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RESPIRATORY SYSTEM
DEVELOPMENTAL
o “DEATH RATTLE” – loud rattle sound w/ breathing that occurs in pt. actively dying o If pt. cannot manage airway secretions – movement of these secretions during breathing causes noisy rattling sound distresses family – treated using anticholinergic medications to dry pt. secretions – ATROPINE DROP OR SCOPOLAMINE PATCH FUNDAMENTALS Pulse oximetry o If pulse plethysmographic waveform – nurse should first evaluate accuracy of reading
- waveforms that are irregular or erratic may contain artifact caused by loose, misapplied, or damaged pulse oximeter or by pt. movement // auscultate next Arterial blood gases o Arterial blood gas (ABG) assessment parameters provide data about efficiency of gas exchange in lungs & effectively evaluate following: o ACID-BASE BALANCE // Oxygenation status // Tissue oxygenation (SaO2 – percentage of available hemoglobin saturated w/ oxygen) o Ventilation (PaCO 2 , partial pressure of carbon dioxide in arterial blood)
Compensations o Metabolic acidosis (pH low, bicarb low) – respiratory alkalosis is body’s natural compensation for metabolic acidosis (increase in respiratory rate) o Metabolic alkalosis (pH high, bicarb high) – compensated by respiratory acidosis (decrease in respiratory rate – retain carbon dioxide) o Respiratory acidosis (pH low, CO2 high) – compensated by metabolic alkalosis – increase in bicarb absorption (aka high serum bicarb) o Respiratory alkalosis (pH high, CO2 low) – compensated by metabolic acidosis – decrease in bicarbonate reabsorption (aka low serum bicarb) o Example: combination of excessive alcohol and alprazolam (Xanax) causes respiratory depression , leading to alveolar hypoventilation secondary to CO2 retention and respiratory acidosis body will increase bicarb absorption HEMOGLOBIN CARBON MONIXIDE POISONING o Carbon monoxide - colorless, odorless gas made by burning fuel in poorly ventilated area o CO toxicity associated w/ smoke inhalation from structure fires, also generated by furnaces/hot water heaters fueled by natural gas or oil, coal or wood stoves, fireplaces, and engine exhaust o CO has a much stronger bond to Hgb than oxygen does – consequently, CO displaces oxygen from Hgb, causing hypoxia that is not reflected by pulse oximeter reading
o PRIMARY ACTION – administer
highly concentrated (100%)
oxygen using non-rebreather
mask at 15L/min reverse displacement of oxygen
DYSPNEA POSITIONING
o Fowler's - priority action to help relieve SOB, facilitate oxygenation (breathing), and promote lung expansion (airway). o Alternate positions: o Orthopneic position: Sitting in chair, on side, or in bed leaning over bedside table, with one or more pillows under arms or elbows for support o Tripod position : Sitting in chair leaning forward w/ hands or elbows resting on knees. Sitting upright and leaning forward pulls scapulae apart, promotes lung expansion, and decreases the diaphragmatic pressure produced by the viscera. o Recovery position : first-aid measure for unconscious pt. who is still breathing // Pt. is placed on left or right side on three-fourths prone position w/ top leg flexed – position maintains airway and ensures pt. doesn’t choke on vomit o MORPHINE : effective in relieving anxiety & decreasing work of breathing by slowing respirations // cause hypoventilation & decrease gas exchange OXYGEN/ AIRWAY (1) NASAL CANNULA - comfortable, low-flow oxygen delivery device - delivering concentrations of up to 44% - short-term in responsive to postoperative pt.’s to treat hypoventilation and reverse hypoxemia effectively (2) Simple face mask – delivers (40-60%), uncomfortable and restrictive, must be removed to eat/ drink // can be used if hypoxemia does not resolve (3) Non-rebreather mask - used in emergencies, delivers high concentrations of oxygen (up to 90-95%) // requires tight face seal // restrictive and uncomfortable o Consists of face mask w/ attached reservoir bag and one-way valve between bag and mask that prevents exhaled air from entering bag and diluting oxygen concentration liter flow must be high enough (15L/min) to keep reservoir bag at least 2/3 inflated during inhalation and to prevent buildup of CO2 in bag o Ports (exhalation valves) are located on each side on mask and are covered w/ rubber discs that act as flutter valves – valves close on inhalation to prevent entry of room air and open on exhalation to prevent reinhalation of exhaled air – ports should be occluded when initiating device to fill reservoir w/ oxygen o (4) Venturi mask – guaranteed oxygen concentration to pt.’s w/ unstable COPD // Pt. cannot tolerate changes in oxygen concentration o (5) Nasopharyngeal airway: tube-like device used to maintain upper airway patency – NPAs are frequently used in alert or semi-conscious pt.’s less likely to cause gagging, and in pt.’s w/ oral trauma or maxillofacial surgery
