Saturday, January 31, 2009

Have a GREAT Weekend Karen 'n bill

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Friday, January 30, 2009

Surgical Experience Anesthesia

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Surgical Experience - Nursing lecture

    • IV line inserted
    • Receiving a sedating agent prior to induction
    • Losing consciousness
    • Being intubated; if indicated
    • Receiving a combination of anesthetic agents
    • Has no recall of events
    • Concurrent medications
    • Optimization of medical treatment for:
      • Diabetes Mellitus (DM) – glycemic control
      • Nutritional status – malnourishment
      • Smoking – cessation
      • Obesity – weight loss
      • COPD – respiratory status, postop exercises
    • • class 1 - able to visualize soft palate, fauces, uvula, ant and post tonsillar pillars
    • • class 2 - able to visualize all of the above, except anterior andposterior tonsillar
    • pillars are hidden by the tongue
    • • class 3 - only the soft palate and base of the uvula are visible
    • • class 4 - only the soft palate can be seen (uvula not visualized)
    • Common classification of physical status
    • at the time of surgery
    • ASA 1 : healthy fit patient
    • ASA 2 : with mild systemic disease
    • ASA 3 : with severe systemic disease that limits activity
    • ASA 4 : with incapacitating disease that is a constant threat to life
    • ASA 5 : a moribund patient not expected to survive 24 hours with/without surgery
  1. Levels Findings Minimal Sedation Patient responds normally to VERBAL commands, Cognitive & Coordination Fxn may be impaired, but Ventilatory & Cardiovascular Fxns Unaffected Moderate Sedation Midazolam(Versed)/Diazepam(Valium) used often. Depressed LOC that does not impair patient’s ability to maintain a patent airway Deep Sedation Patient cannot be easily aroused but can respond purposefully after repeated stimulation. IV or Inhalation. NO2 most commonly used GAS Anesthetic ANESTHESIA State of Narcosis (severe central nervous system depression produced by pharmacologic agents), analgesia, relaxation, and reflex loss. Not arousable.
  2. Stages of ANESTHESIA Findings Beginnning Anesthesia / Induction Patient feels DIZZY,WARMTH and DETACHED . May have ringing, roaring, or buzzing in the ears. AVOID NOISE Excitement PR is rapid. Respirations maybe IRREGULAR. SAFETY of the patient is the PRIMARY CONCERN. Surgical Anesthesia Unconscious patient. RR is regular . PR and BP is normal . SKIN is PINK and slightly Flushed. Continuous administration of Anesthetic agent. Medullary Depression Too much Anesthesia. Pulse is weak and thready. Pupil become WIDELY DILATED .Respiratory and Cardio Support. DEATH rapidly follows.
    • Inhalation – administered with mixing the vapors with OXYGEN. Via ET TUBE or MASK
    • Injection – no buzzing, roaring, or dizziness. THIOPENTAL, agent of choice. Useful in EYE surgery(low Nausea and Vomiting)
    • Rectal – obsolete but sometimes used in Pediatric patients.
    • Tranquilizers and Sedative – Hypnotics
    • a. Benzodiazepines
    • 1. Midazolam ( Versed ) – Monitor Respiratory Status
    • 2. Diazepam ( Valium ) –
    • - may produced Thrombophlebitis
    • - Central vein is preferred
    • 3. Chlordiazepoxide ( Librium ) – hypnosis(induction)
    • 4. Droperidol ( Inapsine ) – Extramidal rigidity
    • 5. Lorazepam ( Ativan ) – Hepatoxic/Nephrotoxic
    • Flumazenil (ANEXATE) – benzodiazepine antagonist
    • b. Opiods
    • 1. Morphine ( High Doses ) –
    • - not a myocardial depressant
    • - orthostatic hypotension(decreasing systemic vascular resistance)
    • 2. Meperidine HCl ( Demerol ) –
    • - “ Spasmolytic effect ”
    • - DOC for bile duct , distal colon , and rectum surgery . - Ready diphenhydramine (benadryl) for Allergic reaction.
    • - refers to combination of short-acting synthetic opiod agent ( fentanyl ) and a butyrophenone ( droperidol )
    • 1. Fentanyl (Sublimaze )
      • 75%-100% more potent than morphine
      • little Cardio effect
      • Respiratory depression
    • 2. Sufentani l (Sufenta)
      • Onset extremely rapid
      • 1/3 duration of fentanyl
    • The patient appears to be asleep or anesthesized, but rather dissociated from surroundings.
    • Ketamine (Ketalar;Ketaject)
      • useful when Hypotension can be hazardous
      • may experience hallucinations
      • AVOID Verbal, Visual, or TACTILE stimulation .(triggers psychic aberration )
      • Droperidol or Diazepam may eliminate such psychic phenomena.
    • Thiopenthal sodium ( Pentothal )
      • not for children
      • Rapid induction
      • Powerful depressant for breathing
    • Methohexital sodium ( Brevital )
      • rapid onset
      • seizures
      • necrosis if IV infiltrates
    • Etomidate (Amidate)
      • Useful for FRAIL patients
      • Transient ADRENAL suppression
      • Involuntary muscle movements
    • Propofol (Diprivan)
      • Rapid induction
      • May have antiemetic effect
      • Pain on injection
      • Myocardial depression
      • Contraindicated in patients with allergy to EGGS and Soybean Oil
    • Anesthetic agent is injected around nerves .
    • Motor fibers have the thickest myelin sheath
    • Sympathetic fibers are the smallest and have minimal covering
    • Sensory fibers are intermediate
    • An anesthetic is worn off until all three are no longer affected.
    • A QUIET environment is THERAPEUTIC
    • Epidural Anesthesia – injection of local anesthetic into the spinal canal in the space surrounding the dura mater.
      • Absence of spinal headache
      • Difficult to introduce anesthetic agent into the epidural rather than the subarachnoid space.
      • HIGH spinal can result(subarachnoid injection) – causes severe hypotension, respiratory depression and arrest (TREATMENT: Airway, IV, Vasopressor)
    • Spinal Anesthesia – local anesthetic is introduced into the subarachnoid space at the lumbar level, usually between L4 and L5.
      • Anesthesia of the lower extremities, perineum and lower abdomen
      • Lumbar puncture procedure – KNEE-CHEST(side)
      • Procaine,tetracaine (Pontocaine), lidocaine (Xylocaine), and bupivacane (Marcaine).
      • Respiratory Paralysis (Temporary/Complete) – High concentrations of med reached the upper thoracic and cervical spinal cord
