Respiratory Therapy Training Manual

Transcription

Respiratory Therapy Training
for Long-Term Care Nurses
Nancy M. Page, RN
Marjorie Wiltshire, RN
October 2012
Respiratory Therapy Training for Licensed Nurses
Table of Contents
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
Introduction ...................................................................................................................1
Assessment
A. Anatomy and Physiology .........................................................................................2
B. Pulse Oximetry ........................................................................................................9
C. Breath Sounds ...................................................................................................... 10
Oxygen
A. Oxygen Facts ........................................................................................................ 15
B. Oxygen Cylinders .................................................................................................. 15
C. Oxygen Delivery Devices ...................................................................................... 18
Respiratory Services
A. Suctioning ............................................................................................................. 22
B. Tracheostomy Care ............................................................................................... 23
C. Nebulizer Treatments ............................................................................................ 27
D. Metered Dose Inhalers (MDI) ................................................................................ 28
E. Respiratory Medications ........................................................................................ 29
F. Incentive Spirometry.............................................................................................. 31
G. Postural Drainage and Chest Percussion .............................................................. 32
Respiratory Disorders
A. Adult Respiratory Syndrome (ARDs) ..................................................................... 33
B. Asthma .................................................................................................................. 34
C. Atelectasis ............................................................................................................. 35
D. Bronchitis .............................................................................................................. 36
E. Cancer (Lung) ....................................................................................................... 37
F. Chronic Obstructive Pulmonary Disease (COPD) .................................................. 38
G. Emphysema .......................................................................................................... 39
H. Influenza ............................................................................................................... 40
I. Legionnaire’s Disease ........................................................................................... 41
J. Pertussis (Whooping Cough) ................................................................................. 42
K. Pleural Effusion/Empyema .................................................................................... 43
L. Pleursy .................................................................................................................. 44
M. Pneumonia ............................................................................................................ 45
N. Pneumothorax ....................................................................................................... 46
O. Pulmonary Edema ................................................................................................. 46
P. Pulmonary Embolism ............................................................................................ 47
Q. Tuberculosis .......................................................................................................... 48
Emergency Treatment of the Respiratory Resident ..................................................... 49
Glossary...................................................................................................................... 51
Miscellaneous
A. Bibliography .......................................................................................................... 57
B. Appendix A: Oxygen Concentrator ....................................................................... 58
C. Appendix B: Pursed-lip Breathing ......................................................................... 59
D. Appendix C: Diaphragmatic Breathing Exercises.................................................. 60
E. Appendix D: Asthma Triggers ............................................................................... 61
Introduction
Many changes have occurred in the long-term care setting over the past two decades. With the
rise in number of residents with higher acuity levels, the move away from hospital and sub-acute
care settings, respiratory therapy is more prominently seen in the nursing home. As a result,
the familiarity with all aspects of respiratory therapy has become an essential part of long-term
nursing care.
Respiratory therapy services are for the assessment, treatment and monitoring of residents with
abnormalities and/or medical conditions that cause deficiency of pulmonary function. These
services include coughing, deep breathing, nebulizers, aerosol treatments, assessment of
breath sounds, C-Pap/Bi-Pap, etc., which must be provided by a respiratory therapist or a
respiratory trained nurse, who has demonstrated proficiency in the above listed modalities.
This training manual was developed to provide the long-term care nurse basic knowledge and
understanding through these various aspects of respiratory therapy. It has been designed as an
interactive training program knowing that each nurse has a different knowledge and skill level.
Competency will be established with documentation that shows the long-term care nurse was
trained and evaluated to ensure they retained information and possess the skills to provide
respiratory services. This will be provided through:
• Classroom didactic with a post-test score of ≥ 75%, and
• A practicum with skills validation completed through competencies.
The long-term care nurse will be required to demonstrate competency in respiratory therapy
services on an annual basis.
“Let us never consider ourselves finished nurses….we must be learning all our lives.”
-Florence Nightingale
All Rights Reserved
No part of this manual may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopy, recording, or any information storage and
retrieval system, without permission in writing from Morningside Ministries.
Respiratory Therapy Training for Long-Term Care Nurses
October 2012
Proprietary of Morningside Ministries
1
Assessment
Anatomy and Physiology
The respiratory system is made up of organs and tissues that help you breathe. The main parts
of this system are the airways, the lungs, linked blood vessels and the muscles that enable
breathing.
The Respiratory System
A
D
B
C
Mosby, Inc. an affiliate of Elsevier, Inc.
Mosby, Inc., an affiliate of Elsevier, Inc.
Figure A shows the location of the respiratory structures in the body.
Figure B is an enlarged view of the airways, alveoli (air sacs) and capillaries.
Figure C is a close up view of gas exchange between the capillaries and alveoli; CO2 is carbon
dioxide and O2 is oxygen.
Figure D shows the circulation of blood.
Figure E Upper Airway (Respiratory Tract).
Figure F Lower Airway (Respiratory Tract).
Airways (Respiratory Tracts)
The airways (respiratory tracts) are pipes that carry oxyhemoglobin (oxygen-rich) air to your
lungs. They also carry carbon dioxide (a waste gas) out of your lungs. The airways are divided
into two distinct parts:
• Upper Airway (Respiratory Tract)
Mouth
Nasal cavities - nose and linked air passages
Pharynx
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E
•
Lower Airway (Tracheobronchial Tree or Lower Respiratory Tract)
Larynx (voice box) – contains the epiglottis and vocal cords
Trachea (windpipe)
Bronchus – left and right mainstem tubes that systematically branch, narrow, shorten
and increase in number toward the lung periphery and are referred to as bronchioles
Lungs – right lung has three lobes (upper, middle, lower) and the left lung has two lobes
(upper and lower)
F
Air first enters your body through your nose or mouth, which wets and warms the air (cold, dry
air can irritate your lungs). The air then travels through your voice box and down your windpipe.
The windpipe splits into two bronchial tubes that enter your lungs. A thin flap of tissue called the
epiglottis covers your windpipe when you swallow. This prevents food and drink from entering
the air passages that lead to your lungs. (See Figure A)
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Except for the mouth and some parts of the nose
nose, all of the airways have fine hairs called cilia
that are coated with sticky mucus. The cilia trap germs and other foreign particles that enter
your airways when you breathe in air. The cilia then sweep the particles up to the nose or
mouth. From there, they're swallowed, coughed, or sneezed out of the body. Nose hairs and
mouth saliva also trap particles and germs.
Lungs, Heart and Blood Vessels
Your lungs and linked blood vessels deliver
oxygen to your body and remove carbon
dioxide from your body. Your lungs lie on either
side of your sternum (breastbone
breastbone) and fill the
inside of your chest cavity. The lungs are
divided into five main sections called lobes,
the left lung having only two lobes to allow
room for your heart.
Within the lungs, your bronchi branch into
thousands of smaller, thinner tubes called
bronchioles.. These tubes end in tiny round air
sacs called alveoli. (See Figure B
B)
Each air sac is covered
d in a mesh of tiny blood
vessels called capillaries. (See Figure C
C) The
capillaries connect to a network of arteries and
veins that move blood through your body.
