34793398 respiratory diagnostics and care mod ali ties

8/9/2019 34793398 Respiratory Diagnostics and Care Mod Ali Ties

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Copyright © 2008 Lippincott Williams & Wilkins.

Respiratory Care




Diagnostic

Assessment




Skin Test: Mantoux Test or TuberculinSkin Test

• This is used to determine if a person has been infected or hasbeen exposed to the TB bacillus.

• This utilizes the PPD (Purified Protein Derivatives).

• The PPD is injected intradermally usually in the inner aspectof the lower forearm about 4 inches below the elbow.

• The test is read 48 to 72 hours after injection.

• (+) Mantoux Test is induration of 10 mm or more.

• But for HIV positive clients, induration of about 5 mm isconsidered positive

• Signifies exposure to Mycobacterium Tubercle bacilli




Sputum Examination

• Laboratory test

• Indicated for microscopic examination of the sputum: Gross appearance,Sputum C&S, AFB staining, and for Cytologic examination/ Papanicolaouexamination

Nursing interventions:

• Early morning sputum specimen is to be collected (suctioning orexpectoration)

• Rinse mouth with plain water• Use sterile container.

• Sputum specimen for C&S is collected before the first dose of anti-microbial therapy.

• For AFB staining, collect sputum specimen for three consecutive

mornings.




Pulse Oximeter

• Non-invasive method of continuously monitoring

he oxygen saturation of hemoglobin

• A probe or sensor isattached to thefingertip, forehead,

earlobe or bridge of thenose


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• Sensor detects changes inO2 sat levels by monitoringlight signals generated bythe oximeter and reflectedby the blood pulsingthrough the tissue at theprobe



• Normal SpO2 = 95% - 100%

• < 85% - tissues are not receivingenough O2

• Results unreliable in:– Cardiac arrest

– Shock

– Use of dyes or vasoconstrictors

– Severe anemia

– High carbon monoxide Level



IMAGING STUDIES

X - ray

CT ScanMRIFluoroscopyPulmonary AngiographyVentilation - Perfusion ScanGallium ScanPET



Chest X-Ray



Front View Side View



Computed Tomography Scan



• This chest CT scan shows a cross-section of a personwith bronchial cancer. The two dark areas are thelungs. The light areas within the lungs represent thecancer.



Magnetic Resonance Imaging

• Similar to CT

scan exceptthat magneticfields andradiofrequencysignals are used

instead of narrow beam-xray.



Fluoroscopy

• Fluoroscopy is a studyof moving bodystructures - similar toan x-ray "movie." A

continuous x-ray beamis passed through thebody part beingexamined, and istransmitted to a TV-

like monitor so thatthe body part and itsmotion can be seen indetail.



Pulmonary Angiography

• This procedure takes X-ray pictures of the

pulmonary blood vessels(those in the lungs).

• Because arteries andveins are not normally

seen in an X-ray, acontrast material isinjected into one ormore arteries or veinsso that they can be

seen.

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• This test is a venous study to lookat the vessels supplying the lungs tolook for any abnormalities.

• Local anaesthetic is given to numbthe area. A small, thin tube called acatheter is inserted into a vein,usually the femoral vein, near thegroin. The catheter is then placed tobest view the veins supplying thelungs. A contrast medium is injectedthrough the catheter.

• Once the radiologist has viewed thepictures taken, he/she will press atthe puncture site for 5 minutes. Thetest takes approximately ½ an hour.You will be on bed rest for 3 hours.



Ventilation - Perfusion Scan

• Radioactive albumininjection is part of anuclear scan test that isperformed to measurethe supply of bloodthrough the lungs.

• After the injection, the

lungs are scanned todetect the location of theradioactive particles asblood flows through thelungs.



• The ventilation scan is used to evaluate theability of air to reach all portions of the lungs.The perfusion scan measures the supply of blood through the lungs.

• A ventilation and perfusion scan is most oftenperformed to detect a pulmonary embolus. It isalso used to evaluate lung function in peoplewith advanced pulmonary disease such as COPDand to detect the presence of shunts (abnormalcirculation) in the pulmonary blood vessels.

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Gallium Scan

• It is a type of nuclear scan involvingradioactive gallium which helps determinewhether a patient has inflammation in thelungs.

• Gallium is injected in a vein and a series of x-rays are taken to identify where thegallium has accumulated in the lungs.