    • Risk Factors
      • Size of spinal needle used
      • Leakage of CSF from the subarachnoid space
      • Patient’s hydration status
      • Decreasing Cerebrospinal pressure
      • 1. Keep patient LYING FLAT
      • 2. QUIET
      • 3. Well hydrated
    • Brachial plexus block – anesthesia of the arm
    • Paravertebral anesthesia – anesthesia of nerves supplying the Chest, Abdominal wall & Extremities .
    • Transsacral (caudal) block – anesthesia of the perineum, and occasionally, the lower abdomen.
    • The injection of a solution containing the local anesthetic into the tissues at the planned incision site
    • Advantages
      • Simple, Economical, non-explosive
      • Equipment needed is minimal
      • Post-operative recovery is brief
      • Undesirable effects of GA are avoided
      • Ideal for SHORT and SUPERFICIAL operations
      • Usually given with EPINEPHRINE
    • maximum dose usually expressed as (mg of LA) per (kg of lean body weight) and as a total maximal dose (adjusted for young/elderly/ill)
    • lidocaine maximum dose: 5 mg/kg (with epinephrine: 7mg/kg)
    • chlorprocaine maximum dose: 11 mg/kg (with epinephrine: 14 mg/kg)
    • bupivicaine maximum dose: 2.5 mg/kg (with epinephrine: 3 mg/kg)
    • Occurs by accidental IV injection, Overdose or unexpectedly rapid absorption
    • CNS effects
      • N umbness of tongue, P erioral tingling
      • D isorientation, d rowsiness
      • T innitus
      • V isual D istrubances
      • M uscle twitching, tremors
      • C onvulsions, seizures
      • G eneralized CNS d epression, c oma, r espiratory arrest
    • CVS effects
      • V asodilation, hypotension
      • D ecreased myo cardial contractility
      • D ose-dependent delay in cardiac impulse transmission
      • P rolonged PR, QRS intervals
      • S inus bradycardia
      • C VS collapse
    • Early recognition of signs
    • 100% O2, manage ABCs
    • Diazepam may be used to increase seizure threshold
    • If seizures are not controlled by diazepam, consider using :
      • Thiopental (increases seizure threshold)
      • SCh (stops muscular manifestations of seizures, facilitates intubation)
    • Nausea & Vomiting
      • Turn to side, head lowered, provide basin
      • Pre-op Antiemetic drugs
      • Suction for Saliva and vomited gastric contents
      • Aspiration of Vomitus can lead to Pneumonitis and Pulmonary Edema leading to HYPOXIA.
    • Anaphylaxis
      • Reaction of the body to foreign substances
      • Meds common cause of anaphylaxis
      • Latex reaction can also occur
      • Life-threatening – vasodilation, hypotension, and bronchial constriction
      • Fibrin sealants and cyanoacrylate adhesives – can also cause anaphylactic reaction
    • Hypoxia and Respiratory Complications
      • Patient’s oxygenation status is the PRIMARY FUNCTION of the ANESTHESIA PROVIDER and the CIRCULATING NURSE .
      • Pulse Oximetry Values are monitored continuously.
      • Anatomic variation, ET tube may be inserted
      • Surgical POSITIONING (Trendelenburg)
    • Hypothermia
      • Glucose metabolism is reduced, TEMP decreases results in METABOLIC ACIDOSIS
      • Below 36.6°C[98.0°F] – below Normal core temp
      • Low temp in OR (Set at 25 to 26.6 Celsius)
      • Infusion of cold fluids (Warm to 37.6 Celsius)
      • Warming should be gradual
    • Malignant Hyperthermia – inherited MUSCLE DISORDER chemically induced by anesthetic agents.
    • Susceptible People
      • Those with strong and bulky muscles
      • History of muscle cramps or muscle weakness
      • Unexplained temperature elevation
      • Unexplained death of a family member after surgery
    • Tachycardia – (150 beats/min), early sign
    • Ventricular dysrhytmia
    • Hypotension
    • Decreased Cardiac Output
    • Oliguria
    • Cardiac Arrest
    • Rigidity , tetanus-like movements
    • Rise in temp , usually a late sign, develops fast
    • 1° to 2° C every 5 mins, can exceed 40°C
    • Trismus (masseter spasm) – common not specific for MH, occurs 1% in children given SCh w/ Halo
    • Death / Coma
    • Disseminated intravascular coagulation (DIC)
    • Muscle Necrosis / weakness
    • Myoglobinuric renal failure
    • Electrolyte abnormalities (i.e. iatrogenic hypokalemia)
    • Suspect possible MH with family history of problems/death with anesthetic
    • Dantrolene prophylaxis no longer routine
    • Avoid all triggers
    • Central Body temp and ET CO2 monitoring
    • Use regional anesthesia if possible
    • Use equipment “clean” of trigger agents
    • Discontinue inhaled anesthetic agent and SCh, terminate procedure
    • Hyperventilate with 100% O2
    • Dantrolene 1mg/kg, repeating until stable or 10mg/kg maximum reached
    • Treat metabolic/physiologic derangements accordingly
    • Control body temperature
    • Diligent monitoring (especially CVS, lytes, ABGs, urine output)
    • Life-threatening, characterized by thrombus formation and depletion of select coagulation proteins, Idiopathic
    • Predisposing factors:
      • Emergency surgery
      • Massive trauma
      • Head Injury
      • Massive transfusion
      • Liver/kidney involvement
      • Embolic events or shock
    • AVOID Derogatory comments
    • Patient is treated as a person
    • Respecting cultural and spiritua l values
    • Providing physical privacy
    • Maintaining Confidentiality
    • 1. A patient in the holding area awaiting surgery indicates that he had not received instructions not to take his usual medications ( antihypertensive agent, diuretic, digoxin, potassium chloride, and insulin injection ); as a result, he took them a few hours ago . What implications does this have for the patient’s care and well-being while awaiting surgery, during surgery, and in the immediate postoperative period?
    • 2. What are the differences in responsibility of the operating room nurse for care of patients who receive general anesthesia, conscious sedation, spinal anesthesia, and regional anesthesia ?
    • 3. While she is being transferred from the stretcher to the operating table, a female patient says she is very anxious about her surgery because of previous negative experiences . What assessment and interventions are indicated at this time?