The pulmonary artery and its branches deliver blood rich in carbon dioxide (and lacking in
oxygen) to the capillaries that surround the air sacs. Inside the air sacs, carbon dioxide (CO2)
moves from the blood into the air. At the same time, oxygen (O2) moves
ves from the air into the
blood in the capillaries. The oxyhemoglobin then travels to the heart through the pulmonary vein
and its branches. The heart pumps the oxyhemoglobin out to the body. (See Figure D)
D
Boyle’s Law:
The smaller the volume, the
higher the pressure.
The larger the volume, the
lower the pressure.
Respiratory Therapy Training for Long-Term
Term Care Nurses
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Muscles Used for Breathing
Muscles near the lungs help expand and contract (tighten) the lungs to allow breathing. These
muscles include the:
• Diaphragm
• Intercostal muscles
• Abdominal muscles
• Muscles in the neck and collarbone area
The diaphragm is a dome-shaped muscle located below your lungs. It separates the chest
cavity from the abdominal cavity. The diaphragm is the main muscle used for breathing.
The intercostal muscles are located between your ribs. They also play a major role in helping
you breathe. Beneath your diaphragm are abdominal muscles. They help you breathe out when
you're breathing fast for example, during physical activity. Muscles in your neck and collarbone
area help you breathe in when other muscles involved in breathing don't work well, or when lung
disease impairs your breathing.
Boyle’s Law
•
•
The smaller the volume,
the higher the pressure.
The larger the volume,
the lower the pressure.
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In order to complete a respiratory assessment, the long-term care nurse must first be
knowledgeable of normal adult respiratory findings as a baseline:
General Appearance
Breathing Pattern
Respiratory Rate
Skin
Nail Bed and
Nail Configuration
Chest Wall Configuration
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Tracheal Position
Vocal Fremitus
Respiratory Excursion
Percussion
Auscultation
•
•
•
•
•
•
•
•
•
Normal Adult Respiratory Findings
Appears relaxed.
Breathing is quiet and easy without apparent effort.
Breathing is quiet and passive.
May have occasional sighing respirations.
Diaphragmatic-thoracic pattern is smooth and regular.
Older adults – calcification at rib articulation points.
12 – 20 respirations per minute.
Appears well oxygenated, no cyanosis or pallor present.
Palpation of skin and chest wall reveals smooth skin and a stable
chest wall; there are no crepitations or bulging.
Minimum angulation between base of nail bed and finger; no
thickening of distal finger width.
Symmetric, bilateral muscle development.
A:P to transverse ratio is 1:2 to 5:7; larger than these ratios is
considered barrel chested.
Downward and equal slope of ribs; costal angle 90 degrees
or less.
Older adults – kyphosis is a common finding in the elderly, there is
a dorsal scoliosis with slight tracheal offset.
Midline and straight directly above the suprasternal notch.
Older adults – may be slightly deviated if kyphosis present.
Bilaterally equal mild sensation.
More intense vibratory feeling in upper posterior wall.
Bilateral equal expansion of ribs during deep inspiration.
Older adults – dept of breath may be less than a younger adult, but
response should be the same.
Resonance heard throughout lung fields.
Quiet breathing heard throughout all lung fields.
Older adults – lung elasticity is diminished resulting in decreased
pulmonary compliance and airway resistance increases.
An assessment of the respiratory resident includes review of pertinent history, diagnostic
evaluations and routine monitoring of the respiratory system. All residents should have a
respiratory assessment upon admission, whenever a change occurs in the resident’s respiratory
status and as indicated by the resident’s diagnosis and/or medical conditions.
Knowledge of the resident’s current and past respiratory history includes:
• Prior oxygen usage
• Any lab results and/or diagnostics (chest x-ray, CT, MRI, pulmonary function test, etc.)
• Steroid use
• Current medication use
• Dietary requirements
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•
•
•
•
•
Smoking history
Any history of cancer
Risk factors for pulmonary emboli
Sputum production to include color, amount and odor
Sleeping position, such as number of pillows, fan use, etc.
Physical exam includes:
• Observation of the resident’s chest for:
Scars
Anterior-posterior
posterior diameter of the chest, should
be smaller than the lateral diameter.
Sternum should be located midline anterior,
giving rise to a visible projection known as
the ‘Angle of Louis’.
Angle of Louis
Remember: the chest tends to become barrel shaped with lung disease.
Normal Chest
Barrel Chest
•
Chest movement:
Inspiratory intercostal retractions occurs in residents with COPD, asthma or pulmonary
fibrosis.
Inspiratory intercostalsathing bulges may mean aneurysm, tumor or cardiac
enlargement.
Use of accessory muscles during respiration suggests respiratory distress; seen in
residents with COPD and asthma.
Abdominal breathing seen in residents with COPD. During exhalation
exhalation,, the resident must
retract abdominal muscles to force trapped air from alveoli.
•
Sternal abnormalities – if severe, any of the following can inhibit respiration and ventilation:
Pigeon chest can be assoc
associated
iated with rickets or emphysema (See Figure A)
Barrell chest occurs with emphysema or asthma. Anterior
Anterior-posterior
posterior dimension of the
chest enlarges; the ribs tend to be more horizontal than sloped; no bulges or depression
(See Figure B).
Funnel chest seen in rickets. Softening of the ribs causes depression of lower
l
sternum
(See Figure C).
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A
B
C
•
Spinal abnormalities – if any of the following abnormalities are severe, they can inhibit the
resident’s respirations and decrease ventilation to the lungs:
Kyphosis – an abnormally increase convexity to the spine.
Scoliosis – lateral deviation of the spine, which results in an ‘S-shaped’ curve.
Kyphoscoliosis – a combination of kyphosis and scoliosis; the spine is convex and ‘Sshaped’.
•
Trachea and bronchi – breath sounds are assessed in an orderly fashion utilizing a
stethoscope. Auscultate the lungs beginning with anterior apical area upper lobes
progressing to lower lobes. Compare one side with the other as you work your way
downward. Continue in same manner with assessment of posterior lungs.
Anterior
Posterior
MVS Pulmonary Auscultation
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Pulse Oximetery
Measuring the amount of oxygen absorbed in the arterial blood
will provide an indication of the effectiveness of the resident’s
breathing and/or oxygen therapy. This is usually done by
using pulse oximetery. A two-sided probe is used to transmit
an alternating light through a finger (preferred site), toe or
earlobe. The wavelength of the light that emerges indicates
the percentage of oxyhemoglobin present in the capillaries.
Normal values of oxygen saturation are 95-99%. Readings of 90-95% are usually a cause for
concern; however, a resident’s medical history must be taken into consideration. For example,
a resident with chronic obstructive pulmonary disease (COPD) may have a baseline oxygen
saturation of 88% and are comfortable at that level.
Factors that may affect accurate readings include, but are not limited to:
• Inappropriately placed.
• Motion artifact, such as tremors.
• Low perfusion.
• Skin pigmentation.
• Skin lotions.
• Nail polish.
• Artificial fingernails.
There are many types of pulse oximeters that may be utilized, such as residential and
commercial. As a facility, you should use a commercial rated oximeter. Be sure to follow
manufacturer recommendations and guidelines for proper use and maintenance on any
oximeter used.