o CONTRAINDICATION – NPAs should never be inserted in pt. who may have head trauma (facial or basilar skill fractures) – NPAs inserted in pt. w/ skull fractures may be mispositioned into underlying tissues/ structures (e.g. brain) (6) Mechanical ventilation via tracheostomy & complications o Tracheostomy – artificial airway inserted into trachea through neck, may be secured w/ sutures or tracheostomy ties // o IMMEDIATE POSTOPERATIVE PRIORITY – prevent accidental dislodgment of tube and loss of airway o Priority nursing action >> ensure tube is placed securely by checking tightness of ties and allowing for 1 finger to fit under these ties o Changing inner cannula and tracheostomy ties not performed until 24 hours after insertion d/t risk of dislodgement w/ immature tract // however dressing can be changed if becomes wet or soiled o To be prepared for dislodgement and replace tube – pt. should always carry 2 spare tracheostomy tubes (one same size and one smaller) – if tube is not easily replaced or is meeting resistance – smaller tube should be used !! o S uctioning can be performed to remove mucus and maintain airway o Cuff is kept inflated to prevent aspiration from secretions and postoperative bleeding // not regularly deflated and re-inflated – RT should monitor amount of air in cuff several times/ day to prevent excessive pressure and mucosal tissue damage o Frequent mouth care to prevent stomal & pulmonary infection is key w/ artificial airway o Humidification – crucial for pt. w/ tracheostomy as upper airways, which provide natural humidity for inhaled air – keeps secretions thin and reduces formation of mucus plugs Complications o Accidental dislodgment of tracheostomy tube medical emergency often resulting in respiratory distress from closure of stoma and airway loss o If it occurs where trach is well formed (>7 days after insertion) – nurse should attempt to open airway by inserting curved hemostat to maintain stoma patency and insert new tracheostomy tube w/ obturator o Application of supplemental oxygen via nonrebreather face mask – may not resolve respiratory distress because air can escape from stoma o Covering stoma w/ sterile, occlusive dressing and ventilating lungs w/ bag-valve mask over nose/mouth may be necessary if tube cannot be reinserted or stoma is immature dry gauze doesn’t adequately seal stoma for ventilation
When is non-invasive not good enough? o Hypoxemia/ hypercapnia is not improving despite aggressive titration o Nausea/ emesis/ copious thick secretions risk for aspiration o Continued exertion or no improvement in work of breathing o Lethargic/ unconscious SUCTIONING o PREOXYGENATION W/ 100% OXYGEN FOR 30 SECONDS BEFORE SUCTIONING , unless otherwise specified o Indications >> high-pressure alarm on MV sounds, saturations drop, rhonchi are auscultated & secretions are audible or visible - indicate excessive secretions impairing airway patency, pt. not able to cough // signs of hypoxia – SOB, cyanosis, restlessness, anxiety o Risks >> HYPOXEMIA, MICRO ATELECTASIS, CARDIAC DYSRHYTHMIAS , SEPSIS (PNEUMONIA), HYPOTENSION, TRAUMA o Suctioning removes secretions & oxygen // to minimize amount of oxygen removed and mucosal trauma, suction is applied ONLY when removing catheter into artificial airway o If secretions thick and difficult to remove, increase hydration!! not suctioning time o AEROSOLS OF STERILE NORMAL SALINE/ MUCOLYTICS SUCH AS ACETYLCYSTEINE (MUCOMYST) administered by nebulizer used to thin thick secretions, water shouldn’t be used. o Aerosol therapy may induce bronchospasm in some pt.’s and can be relieved by use of a bronchodilator (albuterol) o MORPHINE administered to promote breathing synchrony w/ mechanical ventilator , reduce anxiety, and promote comfort in pt. receiving MV o Suctioning of oral secretions performed after suctioning of oropharynx