Unique Introduction ro Cardiovascular Nursing

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Studying Cardiovascular nursing is not rocket science. You just need the proper mindset and material in order to excel in this subject.
    • Aorta & arteries tend to become less distensible
    • Heart becomes less responsive to catecholamines
    • Maximal exercise heart rate declines
    • Decreased rate of diastolic relaxation ( ↑in BP is more pronounced for systolic BP than diastolic BP)
      • Note that hypertension is NOT a normal age-related process
    • Compensatory mechanism are delayed/insufficient = orthostatic hypotension is common
    • Thickness of LV wall may increase with age due to blood vessel changes
    • Also known as coronary HEART disease (CHD)
    • Describes heart disease caused by impaired coronary blood flow
    • Common cause: atherosclerosis
    • CAD can cause the following:
      • Angina
      • Myocardial Infarction (MI) = heart attack
      • Cardiac dysrhythmias
      • Conduction defects
      • Heart failure
      • Sudden death
    • Men are more often affected than women
    • Approximately 80% who die of CHD are 65+ y/o
  1. Risk Factors Non-modifiable Modifiable Age, gender, race, heredity Endothelial injury Stress, diet, sedentary living, Smoking, Alcohol, HPN, DM, Obesity, Contraceptive pills, Hyperlipidemia/hypercholesterolemia Desquamation of endothelial lining (peeling off)
  2. Increased permeability/ adhesion of molecules LDLs & platelets assimilate into the area Plaques begins to form Decreased coronary tissue perfusion Coronary ischemia Decreased myocardial oxygenation ANGINA PECTORIS MYOCARDIAL INFARCTION
    • Inspection:
      • Skin color
      • Neck vein distention (jugular vein)
      • Respiration
      • Peripheral edema
    • Palpation:
      • Peripheral pulses
    • Auscultation:
      • Heart sounds (presence of S 3 in adults & S 4 )
      • Murmurs – audible vibrations of the heart & great vessels produced by turbulent blood flow
      • Pericardial friction rub – extra heart sound originating from the pericardial sac
      • - may be a sign of inflammation, infection, or infiltration
      • - described as a short, high-pitched scratchy sound
    • Dyspnea
      • Dyspnea on exertion – may indicate decreased cardiac reserve
      • Orthopnea – a symptom of more advanced heart failure
      • Paroxysmal nocturnal dyspnea – severe SOB that usually occurs 2-5hrs after onset of sleep
    • Chest Pain – may be due to decreased coronary tissue perfusion or compression & irritation of nerve endings
    • Edema – increased hydrostatic pressure in venous system causes shifting of plasma resulting to interstitial fluid accumulation
    • Syncope – due to decreased cerebral tissue perfusion
    • Palpitations
    • Fatigue
    • ECG (Electrocardiography) – graphical recording of the heart’s electrical activities; 1 st diagnostic test done when cardiovascular disorder is suspected
      • Waves: P wave – atrial depolarization (contraction/stimulation)
        • QRS complex – ventricular depolarization (changes are irreversible)
        • ST segment – ventricular repolarization (changes are reversible)
        • U wave – hypokalemia
      • PR interval (time for impulse to travel) = 0.12-0.20s (3-5 squares) √ for AV block
      • QRS = 0.10s or (<2squares)>
    • Abnormalities:
      • absent P wave = atrial fibrillation
      • saw-tooth pattern = atrial flutter
      • elevated ST segment = MI
      • 3rd degree heart block = prolonged PR then progressively prolonged
    • Cardiac Enzymes (Cardiac Markers):
      • 1 st : Myoglobin
      • a. urine = 0 – 2mg/dL (↑within 30mins – 2hrs after MI)
      • b. blood = <70mg/dl>
    • 2 nd : Troponin* - regulates calcium-mediated contractile process released during MI (Troponin T & I)
    • - blood = <0.6mg/dl>
    • 3 rd : Creatinine kinase (CK) – intracellular enzymes found in muscles converting ATP to ADP
    • CK-MB – specific to myocardial tissue (↑within 4-6hrs & decreases to normal within 2-3days)
        • male = 12-70 mg/dL
        • female = 10-55 mg/dL
    • 4 th : LDH (specifically LDH 1 - most sensitive indicator of myocardial damage) = 45-90mg/dL - ↑within 3-4 days & remains elevated for 14 days
    • Stress Test / Treadmill Test (Treadmill Stress Test) – ECG monitoring during a series of activities of patient on a treadmill
      • Purposes: identify ischemic heart disease
      • evaluate patients with chest pain
      • evaluate effectiveness of therapy
      • develop appropriate fitness program
      • Instructions to patient: get adequate sleep prio r to test
      • - avoid: caffeinated beverages, tea, alcohol, on the day before until the test day
      • - wear comfortable, loose-fitting clothes & rubber-soled shoes on the test day
      • - light breakfast on the day of the test
      • - inform physician of any unusual sensations during the test
      • - rest after the test
    • Pharmacologic Stress Test – use of intravenous injection of pharmacologic vasodilator (dipyridamole, adenosine, or dobutamine) in combination of radionuclide myocardial imaging
      • To evaluate presence of significant CHD for patients contraindicated in TST
      • Dipyradamole blocks cellular re-absorption of adenosine (endogenous vasodilator) & increases coronary blood flow 3-5x above baseline levels
      • If with CHD, the resistance vessels distal to the stenosis already are maximally dilated to maintain normal resting flow, thus, further vasodilatation does not produce increased blood flow
      • Dobutamine – used in patients with bronchospastic pulmonary disease
      • - increases myocardial O 2 demand by increasing cardiac contractility, HR, & BP
    • Cardiac Catheterization – involves passage of flexible catheters into great vessels & heart chambers under local anesthesia
    • - lab is equipped for viewing & recording fluoroscopic images & for measuring pressures in the heart & great vessels, cardiac output studies, & for obtaining ABG samples
    • - Epinephrine – to counteract possible allergic reactions
      • Right heart Catheterization – catheter inserted into peripheral veins (basilic or femoral) then advanced into the right heart
      • Left heart Catheterization – catheter inserted retrograde through peripheral artery (brachial or femoral) into the aorta & left heart
    • Coronary Angiogram – injection of radiographic contrast medium into the heart so that an outline of moving structures are visualized & filmed
    • Coronary Arteriography - injection of radiographic contrast medium into the coronary arteries permits visualization of lesions in these vessels
    • Before Procedure:
      • Check consent form
      • √ for allergies to seafood & iodine
      • NPO post midnight
      • Baseline V/S
      • Explain that warm or flushing sensation may be felt upon administr ation of the dye; “fluttering” sensation may be felt as catheter enters the heart
      • Administer sedatives as ordered
      • Have the client void prior to transport to cath lab
    • After Procedure:
      • Bed rest – upper extremity catheter = until stable v/s, HOB not more than 30 °
      • - lower extremity = 24hrs, flat on bed for 6hrs
      • Apply pressure (5lb-sand bag) over puncture site & monitor for bleeding
      • Monitor v/s q15 for 1 st 2hrs then q1 until stable v/s, esp. peripheral pulses
      • Immobilize affected extremity in extension for adequate circulation