• This test is most often performed whenthere is evidence of inflammation in thelungs (sarcoidosis).



Indirect Bronchography

•A radiopaque medium is instilled directly into the

trachea and the bronchi and the outline of the entirebronchial tree or selected areas may be visualized

through x-ray.

•It reveals anomalies of the bronchial tree and is

important in the diagnosis of bronchiectasis.



• Nursing interventions BEFORE BronchogramSecure written consent

Check for allergies to sea foods or iodine or anesthesia

NPO for 6 to 8 hours

Pre-op meds: atropine SO4 and valium, topicalanesthesia sprayed; followed by local anesthetic injected

into larynx. The nurse must have oxygen and anti

spasmodic agents ready.

• Nursing interventions AFTER Bronchogram

Side-lying position

NPO until cough and gag reflexes returned

Instruct the client to cough and deep breathe client




Positron Emission Tomography




Lung Scan

• Procedure using inhalation or I.V. injection of

radioisotope, scans are taken with a scintillationcamera.

• Imaging of distribution and blood flow in the

lungs. (Measure blood perfusion)

• Confirm pulmonary embolism or other blood- flow

abnormalities




Nursing interventions BEFORE the procedure:Allay the patient’s anxiety

Instruct the patient to Remain still during the procedure

Nursing interventions AFTER the procedureCheck the catheter insertion site for bleeding

Assess for allergies to injected radioisotopes

Increase fluid intake, unless contraindicated.




Endoscopic Procedure

BronchoscopyEndoscopic ThoracoscopyThoracenthesis




Bronchoscopy• Bronchoscopy is a surgical

technique for viewing the interiorof the airways.

• Using sophisticated flexible fiber

optic instruments, surgeons areable to explore the trachea, mainstem bronchi, and some of thesmall bronchi.

• In children, this procedure maybe used to remove foreign objects

that have been inhaled.• In adults, the procedure is most

often used to take samples of (biopsy) suspicious lesions andfor culturing specific areas in thelung.




• A bronchoscope is a tube with a

tiny camera on the end which isinserted through the nose (ormouth) into the lungs.

• During a bronchoscopy procedure,a scope will be inserted through

the nostril until it passes throughthe throat into the trachea andbronchi.

• A bronchoscope is used to providea view of the airways of the lung(tracheobronchial tree).

• The scope also allows the doctorto collect lung secretions and lungtissue for biopsy for tissuespecimens.




Nursing interventions BEFORE Bronchoscopy

Informed consent/ permit needed

Explain procedure to the patient, tell him what to expect, to help

him cope with the unkown

Atropine (to diminish secretions) is administered one hourbefore the procedure

About 30 minutes before bronchoscopy, Valium is given to

sedate patient and allay anxiety.

Topical anesthesia is sprayed followed by local anesthesiainjected into the larynx

Instruct on NPO for 6-8 hours

Remove dentures, prostheses and contact lenses

The patient is placed supine with hyperextended neck during

the procedure




Nursing interventions AFTER Bronchoscopy

Put the patient on Side lying position

Tell patient that the throat may feel sore with .

Check for the return of cough and gag reflex.Check vasovagal response.

Watch for cyanosis, hypotension, tachycardia, arrythmias,

hemoptysis, and dyspnea. These signs and symptoms indicate

perforation of bronchial tree. Refer the patient immediately!




Endoscopic Thoracoscopy




Biopsy of the Lungs

•Percutaneous removal of a small

amount of lung tissue

•For histologic evaluation

•Transbronchoscopic biopsy—

done during bronchoscopy,

•Percutaneous needle biopsy•Open lung biopsy




Nursing interventions BEFORE the procedure:

•Withhold food and fluids

•Place obtained written informed consent in the patient’s

chart.

