Kelsey LeVan

Respiratory Diagnostic Procedures

Pulse oximetry (non invasive measurement of the oxygen saturation of the blood). (Measures arterial oxygen saturation). 2. ABG 3. Bronchoscopy 4. Thoracentesis
1.

ABG Terms
pH- amount of free hydrogen ions in the arterial

blood. (H+) PaO2- the partial pressure of oxygen PaCO2- the partial pressure of carbon dioxide HCO3- bicarbonate in arterial blood SaO2- % of oxygen bound to Hgb as compared to the total amount that can be possibly carried.

Normal ABG Values

pH- 7.35-7.45 PaO2- 80-100 PaCO2- 35-45

HCO3- 22-26
SaO2- 95-100%

RULES FOR AN ABG

Perform the ALLENs Test. Compress ulnar and radial

arteries SIMULTANEOUSLY while instructing the patient to form a fist. Then have the client relax hand while RELEASING pressure on the RADIAL ARTERY. HAND SHOULD TURN PINK QUICKLY INDICATING PATENCY OF THE RADIAL ARTERY. REPEAT FOR THIS PROCESS FOR THE ULNAR ARTERY

Rules for an ABG continued

Hold DIRECT PRESSURE over the site for 5 Minutes.

(20 minutes if pt. is on anticoagulants) Monitor ABG site for bleeding, loss of pulse, swelling, and changes in temp and color
BLOOD CAN ALSO BE DRAWN FROM AN ARTERIAL LINE

Bronchoscopy Uses
Can visualize abnormalities such as tumors,

inflammation, and strictures Biopsy of suspicious tissue (lung tissue) (biopsy can have additional risks for bleeding) Aspiration of deep sputum

Bronchoscopy- Pre procedure

NPO (usually 8-12 hrs. to reduce aspiration risk)
Ensure that consent form is signed Remove the clients dentures

Administer medications are prescribed such as

lidocaine

Laryngospasm
Uncontrolled muscle contractions of the laryngeal

cords that impede the clients ability to inhale

Pneumothorax
Collapsed lung
S/S- diminished breath sounds

Asthma
Chronic inflammatory disorder of the airways in

intermittent and reversible airflow obstruction of the bronchioles The obstruction occurs either by inflammation or airway hyperresponsiveness Cause is unknown.

Manifestations of Asthma
1. Mucosal edema
2. Bronchoconstriction 3. Excessive mucous production

S/s of Asthma
Coughing, wheezing, mucus production, poor oxygen saturation, barrel chest or increased chest diameter

Asthma based on symptoms and classified into 4 categories

1. Mild intermittent- symptoms occur less than 2x a

week 2. Mild persistent- symptoms arise more than 2x a week but not daily 3. Moderate persistent- daily symptoms occur in conjunction with exacerbations 2x a week 4. Severe persistent- symptoms occur continually, along with frequent exacerbations that limit the clients physical activity and quality of life.

Health Promotion/Disease prevention

Triggering Agents of Asthma

Pulmonary function tests (PFT) are the most accurate tests for diagnosing asthma and its severity!

Laborative Tests for Asthma

ABG
- Hypoxemia- PaO2 <80 - Hypocarbia- PaCO2- <35 (early in attack)

- Hypercarbia- PaCO2->45 (later in attack)

Asthma Therapy
Exercise (promotes ventilation/perfusion)
Medications

Medications
Bronchodilators (inhalers)
Anti-inflammatory agents- used to decrease airway

inflammation Combination agents- (bronchodilators and antiinflammatory)

Bronchodilators
Short acting beta2 agonists such as albuterol (Proventil,

Ventolin)- provide rapid relief of acute symptoms and prevent exercise induced asthma. Watch for tremors and tachycardia
Anticholinergic meds- ipratropium (Atrovent)- increases

bronchodilation and decreased pulmonary secretions. (sympathetic nervous system) (GIVE PATIENT CANDY FOR DRY MOUTH!!!))) Methylxanthines- (Theo-Dur)- requires close monitoring of serum med. Levels due to a narrow therapeutic range. Toxicity =tachycardia, nausea, diarrhea

Anti-inflammatory Agents
Corticosteroids- fluticasone (Flovent), prednisone

(Deltasone)
ENCOURAGE THE PATIENT TO TAKE

PREDNISONE WITH FOOD.