      • Monitor for color & temperature changes of extremities
      • Instruct client to report tingling sensations
    • Swan-Ganz Catheterization – to determine & monitor cardiovascular status; inserted via antecubital vein into the right side of the heart & is floated into the pulmonary artery
    • 4 lumens:
    • 1. CVP – specific to right heart RA = 0-12 RV = 5-12
      • Indications: increased CVP = heart failure
    • -decreased CVP = hypovolemia
    • 2. Pulmonary pressures:
      • PAP (pulmonary artery pressure) = 20-30mmHg
      • PCWP (pulmonary capillary wedge pressure) = 8-13mmHg (√ for pulmonary edema)
    • 3. Specimen collection tube – also used for administering meds
    • 4. Balloon
    • Echocardiography – uses ultrasound to assess cardiac structure & mobility
    • Doppler U/S – to detect blood flow of artery & vein specifically of lower extremities (No smoking 1hr before the test)
    • Holter Monitoring – portable 24hr ECG monitoring which attempts to assess activities which precipitate dysrhythmias & its time of the day
    • MRI – magnetic fields & radiowaves are used to detect & define abnormalities in tissues (aorta, tumors, cardiomyopathy, pericardiac disease)
    • - shows actual beating & blood flow; image over 3 spatial dimensions
      • Secure consent
      • Assess for claustrophobia
      • Remove metal items (jewelries, eyeglasses)
      • Instruct client to remain still during the entire procedure
      • Inform client of the duration (45-60mins)
      • CI: clients with pacemakers, prosthetic valves, recently implanted clips or wires
  6. CHD Chronic Ischemic Heart Disease Acute Coronary Syndrome Stable Angina Variant Angina Silent Myocardial Ischemia Non ST-segment Elevation MI (Unstable Angina) ST-segment Elevation MI
    • Ischemia – suppressed blood flow
    • Angina – to choke
    • Occurs when blood supply is inadequate to meet the heart’s metabolic demands
    • Symptomatic paroxysmal chest pain or pressure sensation associated with transient ischemia
  7. Causes: Atherosclerosis, HPN, DM, Buerger’s Disease, Polycythemia Vera, Aortic regurgitation Reduced coronary tissue perfusion Decreased myocardial oxygenation Anaerobic metabolism Increased lactic acid production (lactic acidosis) Chest pain
    • Stable angina – the common initial manifestation of a heart disease
      • Common cause: atherosclerosis (although those with advance atherosclerosis do not develop angina)
      • Pain is precipitated by increased work demands of the heart (i.e.. physical exertion, exposure to cold, & emotional stress)
      • Pain location: precordial or substernal chest area
      • Pain characteristics:
        • con stricting, squeezing, or suffocating sensation
        • Usua lly steady, increasing in intensity only at the onset & end of attack
        • May radiate to left shoulder, arm, jaw, or other chest areas
        • Dura tion: <>
        • Relie ved by rest (preferably sitting or standing with support) or by use of NTG
    • Variant/Vasospastic Angina (Prinzmetal Angina)
      • 1 st described by Prinzmetal & Associates in 1659
      • Cause: spasm of coronary arteries (vasospasm) due to coronary artery stenosis
        • Mechanism is uncertain (may be from hyperactive sympathetic responses, mishandling defects of calcium in smooth vascular muscles, reduced prostaglandin I 2 production)
      • Pain Characteristics: occurs during rest or with minimal exercise
      • - commonly follows a cyclic or regular pattern of occurrence (i.e.. Same time each day usually at early hours)
      • If client is for cardiac cath, Ergonovine (nonspecific vasoconstrictor) may be administered to evoke anginal attack & demonstrate the presence & location of spasm
    • Nocturnal Angina - frequently occurs nocturnally (may be associated with REM stage of sleep)
    • Angina Decubitus – paroxysmal chest pain occurs when client sits or stands up
    • Post-infarction Angina – occurs after MI when residual ischemia may cause episodes of angina
    • Dx: detailed pain history, ECG, TST, angiogram may be used to confirm & describe type of angina
    • Tx: directed towards MI prevention
      • Lifestyle modification (individualized regular exercise program, smoking cess a tion)
      • Stress reduction
      • Diet changes
      • Avoidance of cold
      • PTCA (percutaneous transluminal coronary angioplasty) may be indicated if with severe artery occlusion
    • Nitroglycerin (NTGs) – vasodilators:
      • patch (Deponit, Transderm-NTG)
      • sublingual (Nitrostat)
      • oral (Nitroglyn)
      • IV (Nitro-Bid)
    • Β -adrenergic blockers:
      • Propanolol (Inderal)
      • Atenolol (Tenormin)
      • Metoprolol (Lopressor)
    • Calcium channel blockers:
      • Nifedipine (Calcibloc, Adalat)
      • Diltiazem (Cardizem)
    • Lipid lowering agents –statins:
      • Simvastatin
    • Anti-coagulants:
      • ASA (Aspirin)
      • Heparin sodium
      • Warfarin (Coumadin)
    • Class I – angina occurs with strenuous, rapid, or prolonged exertion at work or recreation
    • Class II – angina occurs on walking or going up the stairs rapidly or after meals, walking uphill, walking more than 2 blocks on the level or going more than 1 flight of ordinary stairs at normal pace, under emotional stress, or in cold
    • Class III – angina occurs on walking 1-2 blocks on the level or going 1 flight of ordinary stairs at normal pace
    • Class IV – angina occurs even at rest
    • Diet instructions (low salt, low fat, low cholesterol , high fiber); avoid animal fats
      • E.g.. White meat – chicken w/o skin, fish
    • Stop smoking & avoid alcohol
    • Activity restrictions are placed within client’s limitations
    • NTGs – max of 3doses at 5-min intervals
      • Stinging sensation under the tongue for SL is normal
      • Advise clients to always carry 3 tablets
      • Store meds in cool, dry place, air-tight amber bottles & change stocks every 6months
      • Inform clients that headache, dizziness, flushed face are common side effects.
      • Do not discontinue the drug.
      • For patches, rotate skin sites usually on chest wall
      • Instruct on evaluation of effectiveness based on pain relief
    • Propanolols causes bronchospasm & hypoglycemia, do not administer to asthmatic & diabetic clients
    • Heparin – monitor bleeding tendencies (avoid punctu res , use of soft-bristled toot hbrush ); monitor PTT levels; use d for 2wks max; do not massage if via SC; have protamine sulfate available
    • Coumadin – monitor for bleeding & PT; always have vit K readily available (avoid green leafy veggies)
    • Unstab le Angina/Non ST-Segment Elevation MI – a clinical syndro me of myocardial ischemia
      • Causes: atherosclerotic plaque disruption or significant CHD, cocaine use (risk factor)
      • Defining guidelines: (3 presentations)
        • Symptoms at rest (usually prolonged, i.e.. >20mins)
        • New onset exertional angina (increased in severity of at least 1 class – to at least class III) in <2months>
        • Recent acceleration of angina to at least class III in <2months>
      • Dx: based on pain severity & presenting sympto ms , ECG findings & serum cardiac markers
      • When chest pain has been unremitting for >20mins, possibility of ST-Segment Elevation MI is usually considered
    • ST-Segment Elevation MI (Heart Attack)
      • Characterized by ischemic death of myocardial tis sue associated with atherosclerotic disease of coro nar y arteries
