapse. Shunting of blood. decreased perfusion, increased capillary pressure. hypoxemia. Impaired gas exchange leads to multisystem organ failure. It is a secondary disorder caused by something such as sepsis, 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 management for ARDS?
Identify the primary disorder. Aggressive 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.Pneumonia's most common etiology; increasing age and comorbidity are risk factors.
Healthcare Acquired (HCAP)- nonhospital but extensive healthcare contact; previous hosp in past 90 days; family member with multi-drug infection.
Hospital 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 comorbidity, prolonged hosp, increased exposure, and elderly.
Ventilator Associated (VAP)- Endotracheally intubated, ventilated 48 + hrs. The risk factor is the length of mechanical ventilation. 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 the 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 and rest
Supportive care can include expectorants (not suppressants), cough medicines like Mucinex or Robitussin decongestants, or nasal sprays.
NOT COUGH SUPPRESSANTS and antitussives: Codeine.
Always culture to determine the bacterial source.
What are the signs the chest tube is not functioning correctly or needs 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 the lung has re-expanded (not necessarily bad but should be reported)
3. Collection Chamber- over 100ml/hr of bright red blood may indicate bleeding and needs to be reported.
What are the signs and symptoms of Emphysema?
PINK PUFFER- damage to alveoli 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 diagnosed?
Positive INTRADERMAL Mantoux testing over 15mm duration= positive TST AND
Chest x-ray and positive sputum cultures
3 sterile positive sputum cultures in 3 consecutive days
What is pleurisy? What are the priority nursing interventions for pleurisy?
Pleurisy is inflammation of the pleural membrane causing sharp pain with inspiration.
Nursing interventions focus on the avoidance of pneumonia. Need to give opioids for pain management before coaching patient to cough & deep breath, use an 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,
Rest
avoid cough suppressants and antitussives- codeine
fluids 2-3L day, high Fowler's, turning- good lung down for hypoxia, infected lung up. Early ambulation, Incentive spirometer;
Antibiotic Therapy
Respiratory assessment- may begin as a URI & progresses to lower resp tract. High fever is typically bacterial pneumonia (101 plus chills), and viral is low grade.
Assess respirations for tachypnea, progressive dyspnea, orthopnea, productive cough, pleuritic chest pain with cough, fatigue, malaise, diaphoresis, and anorexia.
Anticipate- Chest X-ray, sputum culture, blood culture, infiltrates, consolidations on chest x-ray. Sputum culture BEFORE antibiotics
What do you do if the Chest tube is disconnected or falls out?
CHEST TUBE when it is out not pulled by medical staff
1. Apply occlusive (petroleum gauze) dressing secured on only 3 sides.
2. assess pt, call provider
CHEST TUBE DISCONNECTED- place distal end into 250ml of sterile saline
CHEST TUBE REMOVAL- tell pt to deep breathe, hold and bear down.
2. Apply occlusive (petroleum gauze) dressing secured on only 3 sides.
NEVER- milk or strip chest tubes. clamp a chest tube.
What are the signs and symptoms of Chronic Bronchitis?
Inflammation of the bronchi and excessive mucus production result 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 a 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 doesn't return to the yellow zone after taking the rescue inhaler.
What is the 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 patients with COPD?
Proper positioning- sit patient upright/high Fowler's
May need BiPAP- to decrease hypercapnia
Avoid opioids & benzodiazepines because they 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 the lips and avoid the tongue from blocking the opening. As you press the inhaler, take a deep slow inhalation. Hold your breath for at least 10 seconds. Repeat as directed.
If the 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, and orange in tears urine, and sweat. Pts should not wear contacts due to discoloration of tears; oral contraceptives are NOT effective; use backup birth control, monitor for jaundice; hepatotoxic!
INH Isoniazid- interferes with Vit B6 so monitor for peripheral neuropathy- new numbness, tingling 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 and color changes!
How is CF Diagnosed?
What are nursing interventions for CF? Name 2
Sweat test, DNA, and stool test.
Normal findings for CF- recurrent lung infections, blood-tinged sputum, weight loss, loss of appetite, loose fatty stool or steatorrhea mucus build up and lack of enzymes to help break down fat.
Nursing care- High-calorie diet, pancreatic enzymes with all meals, increased fluid intake, exercise, 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 essential discharge instructions for a patient with pneumonia?
Discharge instructions- avoid cough suppressants or antitussives, 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.
What are the vital patient teachings for patients with COPD?
Promote healthy eating- small frequent meals with rest periods, high calories and high protein.
Avoid- high carbs, and 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 an 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- guaifenesin and cool mist humidifier to mobilize secretions.
Pursed lip breathing- inhale for 2 seconds, exhale for 4 seconds.
Hugg coughing technique- sit upright in a chair, deep slow inhalation, hold your 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 wear an N-95 mask with patient care at all times.
The 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.
Priority- Impaired gas exchange related to an imbalance of ventilation and perfusion mismatch
Risk factors- obesity, immobility, heart valve issues or a fibrillation, estrogen birth control.
Signs and symptoms- hypoxemia- restlessness, agitation, 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.