and trachea o Requires use of a rounded-tipped catheter w/ number of side holes at distal end of catheter // Suction catheter: < 1/2 diameter of tracheostomy tube o WALL SUCTION amount of pressure 100-150 // kids 100- o Use of personal protective equipment (goggles, mask, face shield) o Put suction catheter not beyond carina o Rotating catheter enhance removal of secretions that have adhered to sides of tube o OROPHARYNGEAL AND NASOPHARYNGEAL SUCTIONING when pt. is able to cough effectively , but unable to clear secretions by expectorating/ swallowing o OROTRACHEAL & NASOTRACHEAL SUCTIONING Pt. w/ pulmonary secretions is unable to manage secretions by coughing and doesn’t have artificial airway – catheter passed into pt. trachea o Unless in respiratory distress, pt. should be allowed to rest b/w passes of catheter
- if pt. using supplemental oxygen, cannula should be replaced during rest periods o NASO - Using water-soluble lubricant helps avoid liquid aspiration pneumonia o Position semi-fowlers or sitting upright with head hyperextended o Insert catheter as pt. inhales, especially when inserting catheter into trachea o DO NOT insert during swallowing // PT. SHOULD COUGH // If pt. gags or becomes nauseated catheter is probs in esophagus and must be removed
o IF PT. DECREASED LOC SIMS POSITION encourage drainage
o Acute respiratory distress – rapid response team – O2 low d/t secretions o Place in high fowlers position – maximizes ability to expand lungs, promotes oxygenation and helps decrease risk of further aspiration
o Perform oropharyngeal suctioning – priority clear airway after pt. has been placed in position that prevents further aspiration o Administer 100% oxygen by nonrebreather mask – corrects hypoxemia/ hypoxia once airway has been cleared to allow passage of oxygen o Assess lung sounds – performed once emergency measures are in place (oxygen) and pt. has been stabilized o Notify primary HCP PROCEDURES/ TESTS (1) BRONCHOSCOPY & LARYNGOSCOPY o Direct visualization of larynx, trachea, and bronchi w/ fiberoptic bronchoscope o Performed to diagnose problems w/ airways, lungs, or w/ lymph nodes in chest OR to treat problems such growth/mucus in airway! Pre-op: NPO , assess results of coagulation studies , establish IV & administer sedatives (midazolam) to provide comfort// have emergency resuscitation equipment ready !!!! Post-op: o Maintain pt. in semi-fowlers position o Assess return of gag-reflex --- Maintain NPO until reflex returns o Respiratory status, airway patency, vital signs and sedation level should be assessed immediately upon return from procedure and intervals until pt. becomes stable o Monitor for bloody sputum o Blood-tinged sputum is common & can occur from inflammation of airways! But hemoptysis of bright red blood indicate hemorrhage, especially if biopsy was performed o Monitor for complications bronchospasm, indicated by facial or neck crepitus , dysrhythmias, hemorrhage, hypoxemia, and pneumothorax Side effects o Pt.’s who undergo procedure are at risk for becoming unstable !!!! – during bronchoscopy
- larynx, trachea, bronchi are visualized using an endoscope while pt. is under sedation o Educational objective: Pt.’s returning from procedures under sedation should receive priority assessment of vital signs and resp. status (2) CHEST X-RAY Info regarding anatomical location & appearance of lungs o Remove jewelry, metal objects from chest // Assess pt. ability to inhale & hold breath (3) SPUTUM SPECIMEN specimen obtained by expectoration or tracheal sunctioning – identification of organisms o Obtain early morning sterile specimen by suctioning/ expectoration after respiratory treatment if treatment is prescribed o Rinse mouth after collection (15 mL of sputum) o Instruct pt. to take several deep breaths, then cough deeply to obtain sputum o ALWAYS COLLECT BEFORE ANTIBIOTIC THERAPY! (4) THORACENTESIS: o Removal of fluid/ air from pleural space VIA transthoracic aspiration (large-bore needle through intercostal space)