      • Area of infarction is determined by the affected coronary artery & its distribution of blood flow (right coronary artery, left anterior descending artery, left circumflex artery)
      • Dx: based on presenting S/Sx, serum markers, & ECG (changes may not be present immediately after symptoms except dysrhythmias; PVCs/premature ventricular contractions are common after MI)
        • Typical ECG changes: ST-segment elevation, Q wave prolongation, T wave inversion
      • Manifestations:
        • chest pain – severe crushing, constricting, “someone sitting on my chest”
        • - substernal radiating to left arm, neck or jaw
        • - prolonged (>35mins) & not relieved by rest
        • Shortness of breath, profuse perspiration
        • Feeling of impending doom
      • Complications: death (usually within 1 hr of onset)
        • Heart fail ure & cardiogenic shock – profound LV failure from massive MI resulting to low cardiac output
        • Thromboe mboli – leads to immobility & impaired cardiac function contributi ng to blood stasis in veins
        • Rupture of myocardium
        • Ventricul ar aneurysms – decreases pumping efficiency of heart & increase s work of LV
  8. Causes: atherosclerotic heart disease, thrombosis/embolism, shock &/or hemorrhage, direct trauma Myocardial ischemia ↑ cellular hypoxia ↓ myocardial O 2 supply ↓ myocardial contractility ↓ cardiac output ↓ arterial pressure Stimulation of sympathetic receptors ↑ peripheral vasoconstriction ↑ myocardial contractility ↑ afterload ↑ myocardial O 2 demand ↑ HR ↑ diastolic filling ↓ myocardial tissue perfusion
  9. Time after Onset Type of Injury & Gross Tissue Changes 0-0.5hrs Reversible injury 1-2hrs Onset of irreversible injury 4-12hrs Beginning of coagulation necrosis 18-24hrs Continued necrosis; gross pallor of infected tissue 1-3days Total necrosis; onset of acute inflammatory process 3-7days Infarcted area becomes soft with a yellow-brown center & hyperemic edges 7-10days Minimally soft & yellow with vascularized edges; scar tissue generation begins (fibroplastic activity) 8 th week Complete scar tissue replacement
    • Initial Management: OMEN
    • - O 2 therapy via nasal prongs
    • - adequate analgesia ( M orphine via IV – also has vasodilator property)
    • - E CG monitoring
    • -sublingual N TG (unless contraindicated; IV may be given to limit infarction size & most effective if given within 4hrs of onset)
    • Thrombolytic Therapy – best results occur if initiated within 60-90mins of onset (Streptokinase & Urokinase – promote conversion of plasminogen to plasmin)
    • Anti-arrhythmics: lidocaine, atropine, propano lol
    • Anticoagulants & antiplatelets: ASA, heparin
    • Stool softeners
    • Surgery :
      • Revascularization
        • PTCA
        • Coronary stent implantation
        • Coronary Artery Bypass Graft (CABG) – no response to medical treatment & PTCA
      • Resection – aneurysm
    • Promote oxygenation & tissue perfusion (place client on semi-fowler’s, O 2 via nasal cannula, monitor v/s changes, remind client on his activity limitations & restrictions)
    • Promote comfort & rest
    • Monitor the ff perimeters: v/s, ECG, rate & rhythm of pulse, effects of ADLs on cardiac status
    • Diet: low salt, low cholesterol, low calories, avoid alcohol & smoking
    • Take prescribe meds at regular basis
    • Stress management
    • Resume sexual activity after 4-6wks from discharge or when client can go up 2 flights of stairs without difficulty
      • Assume less tiring position (non-MI partner takes active role).
      • Perform sexual activity in a cool, familiar place.
      • Take prescribed NTG before sexual activity
      • Refrain from sexual activity after a large meal or during a tiring day.
      • Moderation should be observed if palpitations, dizziness or dyspnea is observed
    • Also known as Thromboangiitis obliterans
    • Usually a disease of heavy cigarette smoker/tobacco user men, 25-40y/o
    • Inflammatory arterial disorder that causes thrombus formation often extends to adjacent veins & nerves
    • Affects medium-sized arteries (usually plantar & digital vessels in the foot or lower legs)
    • unknown pathogenesis but it had been suggested that:
      • tobacco may trigger an immune response or
      • unmask a clotting defect;
      • -> these 2 can incite an inflammatory reaction of the vessel wall
    • Pain – predominant symptom; R/T distal arterial i schemia
      • Intermittent claudication in the arch of foot & digits
    • Increased sensitivity to cold (due to impaired circulation
    • Absent/diminished peripheral pulses
    • Color changes in extremity (cyanotic on dependent position; digits may turn reddish blue)
    • Thick malformed nails (chronic ischemia)
    • Disease progression ulcerate tissues & gangrenous changes may arise; may necessitate amputation
    • Diagnostic methods – those that assess blood flow (Doppler ultrasound & MRI)
    • Tx: mandatory to stop smoking or using tobacco
      • Meds to increase blood flow to extremities
      • Surgery (surgical sympathectomy)
      • amputation
    • Mechanism: intensive vasospasm of arteries & arterioles in the fi ngers
    • Cause: unknown
    • Usually affects young women
    • Precipitated by exposure to cold & strong emotions
    • Raynaud’s phenomenon – associated with previous injury (i.e.. Frostbite, occupation al trauma associated with use of heavy vibr ating tools, collagen diseases, neuro d/o, chro nic arterial occlusive d/o)
    • Period of ischemia (ischemia due to vasospasm)
      • change in skin color = pallor to cyanotic
      • 1 st noticed at the fingertips later moving to distal phalanges
      • Cold sensation
      • Sensory perception changes (numbness & tingling)
    • Period of hyperemia – intense redness
      • Throbbing
      • Paresthesia
    • Return to normal color
    • Note: although all of the fingers are affected symmetrically, only 1-2digits may be involved
    • Severe cases: arthritis may arise (due to nutritional impairment)
      • Brittle nails
      • Thickening of the skin of fingertips
      • Ulceration & superficial gangrene of fingers (rare occasions)
    • Dx: initial = based on Hx of vasospastic attacks
      • Immersion of hand in cold water to initiate attack aids in the Dx
      • Doppler flow velocimetry – used to quantify blood flow during temperature changes
      • Serial Computed thermography (finger skin temp) – for diagnosing the extent of disease
    • Tx: directed towards eliminating factors causing vasospasm & protecting fingers from injury during ischemic attacks
      • PRIORITIES: Abstinence in smoking & protection from cold
      • Avoidance of emotional stress (anxiety & stress may precipitate vascular spasm)
      • Meds: avoid vasoconstrictors (i.e.. Decongestants)
      • -Calcium channel blockers (Diltiazem, Nifedip ine , Nicardipine) – decrease episodes of attacks
    • Assessment:
      • Hx of symptoms (pain, esp. chest pain; palpitations; dyspnea)
      • v/s
    • Nursing Dx:
      • ineffective tissue perfusion (cardio pulmonary)
      • Impaired gas exchange
      • Anxiety due to fear of death (clients with MI or An gina)
    • Goals:
      • Relief of pain & symptoms
      • Prevention of further cardiac damage
    • Nursing Interventions:
      • Pain control
      • Proper medications
      • Decrease client’s anxiety
      • Health teachings (meds, activities, diet, exercise, etc)