Nursing interventions AFTER the procedure:

•Observe the patient for signs of Pneumothorax and air

embolism•Check the patient for hemoptysis and hemorrhage

•Monitor and record vital signs

•Check the insertion site for bleeding•Monitor for signs of respiratory distress




Thoracenthesis




Nursing intervention BEFORE Thoracentesis

•Secure consent•Take initial vital signs

•Instruct to remain still, avoid coughing during insertion of the

needle

•Inform patient that pressure sensation will be felt on

insertion of needle

Nursing intervention DURING the procedure:

•Reassess the patient

•Place the patient in the proper position:

Upright or sitting on the edge of the bed

Lying partially on the side, partially on the back




Nursing interventions after Thoracentesis•Assess the patient’s respiratory status

•Monitor vital signs frequently

•Position the patient on the affected side, as ordered, for at

least 1 hour to seal the puncture site•Turn on the unaffected side to prevent leakage of fluid in the

thoracic cavity

•Check the puncture site for fluid leakage

•Auscultate lungs to assess for pneumothorax•Monitor oxygen saturation (SaO2) levels

•Bed rest

•Check for expectoration of blood




Respiratory Care Modalities




Oxygen Therapy

• Administration of oxygen at greater than 21% (theconcentration of oxygen in room air) to provideadequate transport of oxygen in the blood, todecrease the work of breathing, and to reducestress on the myocardium

• Assess for signs and symptoms of hypoxia, arterialblood gas results, and pulse oximetry.

• Clients who have difficulty ventilating, those whosegas exchange is impaired or people with heartfailure may require oxygen therapy to preventhypoxia.




Oxygen Delivery System




Nasal Cannula

It delivers a relatively low concentration of oxygen

(24% - 45% ) at flow rate of 2 – 6 L/min.




Simple Face Mask

It delivers oxygen concentrations from 40% - 60% at liter

flows of 5 - 8 L/min




Partial Rebreather Mask

• Delivers oxygen concentrations of 60% - 90% at liter flows of 6

– 10 L/min.

• The oxygen reservoir bag that is attached allows the client to re-

breathe about the first third of the exhaled air in conjunction withoxygen.

Non- Rebreather Mask

• Delivers the highest oxygen concentration possible 95% - 100%

at liter flows of 10 – 15 L/min.

• One way valves on the mask and between the reservoir bag and

the mask prevent the room air and the client’s exhaled air from

entering the bag so only the oxygen in the bag is inspired.




Venturi Mask

• Delivers oxygen concentrations varying from 24% - 40% or50% at liter flows of 4 – 10 L/min.

• Has wide-bore tubing and color – coded jet adapters that

correspond to a precise oxygen concentration and liter flow

Face Tent • Can replace oxygen mask when mask is poorly tolerated by

clients

• Face tents provide varying concentrations of oxygen.

NOTE:Clients using face mask and face tent, frequently check and

inspect the client’s facial skin for dampness or chafing and dry and

treat as needed.




Venturi Mask, Nonrebreathing Mask,Partial Rebreathing Mask




Transtracheal OxygenDelivery

• May be used for oxygen dependent

client.• Oxygen is delivered through a small,

narrow plastic cannula surgically

inserted directly into the trachea.

• Clients require less oxygen .5 – 2L/min, because all of the flow

delivered enters the lungs




T-Piece and Tracheostomy Collar




Oxygen Therapy Safety Precautions

Place cautionary signs reading “ No SMOKING: Oxygen in Use” on the

client’s door at the foot or head of the bed and on the oxygen equipment

Note:

Oxygen is colorless, odorless, tasteless and a dry gas that support combustion,

therefore leakage cannot be detected.

Instruct the client and visitors about the hazard of smoking with oxygen

in use.

Make sure that electric device are in good condition in order to prevent

the occurrence of short-circuit sparks.Avoid materials that generate static electricity, such as woolen blankets

and synthetic fibers. Cotton blankets should be used.

Avoid the use of volatile, flammable materials such as oils, greases,

alcohol and acetone near clients receiving oxygen.

Make known the location of fire extinguishers




Complications of Oxygen Therapy

• Oxygen toxicity

• Reduction of respiratory drive in patients with chronic low

oxygen tension

• Fire




Oxygen Toxicity

• Oxygen concentrations of greater than 50% for extendedperiods of time (longer than 48 hours) can cause anoverproduction of free radicals, which can severelydamage cells.

• Symptoms include substernal discomfort, paresthesias,dyspnea, restlessness, fatigue, malaise, progressiverespiratory difficulty, refractory hypoxemia, alveolar

atelectasis, and alveolar infiltrates on x-ray.• Prevention:

– Use lowest effective concentrations of oxygen.




MEASURES THAT PROMOTE

ADEQUATE LUNG FUNCTION




Incentive Spirometer

• Types: volume and flow

• Device ensures that a volume of air is inhaled and the

patient takes deep breaths.