(8) TONSEILLECTOMY – performed as an outpatient procedure – Complication: postoperative bleeding is uncommon but important complication and can last up to 2 weeks! – manifests w/ frequent or continuous swallowing and/or cough from trickling blood – may also cause restlessness o Discharge teaching o Avoid coughing, clearing throat, or blowing nose o Limit physical activity o Milk products are discouraged d/t coating effect, which can prompt clearing of throat o Oral mouth rinses, gargling and vigorous tooth brushing should be avoided to prevent irritation o Slight ear pain, a low-grade fever, and objectionable mouth odor are common findings during the first 5-10 days after the procedure. CHEST TUBES Visceral pleura is the inner layer of the lung & Parietal layer is the outer layer When breathing 2 layers glide over eachother, small amount of serous fluid prevent them from rubbing together // While gliding negative pressure allows lungs to work properly & inflate and deflate Catheter inserted through thorax - remove air and fluids from pleural space , preventing air/fluid from re-entering and re-establish normal pressures (returns negative pressure) re-expand OR placed in mediastinum space to drain blood/ fluid after cardiac surgery. Indications for a chest tube Pneumothorax (air enters into pleural space – trauma or spontaneous) Hemothorax : blood enters pleural space, trauma, disease, TB, blood clot issue Pleural effusion : fluid in pleural space Empyema : infection in pleural space Chylothorax : lymphatic fluid in pleural space
Types of chest tube drainage WET SUCTION o A. Drainage collection chamber o Drainage collected where chest tube from client connects to system o Drainage drains into and collects in series of calibrated columns o B. Water seal chamber o Contains water, tip of tube is underwater, allowing fluid and air from pleural space and preventing air from entering pleural space o Water oscillates (moves up as pt. inhales and moves down when exhale gradually reduces in intensity as lungs re-expand ) – reduces as lung expands o C. Air-leak monitor area (Part of water-seal) Looking for bubbling // Continuous or intermittent bubbling indicates an
** air leak** in chest tube system
o D. Suction control chamber o Maintains & controls suction to chest drainage system; continuous, gently bubbling indicates that suction level (can be controlled to provide negative pressure to chest – frequently prescribed -20 is appropriate) // amount of suction is controlled by amount of water in chamber and not by wall suction o Increasing amount of wall suction would cause vigorous bubbling , but doesn’t increase suction to client as excess suction is drawn out though vent of suction control chamber // Vigorous bubbling would increase water evaporation and therefore decrease negative pressure applied to system // o Nurse should check water level and add sterile water, to maintain prescribed level
w/o this, lung tissue could be sucked into chest
tube
o Dry suction Dry no water column & suction control, uses suction monitor that balances wall suction & can adjust water suction pressure using rotary suction of side of system There is no bubbling of water & more pressure level options Another type of chest drainage system // because this is a dry suction system, absence of bubbling is noted in the suction control chamber Knob on collection device is used to set prescribed amount of suction; then wall suction source dial is turned until small orange floater valve appears in window on device (when orange floater valve is in window, correct amount of suction is applied) Nursing Interventions: Lung sounds, rate, dyspnea, insertion site, palpate for subcut crepitus (CO2 escapes into tissues (cracking sensation on palpation) // Change clients position frequently to promote drainage and ventilation Occlusive sterile dressing is maintained at insertion site Chest radiograph assesses position of tube and determines whether lung has re-expanded Do not STRIP OR MILK a chest tube // Never CLAMP a chest tube o Clamping causes air to accumulate in pleural cavity –lead to tension pneumothorax – tension pneumothorax results in compression of unaffected lung and pressure on heart and great vessels – as pressure increases, venous return is decreased & cardiac output falls