Did you know? You should never attach a sensor by using adhesive tape as this has the
potential to cause tissue necrosis.
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Breath Sounds
Vesicular
Normal vesicular breath sounds are soft and low pitched with a rustling quality during inspiration
and are even softer during expiration. These are the most commonly auscultated breath
sounds, normally heard over the most of the lung surface. They have an inspiration/expiratory
ratio of 3 to 1 or I:E of 3:1.
Vesicular
esicular breath sounds can be heard over most areas of lungs.
Sound intensity can be higher when the stethoscope is
positioned nearer to the bases and the periphery of the lung.
Diminished vesicular sounds can be heard over the anterior and
posterior chest walls in obese or elderly people
people. This term would
be used comparatively, auscultating from side to side.
3M Solutions – Littmann® Stethoscopes
Diminished vesicular sounds are of lower intensity and are less full or robust than vesicular
sounds. These
hese sounds can occur in resident
residents
s who move a lowered volume of air, such as in a
frail, elderly person or someone who breathes shallowly. They are also heard with obese or
highly muscular people,, where tissue mass impedes sound. They exhibit a normal inspiration to
expiration ratio of 3 to 1, or 4 to 1.
Bronchial
Bronchial breath sounds are hollow, tubular sounds that are lower pitched. They can be
auscultated over the trachea where
ere they are considered normal. There is a distinct pause in the
sound between inspiration and expiration. I:E ratio is 1:3.
Bronchial breath sounds are considered abnormal if heard over
the peripheral lung fields. Bronchial breath ssounds
ounds other than
close to the trachea may indicate pneumonia, atelectasis,
pleural effusions.
Bronchovesicular
Inspirations to expiration periods are equal. These are normal sounds in the mid-chest
mid
area or
in the posterior chest between the scapula. They reflect a mixture of the pitch of the bronchial
breath sounds heard near the trachea and the alveoli with the vesicular sound. They
T
have an I:E
ratio of 1:1.
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These are abnormal in the lung periphery and may indicate
an early infiltrate or partial atelectasis.
3M Solutions – Littmann®
Littmann Stethoscopes
Rhonchi
Low pitched wheezes (rhonchi) are continuous, both inspiratory and expiratory, low pitched
adventitious lung sounds that are similar to wheezes. They often have a snoring, gurgling
gu
or
rattle-like quality.
Rhonchi occur in the bronchi. Sounds defined as rhonchi are
heard in the chest wall where bronchi occur, not over any
alveoli. Rhonchi usually clear after coughing.
Intensity usually is higher over the large airways where bronchi
exist.
Crackles (Rales)
Fine crackles are brief, discontinuous, popping lung sounds that are high
high-pitched.
pitched. Fine crackles
are also similar to the sound of wood burning in a fireplace, or hook and loop fasteners being
pulled apart or cellophane being crumpled.
Crackles, previously termed rales, can be heard in both phases
of respiration. Early inspiratory and expiratory crackles are the
hallmark of chronic bronchitis. Late inspiratory crackles may
mean pneumonia, CHF, or atelectasis.
Such sounds are sometimes associated with congestive heart
failure. During early to mid stages of CHF, fine crackles may be
heard over the resident's
's posterior lung bases.
Coarse crackles are discontinuous, brief, popping lung sounds. Compared to fine crackles they
are louder, lower in pitch and last longer. They have also been described as a bubbling sound.
You can simulate this sound by rolling strands of hair between your fingers near your ear.
Term Care Nurses
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In a resident with chronic bronchitis for example, course
crackles would be heard over most of the anterior and posterior
chest walls.
Early inspiratory crackles (rales), as suggested by the title, begin and end during the early part
of inspiration. The pitch is lower than late inspiratory crackles. A resident's
's cough may decrease
or clear these lung sounds. Early inspiratory crackles sug
suggest
gest decreased FEV1 capacity and are
characteristic of COPD.
In the resident with chronic bronchitis, e
early inspiratory crackles
are heard over all chest walls.
Residentss will have loud noisy mouth breathing as well.
Late inspiratory crackles (rales) begin in late inspiration and increase in intensity. They are
normally higher pitched and can vary in loudness. These adventitious breath sounds resemble
the noise made when hook and loop fasteners are being separated. These sounds are heard
over posterior bases of the lungs. They may clear with changes in posture or several deep
breaths. They do not clear with coughing.
Late inspiratory fine crackles are sometimes associated with
interstitial fibrosis, pneumonia, CHF or atelectasis.
These fine crackles may be heard over the posterior lung
bases.
Wheezes are adventitious lung sounds that are continuous with a musical quality. Wheezes can
be high or low pitched. High pitched wheezes may have an auscultation sound similar to
squeaking. Lower pitched wheezes have a snoring or moaning quality.
The proportion
roportion of the respiratory cycle occupied by the wheeze roughly corresponds to the
degree of airway obstruction. Wheezes are caused by narrowing of the airways.
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In this case, expiratory wheezes are heard over most of the
chest wall. This may indicate airflow obstruction, for example in
residents with mild to moderate obstruction in asthma.
Monophonic wheezes are loud, continuous sounds occurring in inspiration, expiration or
throughout the respiratory cycle. The constant pitch of these sounds creates a musical tone.
The tone is lower in pitch compared to other adventitious breath sounds. The single tone
suggests the narrowing of a larger airway.
These lung sounds are heard over anterior, posterior and lateral
chest walls. These sounds can be more intense over lung areas
affected by partial obstructions.
A fixed monophonic wheeze: same pitch, same place, may be
an indication of foreign body aspiration or tumor.
Polyphonic wheezes are loud, musical and continuous. These breath sounds occur in expiration
and inspiration and are heard over anterior, posterior and lateral chest walls. These sounds are
associated with COPD and more severe asthma.
The higher the pitch, the longer the wheeze, the greater the
obstruction. In addition, there will be an absence of any normal
vesicular sounds.
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Stridor
Stridor is caused by upper airway narrowing or obstruction. It occurs in 10-20% of recently
extubated residents. Less than severe stridor can be auscultated over the larynx. Severe stridor
can be heard without a stethoscope. Auscultation of lung sounds on the chest wall will be
normal.
Stridor is a loud, high-pitched crowing breath sound heard during inspiration but may also occur
throughout the respiratory cycle most notably as a resident worsens. Causes of stridor are
pertussis, croup, epiglottis, aspirations.
Recap of Normal, Abnormal and Adventitious Breath Sounds
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Oxygen
Oxygen therapy is the administration of oxygen at a concentration greater than that in normal
air, with the intent of treating or preventing the symptoms and manifestations of hypoxia. A
range of tubing, connectors and masks ensure that the most appropriate product or combination
of products are utilized for the resident whether the oxygen is delivered from an oxygen tank,
cylinder or an oxygen concentrator.
In variable oxygen concentration devices, the gas flow is less than the resident's inspiratory flow
rate. This means that 21% room air will be drawn into the resident’s airway, and mixes with the
oxygen flow, to create lowered the FiO2 (Fraction of Inspired Oxygen which is percentage of
oxygen) based on:
• The device used,
• The resident’s breathing pattern, such as deep/normal/shallow and/or fast/normal/slow),
• The oxygen flow being supplied by the oxygen source (tank/cylinder/concentrator), and
• The fit of the device to the resident. For example, a loose fit allows oxygen to escape,
lowering how much oxygen gets into the resident’s airway.