• Used to prevent or treat atelectasis

• Nursing care

– Positioning of patient, teach and encourage use, setrealistic goals for the patient, and record the results.




Flow Oriented Volume Oriented




Nebulizer Therapy

• A hand-held apparatus that disperses a moisturizingagent or medication such as a bronchodilator into thelungs. The device must make a visible mist.

• Nursing care: instruct patient in use.

– Patient is to breathe with slow, deep breaths throughmouth and hold a few seconds at the end of inspiration.

– Coughing exercises may be encouraged to mobilizesecretions after a treatment.

• Assess patient before treatment and evaluate patientresponse after treatment.




Chest Physiotherapy

• Includes postural drainage, chest percussion and vibration, andbreathing retraining. Effective coughing is also an importantcomponent.

• Goals are removal of bronchial secretions, improvedventilation, and increased efficiency of respiratory muscles.

• Postural drainage uses specific positions to use gravity to assistin the removal of secretions.

• Vibration loosens thick secretions by percussion or vibration.

• Breathing exercises and breathing retraining improveventilation and control of breathing and decrease the work of breathing.




Postural Drainage Positions: lower lobes,

anterior basal segment





superior segments





lateral basal segment




Postural Drainage Positions: upper lobes,

anterior segment





posterior segments





apical segment




Percussion and Vibration




Back Tapping




High-Frequency Chest Wall Oscillation

Vest




Patient Teaching: Home Oxygen

• Safety considerations

• Flow rate and flow adjustment

• Maintenance of equipment

• Identification of malfunction

• Humidification

• Ordering of supplies and oxygen• Signs and symptoms to report

• Diet and activity, travel

• Electrical outlets




Endotracheal Intubation

• Placement of a tube to provide a patent airway formechanical ventilation and for removal of secretions

• Purpose and complications related to the tube cuff

• Assessment of cuff pressure

• Patient assessment

• Risk for injury/airway compromise related to tuberemoval

• Patient and family teaching




Endotracheal Intubation




Endotracheal Tube




Tracheostomy




Tracheostomy

• Bypasses the upper airway to bypass an obstruction,allow removal of secretions, permit long-term mechanicalventilation, prevent aspirations of secretions, or replacean endotracheal tube

• Complications include bleeding, pneumothorax,aspiration, subcutaneous or mediastinal emphysema,laryngeal nerve damage, posterior tracheal wall

penetration.• Long-term complications include airway obstruction,

infection, rupture of the innominate artery, dysphagia,fistula formation, tracheal dilatation, and trachealischemia and necrosis.




Tracheostomy Tubes




Nursing Diagnoses: Patients with

Endotracheal Intubation or Tracheostomy

• Communication

• Anxiety

• Knowledge deficit

• Ineffective airway clearance

• Potential for infection




Care Issues for the Tracheostomy Client

• Prevention of tissue damage

– Cuff pressure can cause mucosal ischemia.

– Use minimal leak technique and occlusivetechnique.

– Check cuff pressure often.

– Prevent tube friction and movement.– Prevent and treat malnutrition, hemodynamic

instability, or hypoxia.




Tracheostomy Care

• Assessment of the client

• Secure tracheostomy tubes in place

• Prevent accidental decannulation

• Suction

• Remove old Dressing

• Sterile procedure: H2O, H2O2, brush, q-tip, 2X2s

• Turn and remove inner cannula; clean, rinse,replace; turn and click into place

• Clean around stoma




Tracheostomy Care Procedure (continued)

• Replace trach ties– ONE SIDE AT A TIME!

• Tracheostomy care is delivered at least q 8 hrs; or

more often as needed• Tracheostomy dressings are pre-cut to fit around

trach and protect neck and skin from secretions




Air Warming and Humidification

• The tracheostomy tube bypasses the nose andmouth, which normally humidify, warm, and

filter the air.• Air must be humidified.

• Maintain proper temperature.

• Ensure adequate hydration.




Tracheostomy Suctioning

• Suctioning maintains a patent airway and promotes gasexchange.

• Assess need for suctioning from the client who cannotcough adequately.

• Suctioning is done through the nose or the mouth.