Tubing : Keep free from kinks, secure, & are draining down & that it drains freely no clots) & connections are sealed If drainage system cracks or breaks, insert the chest tube into the bottle of sterile water, remove cracked or broken system and replace it with a new system No chest tube drainage o Auscultating breath sounds helps the nurse detect whether breath sounds are audible in all lung fields, potentially indicating that the lung has re-expanded and there is no more drainage. o Other interventions to facilitate drainage include is to have client cough and deep breathe and repositioning the client o If a client has been in one position for a prolonged period, drainage may accumulate and a position change may facilitate improved drainage. Monitor drainage notify HCP if o (1) Drainage is more than 70-100mL o (2) Becomes bright red/ NOT dark bloody drainage o (3) Increases suddenly o MARK THE CHEST TUBE DRAINAGE in the collection chamber 1-4 hour intervals, using a piece of tape WATER SEAL CHAMBER Water seal chamber o Monitor for fluctuations of the fluid level in the water seal chamber Complication What if not fluctuating (1) tube is obstructed, (2) dependent loop exists, (3) suction is not working properly (2)lung may have re-expanded Pneumothorax o Intermittent bubbling in water seal chamber is expected as air is drained from the chest, but continuous bubbling indicated an air leak in the system (notify HCP) AIR LEAK MONITOR AREA Normally should be no bubbling Continuous Bubbling in water-sealed chamber o Leak between the patient and water seal o Cross-clamp chest tube close to patients chest // If bubbling stops air leak is inside patients thorax or at chest tube insertion site o Unclamp tube, and notify physician ASAP // leaving a chest tube clamped tension pneumothorax o Gradually move clamps down drainage tubing away from the pt. and toward suction control chamber, moving one clamp at a time. When bubbling stops leak is in a section of a tubing or connection between clamps SUCTION CONTROL CHAMBER Wet suction column that will bubble continuous bubbling (means its working) POST-OPERATIVE CARE o Pain – give analgesics o Airway clearance – teach effective coughing methods in order to prevent complications – o Splinting incision when coughing, changing position every 1-2 hours, ambulating early, using an incentive spirometer ad hydrating adequately to thin secretions o Atelectasis is maximal during second postoperative night – pt. can be asymptomatic or have increased work of breathing, hypoxia, and basal crackles o Part of lung has collapsed and alveoli sacs are unable to perform gas exchange
o Postop. pain, opioid respiratory depression, limited mobility and reluctance to take a deep breath due to anticipated pain contribute to postoperative atelectasis. o Incentive spirometer encourages pt. to breathe deeply w/ maximum inspiration improves ventilation and oxygenation by expanding lungs, encourages coughing, and prevents or improves atelectasis. o (1) Attach flexible tubing to port o (2) Set goal for pt. w/ marker o (3) Have pt. sit-up and exhale completely o (4) Seal lips around mouthpiece tightly o (5) Pt. inhales deeply and slowly. Piston will rise o (6) Pt. needs to keep inhaling as deep as possible… until unable to hold breath any longer and then hold breath for 6 seconds o (7) Exhale slowly Postoperative period immediate complications (1) Airway obstruction , d/t retained secretions or tongue falling backward against soft palate in sedated pt.’s // suctioning and an artificial oral airway can be used to prevent obstruction until the client becomes more responsive HEAD TILT AND CHIN LIFT – MANEUVER USED TO OPEN AIRWAY – Tongue may fall back and occlude airway d/t muscular flaccidity (2) Hypoxemia , which can be due to atelectasis from increased retained secretions or hypoventilation, aspiration, or bronchospasm. Pulse oximetry and supplemental oxygen are used to maintain pulse oximeter readings >92%; placing the client in side-lying position and administrating antiemetic medications help to decrease aspiration. (3) Hypoventilation , which can be due to depression of the respiratory drive as a result of anesthesia, pain, and opioid analgesia. LUNG CANCER HEALTH PROMOTION o Risk factors: smoking, air pollution, genetic predisposition, and exposure to randon, asbestos, and chemicals in workplace o Smoking cessation is the best way to prevent lung cancer – nicotine replacement therapy (patches, gum, inhalers, lozenges) is effective in helping smokers quit by reducing cravings – although users receive low dose of nicotine, they don’t receive other toxins that cigarettes include
