Digiulio M., Keogh J. Medical-Surgical Nursing Demystified
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CHAPTER 2 Respiratory System
TREATMENT
Treatment is aimed at meeting the body’s oxygen needs, preventing the clot from
enlarging or moving, and preventing other clots from forming.
•
Supplemental oxygen therapy.
•
Administer thrombolytics to enhance breakdown of existing clot:
•
urokinase, alteplase
•
Administer anticoagulants to prevent further clot formation:
•
heparin, warfarin
•
Administer analgesic for pain control and to decrease myocardial oxygen
demand:
•
morphine
•
Surgical insertion of a vena cava filter in select patients to catch clots that
travel from lower extremities up through inferior vena cava toward lung.
•
Bed rest to prevent thrombus from breaking free from lower extremities.
•
Surgical removal of the embolus may be necessary in some cases.
NURSING DIAGNOSES
•
Impaired gas exchange
•
Ineffective tissue perfusion
•
Anxiety
NURSING INTERVENTION
•
Monitor cardiovascular status for heart rate, rhythm, heart sounds, and pulse
deficit.
•
Monitor arterial blood gas for changes and decrease in oxygenation.
•
Monitor pulse oximetry for oxygen saturation.
•
Place patient in high Fowler’s position.
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Have the patient perform turning, coughing, and deep-breathing exercises to
enhance air movement.
•
Monitor respiration for rate, effort, use of accessory muscles, skin color, and
lung sounds.
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•
Explain to the patient:
•
To avoid sitting and standing for too long to decrease chance of clot
formation.
•
Not to cross legs to avoid constriction of vessels in the lower extremities,
decreasing the chances of clot formation.
•
How to identify side effects from using anticoagulants, such as bleeding
or bruising.
•
That pulmonary embolism is an adverse effect from using hormonal con-
traceptives and a different form of birth control needs to be used in the
future.
Influenza
WHAT WENT WRONG?
A viral infection affecting the respiratory tract that spreads through droplets. The
virus can be inhaled or picked up from surfaces through direct contact. Infection
can settle into either the upper or lower respiratory tract. The virus causes damage
to the upper layers of cells. The natural defenses of the respiratory tract are com-
promised and it is easier for bacteria to attach to the underlying respiratory tissues.
PROGNOSIS
Influenza symptoms typically run their course within about a week. Current med-
ications help to decrease the length and severity of symptoms associated with
influenza. Some patients will develop secondary infections, such as sinusitis or
viral or bacterial pneumonia following influenza. Patients with pneumonia have an
increased risk of mortality from influenza.
HALLMARK SIGNS AND SYMPTOMS
•
Symptoms have an abrupt onset
•
Nonproductive cough
•
Chills and sweats
•
Fatigue and malaise
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CHAPTER 2 Respiratory System
•
Fever over 101°F
•
Headache
•
Muscle aches (myalgia)
•
Watery, nasal discharge
•
Sore throat
INTERPRETING TEST RESULTS
•
Nasopharyngeal viral culture.
•
Rapid diagnostic kit.
TREATMENT
Symptomatic treatment to increase patient comfort and medications to shorten
the duration and intensity of symptoms are the focus of patient management.
Medications need to be started early in the symptoms.
•
Administer antipyretics for comfort:
•
acetaminophen
•
Administer antiviral medications:
•
zanamivir, oseltamivir
•
amantadine, rimantadine
NURSING DIAGNOSES
•
Risk for injury
•
Impaired gas exchange
•
Hyperthermia
NURSING INTERVENTION
•
Administer fluids and electrolytes to replace what is being lost due to sweat-
ing and insensible loss from elevated temperature.
•
Monitor vital signs.
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•
Monitor respiratory status for rate, effort, use of accessory muscles, skin color,
and breath sounds.
Crucial Diagnostic Tests
Bronchoscopy
WHY IS IT DONE?
Bronchoscopy is used to view the bronchial tree and to remove foreign obstruc-
tions, obtain tissues for biopsy, or for suctioning fluid.
HOW DOES THE TEST WORK?
The patient is anesthetized and a bronchoscope is inserted into the patient’s mouth
and down the trachea and bronchial tree. The bronchoscope contains a tiny video
camera and probes that the physician manipulates to perform the procedure.