Combination Agents
Ipratropium and albuterol (Combivent)
Fluticasone and salmetrol (Advair)

IF PRESCRIBED SEPERATELY FOR INHALATION AT

THE SAME TIME, ADMINISTER THE BRONCHODILATOR 1st in order to increase the absorption of the anti-inflammatory agent.

Complications of Asthma
Respiratory failure - persistent hypoxemia related to asthma can lead to

respiratory failure -if in respiratory failure, monitor oxygen levels and acidbase balance
Status asthmaticus -LIFE THREATENING! Episode of airway obstruction that

is often unresponsive to common treatment. Extreme wheezing, labored breathing, distended neck veins, use of accessory muscles

COPD

COPD
Encompasses 2 diseases- EMPHYSEMA and

CHRONIC BRONCHITIS Irreversible

Emphysema
Loss of lung elasticity and hyperinflation of lung

tissue Causes destruction of alveoli leading to a decreased surface area for gas exchange, carbon dioxide retention, and resp. acidosis

Chronic Bronchitis
Inflammation of the bronchi and bronchioles due to

chronic exposure to irritants

Risk Factors

Signs and Symptoms of COPD

Chronic dyspnea, productive cough that is most severe

in the morning, resp. acidosis, and comp. metabolic alkalosis, crackles, wheezes, rapid and shallow resps, use of accessory muscles, barrel chest or increased chest diameter, clubbing, decreased o2 levels,

Laboratory Tests
Increased hematocrit is due to low oxygenation levels
Sputum cultures and WBC counts to diagnose acute

respiratory infections

Diagnostic Procedures
Pulmonary function tests
- comparisons of forced expiratory volume (FEV) to

forced vital capacity (FVC) are used to classify COPD as mild to very severe As COPD advances, the FEV to FVC ratio decreases. The expected reference range is 100%. For mild COPD, the FEV/FVC ratio is decreased to <70%. As the disease progresses to moderate and severe, the ratio decreases to <50%

Chest x-ray
Reveals hyperinflation of alveoli and flattened

diaphragm in the late stages of emphysema

ABG results.
Will show..
Hypoxemia decreased PaO2- <80 Hypercarbia-increased PaCO2>45

Resp. acidosis, metabolic alkalosis compensation

AAT (alpha1 antitrypsin) levels

A deficiency in a special enzyme produced by the liver

that helps regulate other enzymes (that help breakdown pollutants) from attacking lung tissue.

Nursing Care
Fowlers
Cough and deep breathe Incentive spirometer

Suction secretions
Breathing treatments Adequate nutrition (soft, high calorie foods) (fluids)

For a patient with diaphragmatic breathing

Incentive Spirometry

Instruct client to keep a tight seal around mouthpiece and to inhale and hold breath for 3-5 sec.

COPD OXYGEN?
Give pt. 2-4 L/min NC or up to 40% via VENTURI

IMPORTANT!!!
IT IS IMPORTANT TO RECOGNIZE THAT LOW

ARTERIAL LEVELS OF OXYGEN SERVE AS THE PRIMARY DRIVE FOR BREATHING..

Medications?
Bronchodilators (inhalers)- Albuterol (Proventil,

Ventolin) (provide RAPID relief) Cholinergic antagonists- ipratropium (Atrovent) Methylxanthines- Theo-Dur which relax smooth muscles of the bronchi. Needs close monitoring of serum levels Anti-inflammatories- fluticasone (Flovent) and prednisone (Deltasone). Monitor for side effects (immunosuppresion, fluid retention, hyperglycemia, poor wound healing)

Therapeutic Procedures
Chest PT
Raising the foot of the bed slightly higher than the

head can facilitate optimal drainage and removal of secretions by gravity.