o Loud snoring , apnea episodes and waking w/ gasping or choking sensation o Day time – morning headaches, irritability, excessive sleepiness , 0 concentration o Other symptoms – forgetfulness, mood changes, and depression INTERVENTIONS o (1) CPAP – use nasal / full face mask - delivers positive pressure to upper airways! – keep structures of pharynx and tongue from collapsing backwards o (2) Limiting alcohol intake – causes muscles of oral airway to relax and lead to airway obstruction o (3) Weight loss and exercise – reduce snoring and sleep apnea-associated airway obstruction // Obesity contributes to OSA (eating before bed interferes w/ sleep + excess weight) o (4) Avoiding sedating medications (benzodiazepines, sedating antidepressants, antihistamines, opiates) --- exacerbate OSA and worsen daytime sleepiness o Relax muscles of oral airway and contribute to excess weight o Stimulants (modafinil) - prescribed for daytime sleepiness, should be avoided at bedtime - causes insomnia ACUTE RESPIRATORY FAILURE o ARF: inadequate gas exchange that is intrapulmonary (pneumonia, pulmonary embolism) or extrapulmonary (head injury, opioid overdose) in origin – associated w / alteration in O2 transfer / absorption is type I hypoxemic failure (ARDS, pulmonary edema, shock) o Respiratory failure associated w/ carbon dioxide retention is type II hypercapnic , or ventilatory failure ( COPD, pneumonia, pulmonary disease, myasthenia gravis, flail chest) o ABG VALUES THAT INDICATE PRESENCE OF ARF: o PAO2 LOWER THAN 60 MM HG o O2SAT <90% o PACO2 > 50 MM HG OCCURRING W/ ACIDEMIA Assessment Consider both respiratory and neurological manifestations o ALTERED MENTAL STATUS (e.g. confusion, agitation, somnolence (drowsiness, decreased LOC, restlessness) d/t brain's sensitivity to inadequate oxygenation and alterations in acid-base balance from retained CO2 // o ++ signs may include paresthesias, dyspnea, tachypnea, tachycardia, hypertension, dysrhythmias and headache Interventions o Identify cause
o Administer oxygen to maintain PaO2 level higher than 60-70 mm Hg. o Place client in a Fowler’s position. o Encourage deep breathing. o Administer bronchodilators as prescribed. o Prepare pt. for mechanical ventilation if supplemental oxygen cannot maintain acceptable PaO2 and PaCo2 levels ACUTE RESPIRATORY DISTRESS SYNDROME (life threatening!!)
o INVOLVES DAMAGE TO ALVEOLAR-CAPILLARY
MEMBRANE, blood-gas barrier across which oxygen diffuses into alveoli –
when membrane is damaged , alveoli collapses and fluid leaks into alveolar space and impairs gas exchange o Impaired gas exchange r/t alveolar-capillary changes & ventilation-perfusion imbalance priority ND for pt. w/ ARDS o Fluid leaks from capillary beds – collects in alveoli sac (filled w/ fluid & problem staying open) – decrease in gas exchange – collapse of sac, hypoxemia (low O2 in blood) – organs suffer !!! o Progressive form of acute respiratory failure high mortality rate – o CAUSES >> develop following PULMONARY INSULT (aspiration, pneumonia, toxic inhalation) or non- pulmonary insult ( sepsis, multiple blood transfusion, trauma) o INSULT TRIGGERS MASSIVE INFLAMMATORY RESPONSE > cause lung tissue to release inflammatory mediators (leukotrienes, proteases) >> damage to alveolar-capillary membrane – result A-C membrane becomes permeable & intravascular fluid leaks into alveolar space >> NONCARDIOGENIC PULMONARY EDEMA o Pulmonary artery wedge pressure measures left atrial pressure >> if reading is less than 18 mmHg >> indicates this is NOT cardiac issue, but most likely ARDS
o REFRACTORY HYPOXEMIA – hallmark of acute respiratory distress
syndrome !! aka DO NOT RESPOND TO INCREASED PERCENTAGE OF OXYGEN (CONCENTRATION) o Respiratory assistance with (Mechanical ventilation with PEEP) Positive end expiratory pressure help open up alveoli sac improve gas exchange o Complication: issues w/ intrathoracic pressure and decrease CO along w/ hyperinflation of lungs (possible pneumothorax or subcut emphysema) o Usually develop d/t systemic inflammation that’s occurring in body immune system send-off inflammatory cells, and if inflammatory cells are in blood damages capillary membrane and causes leakage of fluid o Interstitial edema causes compression and obliteration of terminal airways and leads to reduced lung volume and compliance