WHAT TO DO?
•
Before the procedure:
•
The patient must sign an informed consent for an invasive procedure.
•
The patient is NPO for 8 hours except in an emergency, to reduce chances
of vomiting when the bronchoscope is passed down the throat.
•
During the procedure:
•
Monitor vital signs, respiratory effort, and skin color; cardiac monitor.
•
After the procedure:
•
The patient remains nothing by mouth (NPO) until the gag reflex returns
to avoid aspiration.
•
Verify the cough and gag reflex returns.
•
Monitor respirations for rate, effort, use of accessory muscles, and breath
sounds.
•
Monitor heart rate and respiratory status for changes.
•
Monitor sputum for blood due to irritation within bronchi.
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CHAPTER 2 Respiratory System
Chest X-ray
WHY IS IT DONE?
Used to detect the size and position of the heart and structural abnormalities of
the lungs.
HOW DOES THE TEST WORK?
An x-ray machine directs x-rays through the chest and onto film positioned behind
the patient. As x-rays are directed to the patient, some are absorbed by the body and
others pass through to the film. Areas of the body that absorb x-rays appear light on
the film. Dark areas on the film represent x-rays that passed through the body.
WHAT TO DO?
•
Before the procedure:
•
Explain the test to the patient and that the patient will be asked to hold his
or her breath while the x-ray is taken.
•
Before the test, remove all jewelry, zippers, hooks, and any metal on the
part of the body being x-rayed.
•
During the procedure:
•
Patient should hold his or her breath during the image to get a clear picture.
Pulmonary Angiography
WHY IS IT DONE?
Provides a view of the pulmonary circulatory system so that the physician can
determine the condition of blood flow to the lungs.
HOW DOES THE TEST WORK?
Radiopaque dye is inserted into the patient’s veins after a catheter has been passed
through the heart into the pulmonary artery fluoroscopically. The image is watched
on a screen as the dye flows through the pulmonary circulatory system.
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WHAT TO DO?
•
Before the procedure:
•
Verify that the patient is not allergic to contrast dye, iodine, or shellfish.
If the patient is, then either another diagnostic study will be done, or the
patient will be premedicated for this test if no other test is deemed appro-
priate. Diphenhydramine and prednisone may be given prior to the test to
lessen or prevent an allergic reaction while closely monitoring the patient.
•
The patient must sign an informed consent based on institutional policy.
•
Instruct the patient that a flushed feeling is common when the dye is in-
jected intravenously.
•
During the procedure:
•
Monitor patient for tolerance of procedure and possible reaction to dye.
•
After the procedure:
•
Monitor the insertion site for bleeding.
Sputum Culture and Sensitivity
WHY IS IT DONE?
Sputum from the patient is cultured to determine which, if any, bacteria is con-
tained in the sputum and determine which antibiotic kills the bacteria.
HOW DOES THE TEST WORK?
Sputum is collected from the patient in a sterile container and sent to the lab where
the sample is smeared in petri dishes and incubated to grow the bacteria. Samples
of the bacteria are stained and examined under a microscope to identify the bacte-
ria. The samples are checked periodically, but are usually given 72 hours to com-
plete the testing process. Once identified, bacteria are exposed to known antibiotics
to determine which antibiotic kills the bacteria.
WHAT TO DO?
•
Before the test:
•
Use a sterile specimen container to determine that the bacteria that grow
in the lab have come from the patient and not from contamination.
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•
Collect sputum only and not saliva—there are bacteria naturally found in
the mouth, so saliva samples will grow bacteria in the lab even though it
is not causing any infection.
•
After the test:
•
Sample needs to go to the lab.
•
Teach the patient:
•
How to properly obtain sputum sample.
Thoracentesis
WHY IS IT DONE?
Removal of fluid from the pleural sac to drain fluid or identify the contents of the fluid
HOW DOES THE TEST WORK?
The patient either sits at the edge of the bed or lies on the unaffected side. The
affected site is anesthetized. A needle is inserted into the plural sac and fluid is
drained using a syringe.
WHAT TO DO?
