During assessment gather a
complete history
History of Respiratory Function
- presence of cough: productive/nonproductive, hemoptysis
- dyspnea (asthma, bronchitis, pneumonia)
- pain: rule out chest pain
- environmental exposure/allergies
- frequency of respiratory tract infections: +TB, HIV
- pulmonary risk factors
- past respiratory problems
- current medications
- smoking history and/or secondhand smoke exposure
Types of Chest Pain
- pleuritic chest pain
- pericardial chest pain
- musculoskeletal pain
pleuritic chest pain
radiates to scapular regions
coughing and inspiration worsen pain.
pericardial chest pain
results from inflammation of the pericardia sac.
occurs on inspiration, does not usually radiate
musculoskeletal pain
usually following exercise, rib trauma, prolonged coughing episodes
Breathing Patterns include
- Kussmaul Respirations
- Cheyne-Stokes
- Apnea
Kussmaul Respirations
increased rate and depth in response to decreased pH
Cheyne-Stokes
due to decreased blood flow or injury the the brainstem.
deep breaths mixed with shallow breaths mixed with apnea.
apnea
absence of respirations for a period of time
During assessment, the nurse needs to
- inspect chest wall movement (retraction, use of accessory muscles)
- palpate peripheral pulses, capillary refill
- auscultate: normal/abnormal lung and/or heart sounds
- review diagnostic tests
Nursing Diagnosis RT Oxygenation
- Decreased CO
- Fatigue
- Activity Intolerance
- Impaired Gas Exchange
- Ineffective Airway Clearance
- Ineffective Breathing Pattern
- Risk for Aspiration
Implementations RT Oxygenation
- health promotion
- airway maintenance
- mobilization of pulmonary secretions
- suctioning
- artificial airways
- maintenance and promotion of lung expansion
Health promotion includes
- vaccinations: pneumococcal, influenza
- healthy lifestyle: low-fat, high-fiber diet, maintain body weight, exercise
- environmental pollutants: smoke/secondhand smoke, chemicals
hydration
fluid intake of 1500-2500/day unless contraindicated
humidification
keeps airways moist and loosens pulmonary secretions. Necessary for patients receiving > or equal to 4 L of O2/NP
Nebulization
adds moisture to medication-enhances mucociliary clearance
Chest physiotherapy (CPT)
- postural drainage
- chest percussion
- vibration
Mobilization of Pulmonary Secretions include
- hydration
- humidification
- nebulization
- coughing and deep breathing
- chest physiotherapy
Suctioning Techniques
process no longer than 15 sec.
includes oro and naso pharyngeal; oro and naso tracheal
Oro and Naso pharyngeal
patient able to cough but can not expectorate the secretions
Oro and Naso tracheal
sterile technique
unable to manage by coughing
Artificial Airways
places patient at high risk for infection.
includes oral, endotracheal and tracheal airways
Oral airway
maintains the tongue in the normal position
endotracheal airway
through the mouth past the vocal cords into the trachea
tracheal airway
surgical incision into the trachea
Noninvasive maintenance and promotion of lung expansion
- ambulation
- positioning
- incentive spirometry
- noninvasive ventilation
How does ambulation help promote lung expansion?
decreases atelectasis, decreases VAP and decreases functional limitations
How does positioning promote lung expansion?
45 degree semi fowlers promotes lung expansion
How does incentive spirometry promote lung expansion?
encourages deep breathing (visual)
What are the noninvasive ventilations?
- CPAP - Continuous Positive Airway Pressure
- BiPAP - bi-level positive airway pressure-provides both inspiratory positive pressure and a lesser expiratory airway pressure (PEEP)
Invasive maintenance and promotion of lung expansion
-chest tube insertion
Chest tube insertion
restoring lung expansion.
removes air and/or fluid from the pleural space
2 Types of Pneumothorax
- primary
2. secondary
primary pneumothorax
genetic condition: “bleb” on lung; occurs unexpectedly
secondary pneumothorax
result of chest trauma (stabbing, rib fractures), lung diseases (emphysema), invasive procedures (surgery, placement of subclavian IV line), mechanical ventilation
Hemothorax
accumulation of blood and fluid in the pleural cavity
Methods of Oxygen Delivery
- nasal cannula
2. masks: simple face mask, partial non-rebreather, non-rebreather, and venturi mask
Restorative and Continuing Care include
- CPR
- Respiratory Muscle Training
- Breathing Exercises
Respiratory Muscle Training
incentive spirometer
Breathing Exercises
- Coughing and Deep Breathing Exercises
- Pursed Lip Breathing
- Diaphragmatic Breathing
Pursed-Lip Breathing
deep inspiration and prolonged expiration with pursed lips
Diaphragmatic Breathing
helps expel trapped air; often used in conjunction with pursed-lip breathing