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MS Respiratory System

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A complete yet brief lecture about the Respiratory system. This Lecture focuses on the Anatomy and Physiology, Diagnostic Exams, Lab Values, Respiratory Diseases and Nursing Managements.
  1. Brief Review of System
  2. Upper Respiratory Tract
  3. Lower Respiratory Tract
  4. Lung Volumes & Capacities
    • Lung volumes – amount of air exchanged during ventilation
      • Tidal volume (TV) – amount of air that moves in & out of the lungs during normal breathing (500mL)
      • Inspiratory reserve volume (IRV) – maximum amount of inhaled air in excess of the normal TV (3000mL)
      • Expiratory reserve volume (ERV) – maximum amount of exhaled air in excess of the normal TV (1100mL)
      • Residual volume (RV) – amount of air remaining in the lungs after forced expiration; increases with age (1200mL)
    • Lung capacities – 2 or more lung volumes
      • Vital capacity (VC) = TV+IRV+ERV (amount of air than can be exhaled from maximal inspiration) 4600mL
      • Inspiratory capacity = TV+IRV (maximum amount of inhaled air at the beginning of normal expiration & distending the lungs to its maximum) 3500mL
      • Functional residual capacity = RV+ERV (amount of air remaining in lungs after normal expiration) 2300mL
      • Total lung capacity = sum of all lung volumes; total amount of air that the lungs can hold
    • average pair of human lungs can hold about 8L of air, but only a small amount of this capacity is used during normal breathing
  6. Factors Affecting Lung Volume
    • Larger volumes
      • males
      • taller people
      • non-smokers
      • athletes
      • people living at high altitudes (the body's diffusing capacity increases in order to be able to process more air)
    • Smaller volumes
      • Females
      • shorter people
      • Smokers
      • non-athletes
      • people living at low altitudes (atmosphere is less dense at higher altitude, therefore, the same volume of air contains fewer molecules of all gases
  7. Effects of Aging
    • Progressive loss of elastic recoil of lungs – due to elastin & collagen fiber changes
    • Increased respiratory muscle workload – due to calcification of soft tissues in chest wall
    • Total lung capacity remains constant
    • Increased residual lung volume – result of changes in aging
  8. Physical Assessment
    • Inspection:
        • Symmetry of Chest Expansion
        • Size of chest (barrel chest, pigeon chest, deformities, flail segment/paradoxical movement)
        • Signs of Increased Respiratory Effort
        • Changes in Skin Color (including nail beds)
        • Clubbing of fingernails
        • Include listening to patient’s speech
    • Palpation
      • Trachea – slightly movable & quickly returns to midline after displacement
      • Tactile fremitus –transmission of vibration of air movement through chest wall during phonation (99 method)
      • Thoracic excursion
    • Percussion:
      • Resonant – low-pitched hollow (normal lung sound)
      • Hyperresonant – louder & lower-pitched; presence of increased amount of air (emphysema, pneumothorax)
      • Dull- thudlike
      • Tympanic – hollow (tension-pneumothorax)
      • Flat – soft high-pitched
    • Auscultation:
      • Bronchial, bronchovesicular, vesicular
      • Adventitious Breath sounds:
        • Stridor - High pitched crowing sound, usually heard on inspiration, indication of a tight upper airway
        • Wheezing - Whistling sound, usually heard on expiration, indication of narrowing of lower airways (bronchospasm, edema, foreign material)
        • Ronchi - Rattling sound, caused by mucus in larger airways
        • Rales - Fine crackling sound, indication of fluid in the alveoli
  9. Diagnostics
    • Chest X-ray (Chest radiography; Serial chest x-ray)
      • Visualization of the chest, lungs, heart, large arteries, ribs, and diaphragm while standing in front of the machine
      • Two views are usually taken:
        • Antero-posterior view - x-rays pass through the chest from the back
        • Lateral view - x-rays pass through the chest from one side to the other
      • Nursing Interventions:
        • Instruct client to hold his breath while x-ray is taken
        • Inform client that test is performed in the radiology department (in hospitals, mobile x-rays may be used) & the film plate may feel cold
        • Instruct client to wear a hospital gown and remove all jewelries
  10. B. Pulmonary Function Tests (PFT)
    • a group of tests measuring lung function
    • Measure of diffusion capacity
      • client breathes in a harmless gas for a very short time (one breath)
      • the concentration of the gas in the air exhaled is measured
      • the difference in the amount of gas inhaled and exhaled can help estimate how quickly gas can travel from the lungs into the blood
    • Body plethysmograph - most accurate
      • Client sits in a sealed, clear box that looks like a telephone booth while breathing in and out into a mouthpiece
      • Changes in pressure inside the box help determine the lung volume
  11. Cont…(PFT)
    • Spirometry test – measures airflow; client will breathe through a tight fitting mouthpiece and will have nose clips
    • Nursing Interventions: Instruct client to:
      • breathe into a mouthpiece that is connected to an instrument (spirometer)
      • eat a light meal before the test
      • not to smoke for 4 - 6 hours before the test
      • stop using bronchodilators or inhaler medications 6-8hrs prior
      • Inform client that temporary shortness of breath or light-headedness may be felt
  12. C. Peak Expiratory Flow Rate (PEFR)
    • measures how fast a person can exhale
    • it is one of many tests that measure how well the airways work
    • requires a peak expiratory flow (PEF) monitor, a small handheld device with a mouthpiece at one end and a scale with a moveable indicator (usually a small plastic arrow)
    • commonly used to diagnose and monitor lung diseases such as asthma, chronic bronchitis, chronic obstructive pulmonary disease (COPD), & emphysema
    • Home monitoring helps determine whether treatments are working or detect when your condition is getting worse . This allows anticipation on when breathing will bec ome worse and to take medications or to call hea lth care providers before symptoms become too seve re
    • A decrease in peak flow indicates blocked or narrowed airways
    • A significant fall in peak flow can signal the onset of a lung disease esp. when accompanied by persistent coughing, SOB, or wheezing
    • PEFR measurements are not as accurate as the spirometry
    • Nursing Interventions:
      • Inform client that repeated efforts may cause lightheadedness
      • Loosen any tight clothing that might restrict breathing
      • Sit up straight or stand while performing the tests
      • Instruct client on proper procedure to do this test:
      • Breathe in as deeply as possible.
      • Blow into the instrument's mouthpiece as hard and fast as possible.
      • Do this 3 times, and record the highest flow rate
  13. D. Throat Culture
    • Also known as throat swab culture
    • a laboratory test to isolate and identify organisms that may cause infection in the throat; when throat infection is suspected, particularly strep throat
    • back of the throat is swabbed with a sterile cotton swab near the tonsils
    • Nursing Interventions:
      • Instruct client not to use antiseptic mouthwashes before the test
      • Inform client that he may experience a gagging sensati on when the back of the throat is swabbed
      • Instru ct to resist gagging and closing the mouth during procedure (test only takes a few seconds)
  14. E. Bronchoscopy (Fiber Optic Bronchoscopy)
    • views the airways and diagnose lung disease
    • may also be used during the treatment of some lung conditions
    • flexible bronchoscope is usually used (less than ½ in wide and about 2ft long)
    • scope is passed through the mouth or nose, and then into the lungs
    • rigid bronchoscope requires general anesthesia
    • flexible bronchoscope uses local anesthesia (spray if via mouth and throat; numbing jelly if via nose)
    • IV meds may be given to help relax the client
  15. Cont…(Bronchoscopy)
    • Nursing Interventions:
      • Inform client that spraying of local anesthesia will cause coughing at first, which will stop as the anesthetic begins to work
      • Inform client that as the anesthesia wears off, the throat may be scratchy for several days
      • Instruct client on NPO 6-12hrs prior (withhold ASA or Ibuprofen if client takes it on a regular basis or as ordered)
      • Place client on NPO 1-2hrs after the procedure or until (+) for gag reflex
  16. F. Sputum Culture
    • Sputum - secretion produced in the lungs and the bronchi; what comes up with deep coughing
      • This mucus-like secretion may become infected, bloodstained, or contain abnormal cells that may lead to a diagnosis
    • Nursing Interventions:
      • Drinking a lot of water and other fluids the night before collection may help
      • Perform back tapping or chest clapping on client to aid in loosening the sputum
      • Instruct client on proper specimen collection