•
Before the test:
•
The patient must sign an informed consent for an invasive procedure.
•
Position the patient at the edge of the bed or lying on the unaffected side
with the head of the bed elevated 30 degrees.
•
During the test:
•
Monitor the patient for tolerance of the procedure.
•
Monitor respiratory status for rate, effort, skin color, use of accessory
muscles, and breath sounds.
•
After the test:
•
Lay the patient on the affected side for 1 hour following the procedure. This
applies direct pressure to the puncture site, reducing the chance of bleeding.
•
Monitor the injection site for leakage; reinforce dressing if drainage noted.
•
Monitor respiratory status for changes.
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Pulmonary Function Test (PFT)
WHY IS IT DONE?
This test assesses the lungs’ ability to move air. Monitor change from normal func-
tion; differentiate obstructive from restrictive disease.
HOW DOES THE TEST WORK?
The patient takes a deep breath. The spirometer is inserted into the patient’s mouth
and the patient breathes outward quickly at full force until all air is expelled. A
deep breath is then taken in through the mouthpiece and this process is repeated
three times. A computer then calculates the lungs’ volume and vital capacity by
measuring the amount of air moving in and out. The force of the air flow is meas-
ured. The duration of time of exhalation is measured.
WHAT TO DO?
•
Before the test:
•
The patient should not smoke prior to the test. Smoking may have an
effect on the outcome of the test.
•
During the test:
•
Instruct the patient to take a deep breath and then exhale completely into
the spirometer, followed by deep inhalation.
•
After the test:
•
Administer bronchodilators after the initial testing is done and repeat the
test if indicated. This will show the effect of bronchodilators on pulmo-
nary function. Albuterol or levalbuterol are typically used.
Arterial Blood Gas (ABG)
WHY IS IT DONE?
This determines the patient’s ventilation, tissue oxygenation, and acid-base status.
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CHAPTER 2 Respiratory System
HOW DOES THE TEST WORK?
Three to five milliliters of blood is sampled from an artery in a heparinized
syringe. If the sample cannot be analyzed right away, it should be placed on ice.
•
The normal results are:
•
pH 7.35–7.45
•
PaO
2
80–100 mmHg
•
PaCO
2
35–45 mmHg
•
HCO
3
22–26 mEq/L
WHAT TO DO?
•
Before the test:
•
Provide the lab with information on whether or not the patient is receiv-
ing supplemental oxygen or mechanical ventilation as well as the amount
of oxygen received or the setting of the ventilator. Oxygen supplementa-
tion at the time of testing will be reported with the results.
•
Note the patient’s temperature. Alteration in temperature may alter the
results of the test.
•
After the test:
•
Apply mechanical pressure to puncture site for 5 minutes.
•
Apply pressure dressing to puncture site for 30 minutes once bleeding has
stopped.
•
Monitor the puncture site for bleeding.
Ventilation-Perfusion Scan
(V/Q scan)
WHY IS IT DONE?
Enables visualization of the flow of blood in the lungs to determine if lung tissue
is adequately perfused.
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HOW DOES THE TEST WORK?
The patient inhales radioactive gas mixed with oxygen for the ventilation phase.
Radioisotopes are intravenously injected into the patient’s veins using an IV access
for the perfusion phase.
WHAT TO DO?
•
Before the test:
•
Explain the procedure to the patient.
•
During the test:
•
The patient must lie still for the testing, holding his or her breath as
directed.
Mantoux Intradermal Skin Test (PPD)
WHY IS IT GIVEN?
This determines if the patient has antibodies to the Mycobacterium tuberculosis
bacteria, which indicates that the patient has been exposed to the bacteria.
HOW DOES THE TEST WORK?
An injection of tuberculin is given intradermally. The test is positive if an in-
durated area appears around the injection site after 48 to 72 hours. A positive test
indicates the presence of antibodies. Further testing is used to confirm that the
patient has TB. Following a positive Mantoux test, the patient will typically be
sent for a chest x-ray and may have a sputum culture for mycobacterium done.
WHAT TO DO?
•
Before the test:
•
Explain to the patient why the test is being done, and that a positive result
means that the patient has been exposed to TB. Further testing would need
to be done to know if disease is currently present.