Complications of COPD
Respiratory infections- results from increased mucus

production and poor oxygenation levels Right sided heart failure (COR PULMONALE)- air trapping, airway collapse, and stiff alveoli lead to increased pulmonary pressures.. Blood flow through the lung tissue is difficult= increased workload and enlargment and thickening of the right atrium and ventricle. -s/s= low o2 level, cyanotic lips, enlarged liver, distended neck veins, edema

Pneumonia!

Pneumonia
Inflammatory process in the lungs that produces

excess fluid. Pneumonia is triggered by infectious organisms or by the aspiration of an irritant, such as fluid or a foreign object The inflammatory process in the lung parenchyma results in edema and exudate that fills the alveoli Immunocompromised are more susceptible. Immobility can be a contributing factor

2 Types of Pneumonia
1. Community Acquired (CAP)- most common type.

Occurs as a complication of influenza 2. Hospital acquired pneumonia (HAP)- has a higher mortality rate
**** Older adults are more suspectible to infections

and have DECREASED PULMONARY RESERVES DUE TO NORMAL LUNG CHANGES, including decreased LUNG ELASTICITY and thickening alveoli

S/S
Anxiety, fatigue, weakness, chest discomfort, fever,

chills, diaphoretic, SOB, crackles, wheezes, sputum production (YELLOW), coughing, dull chest percussion over areas of consolidation, decreased O2, pleuritic chest pain
*****CONFUSION!!!!! FROM HYPOXIA IS THE MOST

COMMON MANIFESTATION OF PNEUMONIA IN OLDER PEOPLE!!!!!!!!!

LAB Results
Elevated WBC count
ABG shows hypoxemia (decreased PaO2 < 80)

Chest X-ray
Will show consolidation (solidification, density) of

lung tissue Important

Medications
Cephalosporins- observe client for frequent stools, take

with food Penicillin- take with food Monitor kidney function for people taking these medications! Bronchodilators- given to reduce bronchospasms and reduce irritation. (albuterol) Cholinergic antagonists (anticholinergic meds)- Atrovent Methylxanthines- Theo-Dur- requires close monitoring of serum levels

Medications continued
Anti-inflammatories- decrease airway inflammation
Glucocorticosteroids- fluticasone (Flovent) and

prednisone (Deltasone). Help with inflammation. Monitor for immunosuppression, fluid retention, hyperglycemia, hypokalemia, and poor wound healing.

Complications of Pneumonia
Atelectasis
- airway inflammation and edema lead to alveolar

collapse and increase the risk of hypoxemia SOB, diminished or absent breath sounds, chest xray will show an area of density

Complications of Pneumonia
Bacteremia (SEPSIS!!!)
- this can occur if pathogens enter the bloodstream

from the infection in the lungs

TB
Infectious disease caused by MYOBACTERIUM

TUBERCULOSIS AIRBOURNE Primary affects the LUNGS, but can spread to any organ Risk of transmission decreases after 2-3 weeks of antibiotics Slow onset

Mantoux test

Intradermal injection of tubercle bacillus Should be read in 48-72 hrs Will be positive within 2-10 weeks of exposure An induration (palpable, raised, hardened area) of 10 mm or greater in diameter indicates a + skin test An induration of 5 mm is considered + for immunocompromised clients A + Mantoux test indicates that the client has developed an immune response to TB. It doesnt confirm that active disease is present. Clients who have been treated for TB may retain a positive reaction.

S/S
Persistent cough
Night sweats Anorexia

Fever
Chills Weight loss

Latent TB
People may have been exposed to TB, but havent

developed the disease. Mycobacterium TB is in the body, but body was able to fight it. If not treated, it can lie dormant for several years and then become active as the individual becomes older or immunocompromised. Individuals who have latent TB may have a + mantoux test and may receive tx to prevent development of an active form of the disease

Bacillus Calmette-Guerin (BCG) vaccine

Client who had this vaccine within the past 10 years

may have a false positive mantoux test. These clients will need a chest xray to evaluate for the presence of active TB infection.