        • Collect morning specimen
        • Gargle with water only before specimen collection cough deeply and spit sputum in a sterile cup
      • Send specimen to lab ASAP
  17. G. Oximetry
    • measures oxygen concentration (%) in the blood
    • used in the evaluation of various medical conditions affecting heart & lung functions
    • most commonly used = pulse oximeters because they respond only to pulsations, such as those in pulsating capillaries of the area tested
    • pulse oximeter works by passing a beam of red and infrared light through a pulsating capillary bed
    • ratio of red to infrared blood light transmitted gives a measure of the oxygen saturation in the blood
    • Principle: oxygenated blood is bright red while the deoxygenated blood is blue-purple
    • Other types:
      • intracardiac oximetry - blood that is within the heart or on whole blood that has been removed from the body
      • More recently, using a similar technology to oxymetry, carbon dioxide levels can be measured at the skin as well
  19. Pulmonary Tuberculosis
    • contagious bacterial infection that mainly involves the lungs, but may spread to other organs
    • Cause: Mycobacterium tuberculosis
    • Mode of transmission: inhalation of air droplets from a cough or sneeze of an infected person
    • primary stage of the infection is usually asymptomatic
  20. Pathophysiology
    • High-risk individuals
      • Elderly
      • Infants
      • Immunosuppressed (AIDS, chemotherapy, or antirejection medicines given after a organ transplant)
      • Are in frequent contact with people who have the disease
      • Live in crowded or unsanitary living conditions
      • Have poor nutrition
      • The appearance of drug-resistant strains of TB
    • S/Sx
      • Limited to minor cough
      • Fever and night sweats
      • Fatigue
      • Unintentional weight loss
      • Excessive sweating, especially at night
      • Coughing up blood
      • Phlegm-producing cough
      • Wheezing
      • Chest pain
      • Breathing difficulty
  22. Cont…(PTB)
    • Dx:
      • Chest x-ray – seen on upper lobes (due to higher O 2 concentration)
      • Sputum cultures (Acid-Fast Stain) – confirmatory test
      • Tuberculin skin test (Mantoux Test) – ID purified protein derivative (PPD)
        • 48-72hrs interpretation
        • (+) = 15mm induration (5mm for immunosuppressed clients)
      • Bronchoscopy
      • Thoracentesis (very rare occasions)
      • Chest CT Scan
    • Complications:
      • Miliary TB - widespread dissemination of Mycobacterium tuberculosis from hematogenous spread
      • Pleural Effusion – collection of fluid in the pleural cavity
      • Empyema – purulent drainage It results from an untreated pleural-space infection Empyema
  23. Cont…
    • Tx: Multi-drug therapy = to prevent development of resistance ( RIPES )
    • R ifampicin – inhibits RNA synthesis of the bacilli
    • I soniazid – remarkably potent to the bacilli; prophylaxis; given with Vit. B 6
    • P yrazinamide (PZA) – inhibits cell growth
    • E thambutol – inhibits cell growth
    • S treptomycin – 1 st drug found to be effective against PTB; given by injection
    • Nursing Management:
    • Give meds before meals
    • Maintenance therapy = after 6months
    • Client not communicable after 2wks
    • Rifampicin’s SE: reddish/orange body secretions (urine)
    • PZA prone to hyperuricemia so ↑ oral fluids
    • Ethambutol - A/E: optic neuritis so √ vision/visual changes
      • C/I: pedia – cannot report any visual disturbances
    • Streptomycin – A/E: ototoxic (√ tinnitus)
      • nephrotoxic = √ oliguria
      • neurotoxic = seizure precautions
  24. Asthma
    • Chronic inflammatory airway disease
    • Exposure to allergens (dust, smoke,
    • animal dander, pollen, volatile organic
    • compounds, food, meds, etc)
    • Cold air, exercise, & emotional upset
    • can produce bronchospasm
    • Pathophysiology:
      • allergens -> immune response (mast cells, eosinophils, T lymphocytes) -> mucus production -> bronchospasm -> inflammation -> excessive mucus production -> narrowing of airways -> bronchoconstriction -> asthma attack
    • Manifestations: (asthma attacks differ from 1
    • person to another)
      • Episodic wheezing
      • Feelings of chest tightness
      • Cough may be accompanied by wheezing
      • Prolonged expiration
      • Increased RR
      • Severe attacks = severe dyspnea (use of accessory muscles)
        • Distant breath sounds (due to air trapping)
        • Loud wheezing
        • Fatigue develops
        • Moist skin
        • Anxiety/panic attack
        • Client is able to speak 1-2 words before taking a breath
    • Complication: respiratory failure (onset marked by inaudible breath sounds, diminished wheezing, coughing becomes ineffective
  25. Cont…
    • Dx: careful Hx & physical assessment
      • Spirometry
      • Inhalation challenge test – measures the level of airway responsiveness (histamine, or exposure to non-pharmacologic agent)
    • Tx/ Nursing Management: goal = prevention of attack episodes
      • Pharmacologic
        • Quick-relief – not for daily use; relaxes bronchial muscles (albuterol, terbutaline via MDI or nebulizer)
        • Long-term meds – taken on daily basis; anti-inflammatory (cromolyn via MDI), corticosteroids (budesonide via MDI), bronchodilators (theophylline)
    • Mgt:
      • B ronchodilators
      • R est & relaxation techniques
      • O 2 = low flow (1-2Lpm)
      • N ebulize
      • C hest physiotherapy & controlled breathing (IPPB)
      • H igh-fowler’s/ orthopneic
      • I mmunotherapy
      • A void allergens
      • L iberal fluid intake
    • Meds:
      • A minophylline
      • S teroids
      • T heophylline – relaxes bronchial muscles
      • H istamine antagonist
      • M ucolytics – acetylcysteine (Fluimucil)
      • A ntibiotics
  26. Chronic Obstructive Pulmonary Disease (COPD)
    • clinical syndrome of chronic dyspnea as a result of expiratory airflow obstruction due to chronic bronchitis or emphysema (often both)
    • Causes: long-term smoking (leading cause) & Alpha1-antitrypsin deficiency (only known inherited form of the disease)
    • Risk factors:
      • Exposure to certain gases or fumes in the workplace
      • Exposure to heavy amounts of second hand smoke and pollution
      • Frequent use of cooking gas without proper ventilation
      • Low socioeconomic status
      • Male
      • Living in heavily industrialized urban areas
      • Recurrent respiratory illnesses
      • Family history of chronic bronchitis and emphysema (e.g., alpha1-antitrypsin deficiency)
      • Emotional stress and repressed emotions have also been shown to contribute
  27. Chronic Bronchitis (“Blue Bloaters”)
    • chronic cough, resulting from excessive tracheobronchial mucus production and impaired mucus elimination, on most days for 3 months of a year, for 2 consecutive years
    • Some people, even those with severe COPD, have few or no symptoms
    • Pathophysiology:
      • hallmarked by hyperplasia (increased number) and hypertrophy (increased size) of the goblet cells (mucous gland) of the airway -> increase mucus secretion -> airway obstruction -> cyanosis
      • infiltration of the airway walls with inflammatory cells (neutrophils) -> scarring -> airway wall thickening -> narrowing of the small airway -> metaplasia (abnormal change in the tissue) & fibrosis (further thickening and scarring) of lower airway -> limitation of airflow -> cyanosis
  28. Chronic Bronchitis Illustration
  29. Emphysema (Pink Puffers)
    • enlarged air spaces distal to the terminal bronchioles with destruction of the alveolar walls; there is also a loss of elastic recoil in the lung
    • Pathophysiology:
      • exact mechanism for the development of emphysema is not understood, although it is known to be linked with smoking and age
      • enlarged air sacs (alveoli) of the lungs -> reduces lung surface area -> ↓ lung elasticity -> small bronchioles collapse -> dead air space formation (blebs) -> air trapping -> dyspnea
  30. Emphysema Illustrations
  31. Emphysema vs. Chronic Bronchitis
    • Characteristic Pink Puffers Blue Bloaters
    • Definition - alveolar wall - inflammation of bronchi ->
    • destruction leads ↑ mucus prod uction (goblet
    • to air spaces (blebs) cells) & chronic cough
    • Smoking Hx - usual - usual
    • Age of onset - 40-50y/o - 30-40y/o; mid-age disability
    • Clinical Features
    • Color - acyanotic - cyanosis w/ edema
    • Barrel Chest - dramatic - may be present
    • Weight loss - severe (advanced) - infrequent (often overweight)
    • SOB - compensatory - predominant early symptom
    • pursed-lip breathing
    • Sputum - may be absent - copious sputum production
    • Lung x-ray - overinflated lucent - “dirty lungs”
    • Heart involvement - none, late cor pulmonale - cor pulmonale (RV)
    • ABGs - mild-mod hypoxemia - (+)hypoxemia
    • Dx: physical assessment
      • Chest x-ray or Chest CT Scan = confirmatory
      • PFTs, TST
      • Lab: Arterial Blood Gas (ABG)
    • Below Above
    • Acidosis pH = 7.35 – 7.45 Alkalosis
    • Acidosis HCO 3 = 22 – 26mEq/L Alkalosis
    • Alkalosis PCO 2 = 35 – 45mmHg Acidosis
    • R espiratory Compensation
    • A lternate arrows pH compensatory system