Oxygen Facts
•
•
•
•
•
Oxygen is a colorless, odorless gas.
Oxygen does not burn, however it makes fires burn faster and hotter as it acts as a catalyst.
Avoid using any electrical equipment, such as a hair dryer or electric razor near oxygen
tanks.
Keep flammable materials, such as oil and grease away from oxygen equipment.
Do not use petroleum-based products on your face and hands.
Did you know? Oxygen should always be prescribed by a physician or physician extender
and include the flow rate, delivery system, duration, for what medical condition/disease and
how often to monitor saturations.
Oxygen Cylinders
•
•
•
‘E’ cylinders are the most commonly used in the long-term setting.
‘H’ cylinders are used frequently for continuous oxygen when a concentrator is not available.
Portable cylinders, classified as ‘M’ cylinders are primarily used by private-pay and managed
care residents when they are admitted from home.
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Sunset Healthcare Solutions
E Cylinder Oxygen Supply Time Guide
Pressure
Guage
Reading
Liter Flow Per Minute:
1
2
3
Approximate Time Remaining:
4
5
200 psi
8 Hours
4 Hours
2.5 Hours
2 Hours
1.5 Hours
1500 psi
6.5 Hours
3 Hours
2 Hours
1.5 Hours
1 Hour
1000 psi
4 Hours
2 Hours
1.25 Hours
1 Hour
30 Minutes
500 psi
2 Hours
1 Hour
25 Minutes
15 Minutes
5 Minutes
Hines VA Hospital and VA National Center for Patient Safety
October 2012
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H Cylinder Oxygen Supply Time Guide
Pressure
Guage
Reading
1
2
3
4 Days /
2 Days /
2 Days
6 Hours
12 Hours
3 Days /
1 Day /
1 Day
3 Hours
12 Hours
200 psi
1500 psi
4
5
1 Day
19 Hours
17 Hours
14 Hours
1000 psi
2 Days
1 Day
15 Hours
12 Hours
9 Hours
500 psi
1 Days
12 Hours
7 Hours
6 Hours
4 Hour
Portable Cylinder Oxygen Supply Time Guide
Cylinder
Type
Volume
M2
36 Liters
M4 (A)
113 Liters
M6 (B)
164 Liters
ML6
171 Liters
M9 (C)
246 Liters
D
425 Liters
1
2
3
2 Hours /
1 Hour /
54 Minutes
18 Minutes 24 Minutes
4 Hours /
2 Hours /
7 Hours /
12 Minutes 18 Minutes 54 Minutes
10 Hours /
4 Hours /
6 Hours /
6 Hours /
4 Hours /
11 Hours
30 Minutes 30 Minutes
15 Hours /
9 Hours /
6 Hours /
27 Hours /
16 Hours / 11 Hours /
12 Minutes
6 Minutes
6 Minutes
4
5
48 Minutes
42 Minutes
2 Hours /
24 Minutes
3 Hours /
30 Minutes
3 Hours /
42 Minutes
5 Hours /
18 Minutes
9 Hours /
6 Minutes
2 Hours
3 Hours
3 Hours /
6 Minutes
4 Hours /
30 Minutes
7 Hours /
42 Minutes
Oxygen Concentrator
Oxygen concentrators function by pulling in room air and removes nitrogen, providing a greater
percentage of oxygen concentration to the resident.
Oxygen concentrators come in a variety of sizes and capacities, from 5 to 10 liters/minute.
Usage and maintenance should be in accordance with manufacturer’s recommendations and
guidelines.
Concentrator Oxygen Percentages per Liters/Minute
Oxygen
Percentage
1
2
3
4
5
6
28%
30%
32%
36%
36%
40%
See Appendix A
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Oxygen Delivery Devices
Positive Pressure Breathing Devices
General Information:
• C-PAP (Continuous Positive Airway Pressure) delivers air into the airway
through a specially designed mask. A preset amount of air during
inspiration creates a pressure that opens the airways.
• C-PAP is considered the most effective non-surgical treatment for the
alleviation of snoring and obstructive sleep apnea.
• Bi-PAP (Bi-level Positive Airway Pressure) delivers air into the airway
during inhalation and expiration. The two phases are independent from
each other, which results in lower average airway pressures than those
produced by C-PAP.
• The Bi-PAP system is intended to augment resident ventilation by
supplying pressurized air through a mask. The inspiratory pressure is
always higher than the expiratory pressure.
• The Bi-PAP has different Modes of Operation:
Spontaneous (S) Mode cycles between the inspiratory (IPAP) and
expiratory (EPAP) levels in response to resident triggering.
Spontaneous/Timed (S/T) Mode cycles between the IPAP and EPAP
levels in response to resident triggering. If the resident fails to initiate a
breath, the unit will cycle into IPAP based on a preset rate control.
•
•
•
•
•
Pros of C-PAP and Bi-PAP
Daytime sleepiness improves or resolves.
Heart function and hypertension improve.
Quality of life improves.
Survival rates may increase, according to
some studies.
Therapy improves obstructive sleep apnea
and some central apneas.
•
•
•
Cons of C-PAP and Bi-PAP
Many residents find the mask uncomfortable
or claustrophobic.
Since C-PAP and Bi-PAP are not a cure and
must be used every night for life, noncompliance is a problem.
The sound of the machine may be disruptive
to the resident or roommate.
Side effects related to forced air delivery include:
• Difficulty exhaling
• Sensation of suffocation
• Inability to sleep
• Nasal congestions
• Sore eye
• Sore or dry throat
• Headaches
• Abdominal bloating
• Chest muscle discomfort (caused by increased lung volume)
• Nosebleed
• Mask related issues, such as rash, skin breakdown and conjunctivitis
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Contraindications:
• Pre-existing pneumonthorax.
• Hypotension due to or associated with intravascular volume depletion.
• Pre-existing bullous lung disease.
• Facial and/or skull fractures.
• Post-operative residents who have recently undergone abdominal surgery.
Considerations:
• The best results occur with trial periods throughout the day of 30 minutes or longer.
• Encourage nighttime usage >5 hours.
• Involve the resident and family in the planning and implementation of care.
• Proper fitting masks or nasal pillows are a must.
Positive airway pressure devices come in various styles and should be used and maintained in
accordance with the manufacturer’s recommendations and guidelines.
C-PAP Machines
Bi-PAP Machines
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Oxygen Supplies
The oxygen figures stated for each device (listed below) are based on a normal breathing rate
for an adult resident using a proper fitting oxygen device, with normal tidal volumes of 7.5 L/kg
per breath.
Nasal Cannula
•
•
•
•
•
•
•
Most common delivery device used.
Best used for residents with mild hypoxia of oxygen
saturations between 90% and 93% and for long-term use in
COPD residents to maintain oxygen saturations between 88%
and 92%.
Tubing varies in length to allow for mobility. In some cases,
an extension tubing can be connected.