o Fever, chills, productive cough, dyspnea, decreased O2 saturation o Tachycardia, Tachypnea o Pleuritic chest pain o Aching/ Activity Intolerance/ Accessory muscle use o Increased vocal/ tactile fremitus – transmission of palpable vibrations (fremitus) is increased when transmitted through consolidated versus normal lung tissue (lung consolidation occurs when air that fills small airways in lungs is replaced by fluid etc.) o UNEQUAL CHEST EXPANSION – decreased expansion of affected lung on palpation o Dullness – percussion of medium-pitched sounds over consolidated lung tissue (pneumonia) or fluid-filled spaced (pleural effusion - a complication of pneumonia) o Neurological changes (presence of confusion, agitation) o N&V (no appetite) o Elevated labs (PCO2 > 45) – retaining carbon dioxide bc it can’t pass capillary of alveoli sac), increased WBC (d/t infection WBC > 11,000) o ANTIBIOTIC THERAPY - first-line of treatment, but antibiotic resistance frequently occurs in HAP // If antibiotic therapy is effective – clinical improvement usually occurs within 3-4 days of initiation of IV antibiotics Risk factors for developing pneumonia o ADVANCED AGE (>65) -coexisting diseases, decreased gag & cough reflex , decreased immune response & lung function // Young age (<2) – immature immune system o CNS depression or decreased level of consciousness o Chronic disease (cardiovascular, pulmonary) // Immunosuppression // Inadequate nutrition compromised immune system & impaired ability to fight infection
o PROLONGED IMMOBILITY , smoking & air pollution, upper respiratory tract
infection, tracheal intubation – impaired mucociliary clearance Strategies to prevent postoperative pneumonia o (1) ADEQUATE PAIN CONTROL – PRIOIRTY – so pt. can move, deep breathe, and cough more effectively & comfortably // Opioids are effective for relieving postop. pain, but because they depress respirations and cough reflex – assessing pt. response to o (2) AMBULATE WITHIN 8 HOURS AFTER SURGERY, IF POSSIBLE – Mobilization/ early ambulation decreases atelectasis and hypoventilation, promotes coughing, deep breathing, and lung expansion – o (3) COUGHING W/ SPLINTING QHOUR – Splinting of incision & pain management are useful for promoting effective cough (huff, cascade) that clears secretions o (4) DEEP BREATHING & USE OF INCENTIVE SPIROMETER QHOUR – deep breathing in conjunction w/ use of incentive spirometer promotes ventilation and oxygen
- opens pores of Kohn that permits air from well-ventilated alveoli to move into collapsed alveoli – helps prevent/ decrease atelectasis and hypoventilation caused by effects of anesthesia, analgesia, and pain o (5) SWAB MOUTH W/ CHLORHEXIDINE Q12 HOURS – Mouth care prevents ventilator-associated and postoperative pneumonia o (6) HAND HYGIENE – o (7) PLACE IN FOWLER’S POSITION – promote oxygenation and prevent aspiration Interventions to facilitate secretion removal in pt. w/ pneumonia: o (1) Chest physiotherapy (percussion, vibration, postural drainage) - loosen and break up thickened secretions
o (2) Assist pt. to perform huff coughing – raises secretions from lower to upper airway for expectoration o (3) Ensure hydration thru increased oral fluid intake (> 2-3L/day) and administration of prescribed IV fluids – thins pulmonary secretions to promote improved secretion clearance o (4) High fowlers to promote effective coughing and optimal lung expansion Interventions to increase oxygen perfusion o Blood flow in lungs is partially influenced by gravity , meaning that blood flows in higher volumes to dependent parts of lung. Thus pt. w/ e.g. left lobar pneumonia should be positioned in right lateral position with the unaffected ( good ) lung down to increase blood flow to lung most capable of oxygenating blood o Side-lying positioning is utilized in hypoxic pt.’s w/ unilateral pneumonia to increase perfusion to healthy lung by gravity and improve oxygenation by positioning pt. w/ unaffected (good) side down. However, side-lying position alone doesn’t improve secretion clearance Discharge teaching o Avoid use of OTC cough suppressant medications – unless prescribed by HCP – cough suppressants are avoided as they impair secretion clearance o Schedule follow-up w/ HCP & chest x-ray - follow-up is needed at about 2 weeks after completion of antibiotic therapy. X-ray may be needed in certain high-risk pt. to make sure pneumonia is resolved with no underlying cancer o Teach pt. that symptoms of pneumonia remain after discharge even though bacteria are no longer present and will dissipate over 2-4 week period, depending on current health