Risk Factors
Close contact with an untreated person
Low economic status Homelessness

Age
Substance abuse Recent travel outside of US

Health care occupation Crowded environments

Lab Test
QuantiFERON-TB gold
- blood test that detects release of interferon-gamma

(IFN-g) in fresh heparinized whole blood from sensitized people Diagnostic for infection, whether it is active or latent

Acid-fast bacilli smear and culture

A + acid-fast test suggests an ACTIVE INFECTION
The diagnosis is confirmed by a positive culture for

myobacterium tuberculosis
Nursing Actions 1. 3 morning sputum samples are obtained 2. Wear PPE when obtaining specimen 3. Samples should be obtained in a negative airflow

room

Nursing Care
Wear an N95 or HEPA respirator
Place the pt. in a negative airflow room Airborne precautions

TB medications
4 meds @ a time is recommended
MEDS MUST BE TAKEN FOR 6-12 MONTHS.

MEDICATION NONCOMPLIANCE IS A MAJOR CONTRIBUTING FACTOR IN THE DEVELOPMENT OF RESISTANT STRAINS OF TB

THE 4 MEDICATIONS
1. ISONIAZID- (INH)
2. RIFAMPIN (RIF) 3. PYRAZINAMIDE (PZA)

4. ETHAMBUTOL (EMB)
5. MAY CONTAIN STREPTOMYCIN SULFATE

(STREPTOMYCIN). DUE TO ITS HIGH LEVEL OF TOXICITY, THIS MED. SHOULD ONLY BE USED IN PTS WHO HAVE MULTI DRUG RESISTANCE TB

ISONIAZID
Bactericidal. Inhibits the growth of mycobacteria by

preventing synthesis of mycolic acid in the cell wall Take on an empty stomach Monitor for hepatotoxicity and neurotoxicity such as tingling of the hands and feet Vitamin b6 (pyridoxine) is used to prevent neurotoxicity from isoniazid

Rifampin
Bacteriostatic and bactericidal antibiotic that inhibits

DNA-dependent RNA polymerase activity in susceptible cells Observe for hepatotoxicity Urine and other secretions will be orange Advice client to report yellowing of the skin, pain or swelling of joints, loss of appetite, or malaise immediately. May interfere with contraceptives

pyrazinamide
Bacteriostatic and bactericidal and its exact

mechanism of action is not known Observe for hepatotoxicity Increase fluids Advise client to report yellowing of skin, pain or swelling of joints, loss of appetite, or malaise immediately. Avoid alcohol

Ethambutol
Bacteriostatic and works by supressing RNA synthesis,

subsquently inhibiting protein synthesis

Obtain visual acuity tests Determine color discrimination ability Not to be given for children under 13 INSTRUCT THE CLIENT TO REPORT CHANGES IN

VISION IMMEDIATELY

Streptomycin sulfate (Streptomycin)

Aminoglycoside antibiotic. Potentiates the efficacy of

macrophages during phagocytosis Highly toxic Should only be used in clients who have multi-drug resistant TB Can cause ototoxicity (notify doctor!!!) Report significant changes in urine output and renal function studies Advise pt to drink at least 2-3 L of fluid daily

Client Education
Instruct client to continue with follow up care for 1 full

year Inform the client that sputum samples are needed every 2-4 weeks to monitor therapy effectiveness. Clients are no longer considered infectious after 3 negative sputum cultures

Military TB
Organism invades the blood stream and can spread to

multiple body organs with complications including: - headaches, stiff neck, drowsiness Pericarditis -dyspnea, swollen neck veins, pleuritic pain, hypotension due to an accumulation of fluid in pericardial sac that inhibits the hearts ability to pump effectively