• Suctioning can cause:

– Hypoxia (see causes to follow)

– Tissue (mucosal) trauma

– Infection

– Vagal stimulation and bronchospasm

– Cardiac dysrhythmias from hypoxia caused bysuctioning




Things to Remember about Suctioning

• 80 – 120 mmHg suction

• Less is better

• Hyperoxygenate before suctioning

• Instill NS only if secretions are dry or to inducecough

• Insert tube until resistance, then withdraw 1-2 cm

– Must be past end of artificial airway

– Less than 10 seconds

– Twist catheter as it is withdrawn

– Any suctioning causes mucosal damage




Causes of Hypoxia in Clients with Tracheostomy

• Ineffective oxygenation before, during, and aftersuctioning

• Use of a catheter that is too large for the artificialairway

• Prolonged suctioning time

• Excessive suction pressure

• Too frequent suctioning




Weaning from a Tracheostomy Tube

• Weaning is a gradual decrease in the tube size andultimate removal of the tube.

• Cuff is deflated as soon as the client can manage

secretions and does not need assisted ventilation.

• Change from a cuffed to an uncuffed tube.

• Size of tube is decreased by capping; use a smallerfenestrated tube.

• Tracheostomy button has a potential danger of getting dislodged.




Mechanical Ventilation

• Positive or negative pressure breathing device tomaintain ventilation or oxygenation

• Indications

• Negative pressure

– “Iron lung,” chest cuirass

• Positive pressure– Pressure-cycled

– Time-cycled

– Volume-cycled




Ventilators




Noninvasive Positive-Pressure Ventilation

• Use of mask or other device to maintain a seal andpermit ventilation

• Indications

• Continuous positive airway pressure (CPAP)

• Bi-level positive airway pressure (bi-PAP)




Ventilator Modes




Nursing Process: The Care of Patients whoare Mechanically Ventilated: Assessment• Assessment of the patient

– Systematic assessment; include all body systems

– In-depth respiratory assessment, including allindicators of oxygenation status

– Comfort

– Coping, emotional needs

– Communication

• Assessment of equipment




Nursing Process: The Care of Patients whoare Mechanically Ventilated: Diagnosis

• Impaired gas exchange

• Ineffective airway clearance

• Risk for trauma

• Impaired physical mobility

• Impaired verbal communication

• Defensive coping

• Powerlessness




Collaborative Problems

• Alterations in cardiac function

• Barotrauma

• Pulmonary infection

• Sepsis




Nursing Process: The Care of Patients whoare Mechanically Ventilated: Planning

• Goals include optimal gas exchange, maintenance of patent airway, optimal mobility, absence of trauma or

infection, adjustment to nonverbal methods of communication, acquisition of successful copingmeasures, and absence of complications.




Impaired Gas Exchange

• Monitor ABGs and other indicators of hypoxia. Notetrends.

• Auscultate lung sounds frequently.

• Judicious use of analgesics

• Monitor fluid balance.

• A complex diagnosis that requires a collaborativeapproach




Impaired Airway Clearance

• Assess lung sounds at least every 2-4 hours.

• Measures to clear airway: suctioning, CPT, position

changes, promote mobility• Humidification

• Medications




Risk for Trauma and Infection

• Infection control measures

• Tube care

• Cuff management

• Oral care

• Elevation of HOB




Other Interventions

• ROM and mobility; get out of bed

• Communication methods

• Stress reduction techniques

• Interventions to promote coping

• Include in care: family teaching, and the emotional and

coping support of the family.




Weaning

• Process of withdrawal of dependence upon the ventilator

• Successful weaning is a collaborative process.

• Criteria for weaning

• Patient preparation

• Methods of weaning




Patients Undergoing Thoracic Surgery

• Preoperative assessment

• Preoperative preparation

• Patient teaching

• Reduction of anxiety

• Postoperative expectations

• Strategies to reduce postoperative complications:atelectasis and infection




Chest Drainage

• Used to treat spontaneous and traumatic pneumothorax

• Used postop to re-expand the lung & remove excess air, fluid,blood

• Types of drainage systems: See Table 25-3

• Traditional water seal

– Dry suction water seal

– Dry suction

• Management: See Chart 25-18

• Prevention of cardiopulmonary complications: See Chart 25-19




Chest Tube Drainage System




Heimlich Valve




Patient Teaching and Home Care

Considerations

• Breathing and coughing techniques

• Positioning

• Addressing pain and discomfort

• Promoting mobility and arm and shoulder exercises

• Diet

• Prevention of infection

• Signs and symptoms to report




Technique for Supporting Incision While a

Patient Coughs



Arm and Shoulder Exercises

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