Monitor for skin breakdown behind the ears.
Monitor for drying of nares; if flow is 4 liters/minute or greater,
a humidifier should be utilized.
Flow rates greater than 5 liters/minute should be avoided as
this will dry out nasal mucosa and cause nasal irritation.
Never use a petroleum based jelly in nares; water-based gels
should be utilized for nasal irritation.
Nasal Cannula - Oxygen Percentages per Liters/Minute
Oxygen
Percentage
1
2
24%
28%
3
32%
4
36%
5
40%
Simple Facemask
The simple facemask is made of a clear soft vinyl construction mask to cover the mouth and
nose, a metal frame to ensure a tight fit at the nose. The strap on the mask ensures a tight
fit around the cheeks and chin, providing maximum resident comfort. Holes in the side of the
mask allow for air to be drawn into the mask to supplement the oxygen accumulating in the
mask itself.
•
•
•
•
•
•
Best used for residents with moderate hypoxia and oxygen
saturation between 85% and 93%.
Must be used with a concentrator that delivers >5 liters/minute.
Flow rates less than 5 liters/minute will result in unwanted
carbon dioxide (CO2) retention.
Usual order is between 6 – 10 liters/minute for a concentration
of 40 - 60% of oxygen.
Do not place a humidifier on this device.
Switch to a nasal cannula for meals.
Simple Facemask - Oxygen Percentages per Liters/Minute
Oxygen
Percentage
5
6
40%
44%
October 2012
7
48%
8
52%
9
56%
10
60%
20
Non-rebreather Facemask
The non-rebreather facemask comes with a clear soft vinyl construction mask to cover the
mouth and nose, a metal frame to ensure a tight fit at the nose. A strap on the mask to
ensure a tight fit around the cheeks and chin and an oxygen reservoir bag to store oxygen to
allow for much greater oxygen than the standard mask.
•
•
•
•
•
•
•
Best used for residents with severe hypoxia and oxygen
saturations below 85%.
Often used in emergency situations.
Do not use a humidifier.
Flow rates less than 8 liters/minute will fail to sufficiently inflate
the oxygen reservoir bag resulting in rebreathing unwanted
carbon dioxide and a sensation of suffocation.
It is essential that the oxygen reservoir bag is fully inflated before
applying the facemask to the resident. This can be achieved
quickly by placing a finger over the outlet plug of the oxygen
reservoir bag.
Oxygen flow should be over 10 liters/minute for maximum
effectiveness.
Liter flow is determined by the resident’s current respiratory
needs. For example, hyperventilation requires increase in
liter flow.
Non-rebreather Facemask - Oxygen Percentages per Liters/Minute
Oxygen
Percentage
8
9
80%
84%
10
88%
11
92%
12
96%
Venturi Mask
The venturi mask is often referred to as a variable flow oxyen mask. The mask mixes
oxygen with room air based on the color port attached. This system provides for the most
accurage constant oxygen percentages of all the masks available on the market. The larger
the ports in the colored connector, the more external air that is drawn in during a breath,
reducing the percentage of oxygen.
•
•
•
•
•
•
Best used when there is concern about carbon dioxide
retention.
The only mask that will give a precise oxygen concentration
based on manufacturer liter flow.
Best used when exact oxygen concentration must be utilized
when treating certain disease processes.
Venturi adapter is color coded to indicate percentage of
oxygen and liter flow delivered. The adaptors allow for an
oxygen range between 24% at 4 liters/minute to 50% at 12
liters/minute.
Never humidified.
Switch to a nasal cannula for meals.
October 2012
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Tracheostomy Mask
•
•
•
Used on resident’s who have a tracheostomy and requires
oxygen continuously.
Should be humidified to prevent drying of the mucosa of the
trachea.
Is adaptable to nebulizer treatments to be directly attached if
needed.
Respiratory Services
Suctioning
Suctioning is a removal of secretions through the use of negative pressure utilizing a suction
catheter device. Suctioning is intended to remove accumulated secretions, blood, vomitus and
other foreign material from the trachea that cannot be removed by the resident’s cough.
The need to maintain a patent airway and remove secretions from the trachea due to the
inability to clear secretions and audible and visual evidence of secretions that persist in spite of
the resident’s best cough effort.
Contraindications:
• Occluded nasal passages
• Acute head or neck injury
• Irritable airway
• Nasal bleeding
• Bleeding disorder
• Epiglottis
• Laryngospasm
Hazards:
• Hxypoxia
• Hypotension
• Gagging/vomiting
• Nosocomial infection
• Misdirection of catheter
• Cardiac arrest
• Respiratory arrest
• Laryngospasm
• Atelectasis
• Increased intracranial pressure
• Bradycardia
• Uncontrolled coughing
• Bronchospasm
October 2012
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The following should be monitored during and following suctioning:
• Breath sounds
• Skin color
• Breathing pattern
• Pulse rate and rhythm (regular/irregular)
• Sputum/secretions
Color
Consistency
Amount
Presence of blood
• Cough
• Pulse oximetry
Effectiveness of suctioning should be reflected by improved breath sounds and by removal of
secretions. Suctioning can be completed through multiple methods:
• Nasal
• Nasopharyngeal
• Oral – catheter or Yankeaur
• Tracheostomy
Tracheostomy Care
Basic Definitions:
• Tracheotomy - a procedure that results in a surgical incision through the skin and muscles of
the neck overlying the trachea (windpipe) for the purpose of establishing an alternate
airway.
• Tracheostomy - a surgical opening into the trachea (stoma) that results from a tracheotomy.
• Trach - tracheostomy site or tube is often referred to as a “trach”.
• Outer Cannula - the tracheostomy tube which is inserted into the
tracheotomy to form the passageway. Usually secured around the
neck by twill ties.
• Inner Cannula - “sleeve” which fits inside the outer cannula and may
be removed for cleaning. Usually has a “lock” mechanism to connect
it to the outer cannula so that it cannot be coughed out easily.
• Obturator – a taper-tipped device that guides the tracheostomy tube into
position without causing trauma to tissues. It is removed once the
tracheostomy tube is in place.
• Flange (Neck Plate) - holds ties, prevents pressure points and movement.
• Cuff - surrounds the outer cannula. Inflated with air inside the trachea to prevent aspiration
and to seal the tracheostomy wall to allow a more efficient air exchange.
• Fenestration - hole in tracheostomy tube to allow air passage for speaking (tracheostomy
tube is below larynx, making speech with a cuffed non-fenestrated tube impossible).
• Twill ties - cotton tie (sometimes has a Velcro attachment) around the neck to decrease
movement of tracheostomy tube.
• Decannulation - the process of weaning a resident from tracheostomy use. Considered
once a resident has a patent upper airway. Consists of straight removal or plugging the tube
for periods of time.
October 2012
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Reasons for a tracheostomy:
• Maintain a patent airway by means of bypassing upper airway (mouth/throat) obstructions,
including:
foreign bodies
vocal cord paralysis
tumors
burns
inflammation
edema (swelling)
congenital abnormalities
traumatic injuries - surgical or accidental.
• Facilitate removal of secretions related to:
neuromuscular disorders, i.e., Guillain-Barré
paralysis of chest muscles and diaphragm
severe bronchitis in a debilitated resident.