Larngeal Cancer
More common in men
Greatest risk factors is tobacco and alcohol use

S/S of Laryngeal Cancer

Persistent hoarseness, lump in throat, mouth or neck,

dysphagia, persistent or unilateral ear pain, weight loss, foul breath Hard, immobile lymph nodes in the neck (if metastasis has occurred) Dyspnea (if tumor is an advanced stage)

Laboratory Tests
Tumor mapping may be done by taking multiple

biopsy samples Mapping verifies where the tumor is located, its margins, and type Staging is done using this info

Diagnostic Procedures
X-rays of skull, sinuses, neck and chest CT and MRI scan These help to determine the extent and exact location of the

tumor and level of soft tissue invasion

Indirect and direct laryngoscopy - indirect is done to see if the tumor can be visualized - direct is used to visualize the tumor more closely and to obtain

a biopsy which will determine cell type and staging Before procedure, pt must be NPO. Post procedure assess for return of GAG reflex Inform clients after topical anesthetic is applied, they may feel like they cannot swallow.

Bone Scan and PET scan

Determines presence of metastasis

Interdisciplinary Care
If surgical removal of the larynx is done, initiate a

speech therapy consult. Social work consult for the client if outpatient radiation or chemotherapy is ordered

Laryngectomy
May be a partial (removal of one or part of 1 larynx) or total

laryngectomy (removal of both larynx) * if cancer is advanced, all or part of the epiglottis may need to be removed ** temp. tracheostomies may be established for clients who required only a partial laryngectomy Permanent tracheal stomas are created for clients who have undergone total laryngectomies A laryngectomy tube is inserted into the stoma immediately after the surgery. This prevents contractures from forming while the stoma is healing. The 11th cranial nerve may be cut resulting in drop following surgery

Total laryngectomy
Pts will lose their natural voice

Cordectomy/hemilaryngectomy
Excision of 1 vocal cord
Risk for aspiration (tuck chin under when swallowing)

(arch the tongue in the back of the mouth)

Client Education
Use saline and cotton-tipped swabs to cleanse the stoma Humidifier/ saline atomizer to moisten the environment

and stoma frequently during the day Wear a bib, scarf, bandana, etc to cover stoma Instruct patient to avoid lifting. Client unable to lift because the client cannot perform the valsalva maneuver with an open airway Oxygenate prior to suctioning Aspiration may lead to the development of pneumonia Those with a total larygenectomy will not be able to aspirate due to the surgical seperation of the trachea from the esophagus.

Lung Cancer
One of the leading causes of cancer-related deaths
Prognosis is often poor because of late diagnosis Bronchogenic carcinomas account for 90% of primary

lung cancers Histolic cell type determines lung cancer classification: Non small cell lung cancer (NSCLC) - most lung cancers - includes squamous, adeno, and large cell carcinomas

Small cell lung cancer (SCLC)

Fast growing
Almost always associated with a hx of smoking!

Staging
T= tumor
N=nodes M=metastasis

Chemotherapy
Primary choice of treatment
Cistplatin (Platinol AQ)

S/S
Persistent cough with or without hemoptysis,

hoarseness, dyspnea, unilateral wheezing, chest wall pain, muffled heart sounds, fatigue, weight loss, clubbing of fingers

Bronchoscopy
Can provide direct visibility of the tumor
Allows for specimen and biopsy NPO before and after scope

Assess for return gag reflex

Hair loss
-Will occur 7-10 days after chemotherapy treatment

begins

Opioid agonists
Morphine sulfate (MS Contin)
Oxycodone (OxyContin) Fentanyl (Duragesic) (PATCH takes several hrs to take

effect) Short acting pain medication is used for breakthrough pain

All used to treat moderate to severe pain caused by illness.

Act on the mu and kappa receptors that help to alleviate pain Assess pain q4 hrs

Surgical Intervention
Goal is to remove all tumor cells, including lymph

nodes Often involves removal of a lung, lobe, segment, or peripheral lung tissue