    • M etabolic uncompensated abnormal no change
    • S ame arrows partially abnormal change
    • Fully normal change
    • Management: STOP SMOKING
      • Improve oxygenation
        • Monitor respiratory patterns & assess breath sounds
        • Low flow O 2 (1-3Lpm)
        • High fowler’s position
        • Energy conservation techniques
      • Decrease CO 2 retention (airway clearance)
        • facilitate coughing
        • pursed-lip breathing technique
        • Maintain adequate hydration & room humidity
      • Meds: bronchodilators - to increase airflow and reduce dyspnea
        • sometimes theophylline - requires frequent blood monitoring for toxicity
        • inhaled steroids
        • Antibiotics - during flare-ups of symptoms
        • Alpha1-antitrypsin replacement therapy
  32. Pleurisy
    • inflammation of the lining of the lungs that ca uses pain when you take a breath or cough
    • normally smooth lining of the lungs (the pleura) become rough, they rub together with each breath, and may produce a rough, grating sound called a "friction rub."
    • Causes:
      • may develop when you have lung inflammation due to infections such as pneumonia or tuberculosis
      • Asbestos-related disease
      • Certain cancers
      • Chest trauma
      • Pulmonary embolus - blockage of an artery in the lungs by fat, air, blood clot, or tumor cells
      • Respiratory tract infections
    • S/Sx: main symptom = chest pain
      • Some people feel the pain in the shoulder
      • Deep breathing, coughing, and chest movement makes the pain worse
      • fluid may collect inside the chest cavity & may cause the following:
        • Coughing
        • Cyanosis
        • Shortness of breath, tachypnea
    • Dx: Complete Blood Count (CBC)
    • Activity intolerance (fatigue) RBC = 4.5M – 5.4M Risk for injury (CVA/Thrombosis)
    • Risk for infection WBC = 5K – 10K Actual infection
    • Risk for injury (bleeding) Platelets = Risk for injury (CVA- 150k – 450k clot formation)
    • Fluid volume deficit Hematocrit = Fluid volume excess
    • (dehydration) 35 – 45%
      • Thoracentesis - procedure to remove fluid from the space between the lining of the outside of the lungs (pleura) and the wall of the chest; local anesthesia
      • Pleural Biopsy - procedure to remove a sample of the tissue lining the lungs and the inside of the chest wall to check for disease or infection
      • Ultrasound of the chest or Chest x-ray
      • Sputum exam
    • Tx: depends on what is causing the pleurisy
      • Bacterial infections = antibiotics (some bacterial infections require a surgical procedure to drain all the infected fluid)
      • acetaminophen or anti-inflammatory drugs such as ibuprofen (for pain control)
      • Thoracentesis
    • Complications: Collapsed lung due to thoracentesis
      • Complications from the original illness
    • Nursing Management:
      • Health teachings (infection, work environment, splinting ribcage with pillow)
      • Position client on affected side
      • Thoracentesis: Instruct client not to cough, breathe de eply, or move during the test to lung puncture
        • Instruct to report SOB &/or chest pain during procedure
        • Apply pressure on puncture site & monitor for bleeding
  33. Tracheostomy
    • Tracheostomy – used for severe lung disorder , neurological problem, or infection makes it impossible to breathe,
    • to keep the windpipe open and supply air
    • a small opening (stoma) through the skin on the throat
    • a breathing tube is directly inserted into the windpipe (trachea).
    • The trache tube is sometimes sewn to the skin around the stoma
    • It can also be held in place with trache ties
    • Some trache tubes have an inflatable cuff near the outer end to keep it from coming out and to prevent air leaks
    • trache tube parts
      • Obturator - used to pass the trache into the windpipe
      • outer cannula (tube) - has a plastic "trache plate" that lies against the skin of the neck and holds the trache in place
      • Inner cannula that fits inside the outer one and locks into place
    • Obturator and clamp should always be at bedside
  34. Tracheostomy Care
    • clean the inner cannula on a daily basis
    • Observe proper precautions & handwashing before & after care
    • Whenever the tube threatens to become clogged with mucus, suction it clear
    • Materials:
      • kidney basin
      • a small brush (like a toothbrush) or twisted OS
      • H 2 O 2 &/or sterile NSS
      • 4x4 gauze pad
      • scissors
    • Procedures:
      • Place a “trache bib” under the trache plate with a gauze pad (upright “U”)
      • Unlock the inner cannula and remove it by pulling it gently out and down
      • Put a clean wet inner cannula (if reserve is available) as replacement & lock in place
      • Clean the dirty cannula by soaking it in H 2 O 2
      • Scrub it with the small brush when bubbling stops
      • Rinse well the inner cannula by pouring the sterile NSS
      • Return in place & lock if client has no reserve
  35. Endotracheal (ET) Tube
    • most common artificial airway used for short-term airway management or mechanical ventilation
    • may be inserted either orally or nasally
    • has a cuff that is inflated with air to hold the tube in place in the trachea
    • amount of air in the cuff should be checked every 8hrs to ensure that the cuff is not exerting too much pressure on the trachea walls
    • client with ET tube must be closely monitored:
      • to ensure that the tube remains patent
      • that skin breakdown does not occur from the tube (either the oral or nasal cavity)
      • infection is prevented
  36. Intubation Illustrations 2 Intubation 3 ET tube Placement 4 Securing the ET tube 1 ET tubes
  37. Securing Apparatuses for ET Tube ETAD Thomas Tube Holder
  38. Nursing Management
    • RNs prepare all needed materials needed for in tubation &/or assist in placement by securing p at ient’s position (head tilted on supine)
    • Sterile suction kit, a bottle of sterile NSS, sterile gloves, a clean bite block if necessary, and tape already torn into appropriately-sized pieces, laryngoscope
    • Documentation (note also tube distance at client’s lips)
    • All waste should be properly disposed
    • Complete airway check every 8hrs & prn
    • The insertion point (in cm) of the ET tube should be confirmed to be the same as prior to the procedure, unless the purpose of the procedure was to change the depth of the tube (via X-ray)
  39. Cont…
    • Primary portion of ET tube management is suctioning every 2hrs or prn
    • Client should be hyperoxygenated prior to suctioning
    • Color and amount of any sputum return should be noted
    • Oral cavity should also be suctioned
    • Thorough oral care every 8hrs and prn
    • If client has a bite block, it must be removed and cleaned or replaced every 8hrs
    • tube should be repositioned so as not to continuously exert pressure in the same area
    • If the tube is taped to the client's face, tape must be removed and replaced on the opposite side of the face at least once per day and prn
  40. Devices for Oxygen Administration
    • nasal cannula (NC) - thin tube with two small nozzles that protrude into the nostrils
      • It can only provide oxygen at low flow rates, 2-6 litres per minute (LPM), delivering a concentration of 28-44%.
    • simple face mask - basic mask used for non-life-threatening conditions but which may progress in time
      • Often set to deliver oxygen between 2-10 LPM
      • The final oxygen concentration delivered by this device is dependent upon the amount of room air that mixes with the oxygen
    • non-rebreather mask- utilized for those requiring high-flow oxygen, but do not require breathing assistance
      • It has an attached reservoir bag where oxygen fills in between breaths, and a valve that largely prevents the inhalation of room or exhaled air.
  41. Cont…
    • bag-valve-mask (Ambubag) - use d in CPR or if client is in critical condition
      • An oxygen reservoir bag is attached to a central cylindrical bag, attached to a valved mask
      • administers almost 100% concentration oxygen at 8-15 Lpm
      • The central bag is squeezed manually to deliver a "breath"
    • anaesthetic machine - used for general anesthesia
      • allows a variable amount of oxygen to be delivered, along with other gases including air, nitrous oxide and inhalational anaesthetics

1/30 NP Jobs Karen 'n bill

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Thursday, January 29, 2009

More SNOW!

This is Bear Jr, after coming in from the snow... he was NOT pleased!

Now... can we please have NO MORE SNOW? It's enough already! I mean it! NO MORE! It's still snowing! The weather lady on the news last night said another 50 days of winter and that Montreal has already gotten over 67cm of snow, when the average is usually 52cm! YEAH, EWWW! And it's snowing again...

1/29 NP Jobs Karen 'n bill

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Wednesday, January 28, 2009

Julie's picks from the literature: Jan 09

SJH/CHOC staff may access the full text of many of these journal articles via Burlew Medical Library's website or by calling the library at 714 771-8291.

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