• Decrease work of breathing and increase volume of air entering lungs by reducing
anatomical dead space:
severe chronic obstructive pulmonary disease (COPD)
respiratory failure
spinal cord injury (high lesion/fracture)
prolonged trauma
• Prevent aspiration of gastric contents
Anatomical positioning for a tracheostomy tube:
A surgical tracheotomy
is made through the
skin and neck muscles,
bypasses the epiglottis
and incised in the
anterior wall of the
trachea below the 2nd
and 3rd tracheal rings.
Respiratory Disorders, Mosby’s Clinical Nursing Series
Types of tracheostomy tubes:
Shiley, Portex
Jackson
October 2012
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• The choice of tube is based on the resident’s condition, neck shape, size, and purpose of
the tracheostomy.
• Tracheostomy tubes are available in several sizes and are made of various materials to
include semi-flexible plastic, rigid plastic (Shiley, Portex), or metal (Jackson).
• Tracheostomy tubes can be either disposable or reusable.
• Tracheostomy tubes may have an inner cannula that is either disposable or reusable.
• Tracheostomy tubes may or may not have a cuff.
Cuffed trach tubes are generally used for residents who have swallowing difficulties in
the long term care setting.
Non-cuffed trach tubes are the most common used to maintain the resident’s airway
when the condition is long term.
Complications:
• Immediate (post procedure to two weeks) hemorrhage
pain
pneumothorax
subcutaneous emphysema
mediastinal emphysema
cardiovascular and respiratory collapse
dislodged tracheostomy tube
• Latent
aspiration of secretions and/or gastric contents
airway obstruction related to secretions, improper tube placement, over-inflated cuff, or
constricted airway due to ties
tracheal damage, i.e., formation of fistula
infection, usually nosocomial- respiratory or stomal
tracheal stenosis (can occur up to five years after procedure)
dislodged tracheostomy tube
• Associated with suctioning
hypoxemia
hypotension
dysrhythmia (irregular pulse rate and rhythm)
atelectasis (lung collapse)
mucosal tissue damage
bronchospasms
tracheobronchial bacterial growth, i.e., MRSA
vagal stimulation
cardiac arrest
• Psychosocial impact
alteration in body image
anxiety and fear of suffocation
alteration in communication
risk for unmet needs
October 2012
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The tracheostomy resident requires that the following equipment be maintained at the bedside
at all times:
• obturator for the existing tracheostomy tube (some surgeons prefer one size smaller;
• 10 mL syringe (if a cuffed trach);
• replacement trach tube;
• ambu bag;
• oxygen source;
• suction machine;
• sterile suction catheters; and
• sterile water.
The resident with a tracheostomy has an increased risk to nosocomial respiratory infections,
such as pneumonia. As well as infections at the stomal site. The susceptibility to respiratory
infections is due to:
• nasopharyngeal defense mechanisms are bypassed by the tracheostomy
• aspiration risk of fluids, food, and secretions
• inhalation therapy
• tracheal suctioning
• lack of adequate equipment cleaning
• lack of aseptic technique during care
• frequency in manipulation of tube by the resident
The resident has an increased risk to nosocomial infections at the stoma site also, related to:
• moist area
• secretions
• frequency in manipulation of tube by the resident
• lack of aseptic technique during tracheostomy care
• lack of clean technique during activities of daily living (brushing teeth, facial shaving, etc.)
Preventive steps include:
• handwashing before,
during (if contamination occurs), and
after.
• sterile suction catheters, used only once and this discarded properly;
• sterile solutions only, once opened, dated and initialed and discarded per facility protocol hydrogen peroxide;
normal saline; and
sterile water.
• suction machine cleaned, rinsed out, and dried daily;
• oxygen tubing changed when visibly soiled and as per facility protocol;
• non-disposable humidification equipment should be cleaned, rinsed out, and dried daily;
• aerosol equipment should be changed out per facility protocol;
• clean from the edge of the stoma outward, using a new swab for each stroke;
• always dispose of supplies and equipment appropriately.
October 2012
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Tracheostomy care consists of two parts, suctioning and cleaning of the tracheostomy tube.
• Suctioning removes secretions and fluids from the trachea, bronchi, and throat while
stimulating the cough reflex. Tracheal suctioning aids to maintain a patent airway and provide
optimal gas exchange of oxygen and carbon dioxide. An indication for suctioning may
include:
increased heart rate
increased respiratory rate
decreased oxygen saturation (commonly referred to as O2 sat)
restlessness
noisy expirations
noted mucous in the tracheostomy tube
• Cleaning keeps the cannula path open. Cleaning of the tracheostomy tube includes:
the removal and cleaning of the inner cannula (in some cases, the inner cannula is
disposable and replaced instead of the cleaning process)
cleaning around the outer cannula
cleaning of the stoma
Nebulizer Treatments
Nebulizers are used to turn prescribed liquid medication into a mist so that it can be inhaled.
These aerosolized medications are utilized to relieve bronchospasms, mobilize bronchial
secretions, administer antibiotics and humidify the respiratory tract.
Basic guidelines for nebulizer treatments are as follows:
• Require a physician order to include dosage of medication(s), frequency and length of
time of treatment.
• Monitor the resident before, during and after each treatment for heart rate, breath sounds,
respiratory rate, pulse oximetry and effectiveness of treatment.
• Encouraging/assisting the resident to deep breath and cough after each treatment.
Monitor the resident for side effects. If he/she experiences any of the following, stop the
treatment, rest for five to ten minutes. If the sensation goes away, continue with your treatment.
If physical problems persist, stop the treatment and notify the physician:
• Increase in pulse by 20 beats per minute
• Palpitations (noticeable heart beat)
• Hyperventilation
• Dizziness
• Shakiness
• Nausea
• Chest pain
• Uncontrollable coughing
• Facial redness
October 2012
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Nebulizer equipment may vary in appearance; most models
contain the components shown to the right. The equipment
should be utilized and maintained according to the manufacturer’s
recommendations and guidelines.
The compressor is medical equipment and should only be worked
on by a professional. If you are having trouble with the
compressor, disconnect from the electrical outlet and notify your
Central Supply designee.
Safety Precautions
• Never try to clean the compressor by submerging it into water. The electrical components
will be damaged and could cause a shock to the user the next time is plugged. Into an
electrical outlet.
• Never plug in the compressor if the unit is wet, for example if on the nightstand and a cup of
water was spilled and fluid rolled under it.
• Never use the compressor with an extension cord.
Common Problem
Medication is not
making a mist.
Probable Cause
•
•
Nebulizer cup is not properly
assembled.
Nebulizer cup is not clean.
Compressor does not
turn on.
•
•
Unit is not plugged in.
Electrical outlet is nonfunctioning.
Medication leaks out of
nebulizer cup.
•
Nebulizer cup is cross
threaded.
Nebulizer cup is cracked.
•
Compressor unit does
not have enough flow.
Compressor filter is dirty.
Solution
Reassemble nebulizer cup.
Clean nebulizer cup.
Discard and use a new
nebulizer cup.
• Plug in.
• Plug into an alternate
electrical outlet; notify
maintenance.
• Unscrew cap from nebulizer
cup and reassemble.
• Discard nebulizer cup and use
a new cup.
Clean and/or replace compressor
filter.
•
•
•
Metered Dose Inhalers (MDI)
A metered dose inhaler (MDI) delivers a specific amount of
medicine in aerosol form from a pressurized canister in a
plastic case with a mouthpiece. This makes it possible to
inhale the medication, instead of taking it in pill form. Pressing
the MDI releases a mist of medication.
October 2012
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It is important to use a MDI correctly in order to get the full dosage. A good technique can assist
in reducing the side effects of medication and increase its effectiveness when in reaches the
small airways. MDI's are commonly used to treat asthma, COPD, and other respiratory
conditions.
Steps for Using a MDI:
1. Remove the cap from the inhaler
2. Hold the inhaler with the mouthpiece at the bottom
3. Shake the inhaler to mix the medication properly
4. Open mouth technique - hold the mouthpiece 1 ½ - 2 inches (2 – 3 finger widths) in front of
your mouth or Close mouth technique – seal your lips tightly around the inhaler mouthpiece
5. Tilt your head back slightly and open your mouth wide
6. Gently breathe out
7. Press the inhaler and at the same time begin a slow, deep breath; continue to breathe in
slowly and deeply over 3 – 5 seconds; breathing slowly delivers the medication deeply into
the airways
8. Hold your breath for up to ten seconds; this allows the medication time to deposit in the
airways
9. Resume normal breathing
10. Repeat steps 3 – 9 for each puff prescribed
11. Clean the plastic case and cap by rinsing thoroughly with warm water
Respiratory Medications
The following medications are commonly used, the list is not all inclusive:
• Albuterol - Broncodilator
Proventil – SVN: 0.5 ml of 0.5% in 2.5 ml saline TID or QID or
Ventolin – MDI: 2 puffs 90 ug/puff TID or QID
Onset occurs in 15 minutes
Peak occurs in 30 – 60 minutess
Duration is for 5 – 8 hours
Monitor blood pressure, pulse
Contraindicated in residents with known heart disease
Side effects include palpitations, anxiety, headache, dizziness and sweating
Medication safety includes no exposure to heat, light and air; store in amber bottles
• Levalbuterol - Bronchodilator
Xopenex – SVN: 0.63 mg/3 ml TID; 1.25 mg/3 ml TID or
Xopenex – MDI: 2 puffs every 4 – 6 hoursTID; 1 puff every 4 hours
Peak occurs in 30 – 60 minutes
Side effects include dizziness, tremor, nervousness, anxiety, headache, cough, runny
nose, nausea and leg cramps
Medication safety includes foil pouches stored at room temperature, no exposure to
heat or light
October 2012
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•
•
•
•
•
Ipratropium Bromide - Bronchodilator
Atrovent – SVN: 2.5 ml of 0.02% strength (500 ug) TID or QID or
Atrovent – MDI: 2 puffs 18 ug/puff QID or
Atrovent – nasal spray: 0.03% strength 2 sprays per nostril BID or QID; 0.06% strength 2
sprays per nostril BID or QID
Peak occurs in 1 – 2 hour
Monitor blood pressure, pulse; protect eyes from medication
Contraindicated in residents with known hypersensitivity to soybeans or peanuts
Side effects include palpitations, anxiety, headache, dizziness, tremors, nervousness
and dry mouth
Ipratropium Bromide/Albuterol – Bronchodilator
DuoNeb – SVN: Ipratropium 0.5 mg and Albuterol sulfate 3mg QID or
Combivent – MDI: 2 puffs 18 ug/puff of Ipratropium with 90 ug/puff Albuterol QID
Contraindicated in residents with known hypersensitivity to soybeans or peanuts
Side effects include bronchitis, coughing, headache, dizziness, tremors, shortness of
breath, upper respiratory tract infection, fatigue and dry mouth
Tiotropium Bromide – Bronchodilator
Spiriva – DPI: 18 mg/inhalation 1 inhalation daily
Peak occurs in 3 hours
Duration is for 24 hours
Side effects include blurred vision, constipation, indigestion, muscle aches, nosebleed,
runny nose, sore throat, stomach pain, vomiting, yeast infection and dry mouth
Aceylcysteine – Reduce Mucus and Secretions
Mucomyst – SVN: 3 - 5 ml, 10% or 20% strength TID or QID
Precautions = will cause broncospasms, do not use alone must use with a
bronchodilator; cannot be mixed with antibiotics, can be given aerosolized if antibiotic is
given by another route
Side effects include rash, cold, clammy skin, drowsiness, fever, inflammation of mouth or
tongue, nausea, runny nose and sore throat
Fluticasone Proprionate and Salmeterol – Reduce and Control Inflammation
Advair Diskus – DPI: 100 ug, 250 ug and 500 ug of fluticasone with 50 ug salmeterol,
one inhalation BID or
Advair – MDI: 45 ug, 115 ug and 230 ug of fluticasone with 21 ug salmeterol, one
inhalation BID
Precautions = always rinse resident’s mouth after use
October 2012
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Side effects include palpitations, nausea, dizziness, headache, tremor, constipation,
diarrhea, bronchitis, fungal infection of mouth and muscle pain
Budesonide – Reduce and Control Inflammation
Pulmicort Turbuhaler – DPI: 180 ug/activation, 180 ug BID to 800 ug BID (titrated dose)
or
Pulmicort Respules – SVN: 0.25 mg/2 ml and 0.5 mg/2 ml, 0.5 mg up to 1 mg every day
or BID in divided doses
Side effects include dry, irritated throat, hoarseness, cough, respiratory infection, runny
nose, earache, hypertension, migraine and fatigue
Medication safety includes protecting from light
Budesonide/Formoterol Fumarate – Reduce and Control Inflammation
Symbicort – MDI: 80 mcg/4.5 mcg or 160 mg/or BID in divided doses4.5 mcg 2 puffs
BID, morning and evening
Side effects include dizziness, dry mouth, headache, nausea, nervous
Medication safety includes protecting from lightess, stomach pain, stuffy nose, throat
irritation, tiredness, tremor, trouble sleeping and vomiting
•
•
Incentive Spirometry
An incentive spirometer is an apparatus used in which visual and
vocal stimuli are given to the resident to produce maximum effort
during deep breathing. It is commonly used after surgeries to
help keep the resident’s lungs clear during their time of
decreased mobility.
Steps that should be utilized to assist the resident use an incentive spirometer properly:
1. Have the resident sit on the edge of his/her bed or sit up as far as possible in the bed or the
bedside chair.
2. Hold the incentive spirometer in an upright position.
3. Have them place the mouthpiece in their mouth and seal their lips tightly around it.
4. Have them breathe in slowly and as deeply as possible, raising the piston toward the top of
the column. The indicator should be in the blue outlined area.
5. Have the resident hold his/her breath as long as possible, for at least five seconds; allow the
piston to fall to the bottom of the column.
6. Have the resident rest for a few seconds and repeat steps one to five following the
physician’s prescribed treatment.
7. Position the indicator on the left side of the spirometer to show the resident his/her best
effort. Use the indicator as a goal to work toward during each repetition.
8. After each set of 10 deep breaths, encourage the resident do cough in order to clear the
lungs. If the resident had surgery, have him/her support the incision when coughing by
placing a pillow firmly against the incision site.
October 2012
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Postural Drainage and Chest Percussion
Postural drainage and ches percussion are designed to improve the mobilization of bronchial
secretions based on the effects of gravity and external manipulation of the thorax. Indications for
use include:
• Inability or reluctance of resident to change body position.
• Evidence of difficulty with secretion clearance.
• Presence of atelectasis casued by suspected mucus plugging.
• Diagnosis of diseases such as, cystic fibrosis, bronchiectasis or cavitating lung disease.
Contraindications:
• Brain injuries
• Head and neck injuries
• Recent spinal injury
• Active hemoptysis
• Empyema
• Bronchial fistula
• Large plueral effusions
• Rib fracture
• Eye surgery
• Uncontrolled hypertension
• Pulmonary edema
• Pulmonary embolism
• Surgical wound
• Distended abdomen
• Esophageal surgery
Chest percussion should not be performed on residents with:
• Subcutaneous emphysema
• Recent spinal infusion
• Recent skin grafts on the thorax
• Burns
• Wounds
• Infections of the thorax
• Tuberculosis
• Lung contusion
• Bronchospasms
• Osteoporosis
• Complaint of chest wall pain
Complications:
• Hypoxemia
• Increased intracranial pressure
• Acute hypotension
• Pulmonary hemorrhage
• Vomiting
• Aspiration
October 2012
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Postural drainage and chest percussion is a component of bronchial hygiene therapy. It
consists of postural drainage, positioning, turning and percussion. Optimal hydration of the
resident is directly related to improved secretions. Turning improves oxygenation and lung
expansion. Postural drainage utilizes gravity to drain secxretions to assist a resident with
coughing.
Chest percussion is used to intermittently apply kinetic energy to the chest wall and lung. This
is accomplished by rhythmically striking the thorax with cupped hands or a mechanical device
(acapella device) directly over the lung segments being drained.
Respiratory Disorders
As a person ages, changes occur to the respiratory system include:
• Decreased exchange of oxygen and carbon dioxide, caused by decreased circulation.
• Increased anterior/posterior diameter of the chest due to skeletal changes assoicated with
aging (kyphosis).
• Chest wall becomes stiffer and more difficult to move.
• Respiratory muscles may weaken.
• Lungs lose some of their elastic recoil (like a rubber band in the sun).
• Muscles of the larynx and pharynx atrophy.
• Decreased vital capacity, residual volume and functional capacity.
• Increased airway resistance.
• Impaired cough mechanism.
Adult Respiratory Distress Syndrome
http://radiopaedia.org/encyclopaedia
Etiology and Pathophysiology
• A disease with numerous etiologies that is characterized by interstitial and alveolar
edema and progressive hypoxemia
Complication of other disease processes
Direct or indirect pulmonary injury
• Also referred to as shock lung or post-traumatic lung
October 2012
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Signs and Symptoms
• Respiratory distress
• Tachycardia
• Hypotension
• Decreased urinary output
Medical Management/Nursing Interventions
• Treat cause
• Oxygen
• Corticosteroids
• Diuretics
• Morphine
• Lanoxin
• Antibiotics
Asthma
• A pulmonary disease characterized by reversible airway obstruction, airway
inflammation and increased airway responsiveness to a variety of stimuli
• Airway obstruction is due to combination of factors that include bronchoconstriction
(narrowing of the airways), bronchospasm, airway edema and excess mucus
production
• Extrinsic or intrinsic factors
• Influenced by secondary factors
• Antigen-antibody reaction
Signs and Symptoms
• Mild asthma
Dyspnea on exertion
Wheezing
• Acute asthma attack
Tachypnea
Expiratory wheezing; productive cough
Use of accessory muscles; nasal flaring
Cyanosis
October 2012
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• Maintenance therapy
Serevent inhalant, prophylactic
Corticosteroid inhalant
Avoid allergens
• Acute or rescue therapy
Proventil inhalant
Aminophylline IV
Corticosteroid and epinephrine, oral or subcutaneous
Oxygen
Did you know? That residents with acute severe asthma should have their nebulizers
administered via oxygen or they will become hypoxic. If necessary, low-flow oxygen may be
administered via nasal cannula to residents while a drug is nebulized with air. This is
because it requires high-flow oxygen to nebulize a drug (6-8 liters/minute) and if the resident
has chronic respiratory disease he will only require a low-flow of oxygen to stimulate his
respiration.
Atelectasis
• Incomplete expansion of the lung tissue usually caused by pressure from exudate,
fluid, tumor or an obstructed airway; may involve a lung segment or an entire lobe.
• Collapse of lung tissue due to occlusion of air to a portion of the lung
Signs and Symptoms
• Dyspnea
• Tachypnea
• Pleural friction rub
• Crackles
• Restlessness
• Elevated temperature
• Decreased breath sounds
October 2012
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• Cough and deep-breathe
• Analgesia
• Early ambulation
• Incentive spirometry
• Intermittent positive-pressure breathing (IPPB)
• Oxygen
• Chest percussion and postural drainage
• Bronchodilators
• Antibiotics
• Mucolytic agents
• Chest tube
Bronchitis
• Inflammation of the trachea and bronchial tree
• Usually secondary to upper respiratory infection
• Exposure to inhaled irritants
• Hypertrophy of mucous glands causes hypersecretion and alters cilia function
• Increased airway resistance causes bronchospasm
Signs and Symptoms
• Productive cough
• Dyspnea
• Use of accessory muscles to breathe
• Wheezing
• Chest pain
• Low-grade fever
• Malaise
• Headache
• Bronchodilators
• Mucolytics
October 2012
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•
•
•
•
•
•
•
•
Antibiotics
Oxygen (low-flow)
Pursed-lip breathing
Cough suppressants
Antitussives
Antipyretics
Vaporizer
Encourage fluids
Cancer (Lung)
• Primary tumor or metastasis
• Small-cell, non-small–cell, squamous cell and large-cell carcinoma
Signs and Symptoms
• Hemoptysis
• Dyspnea
• Wheezing
• Fever
• Chills
• Pleural effusion
• Surgery
Most are not diagnosed early enough for curative surgical intervention
Segmental resection
Lobectomy
Pneumonectomy
• Radiation
• Chemotherapy
October 2012
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Chronic Obstructive Pulmonary Disease (COPD)
• Gradual, irreversible process that involves chronic dilation of bronchi resulting in loss
of elasticity and obstructed airflow or exhalation.
• Chronic bronchitis, emphysema and asthma are types of obstructive lung disease.
Signs and Symptoms
• Dyspnea
• Coughing
• Wheezes and crackles
• Cyanosis and clubbing of fingers
• Fatigue
• Weakness
• Loss of appetite
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Some additional characteristics that are often experienced by the elderly with COPD:
• Frequent pneumonia
• High anxiety levels
• Increased respiratory rate
• Increased sputum production
• Lower oxygen saturation
• Confusion and somnolence
• Demanding behavior
• Oxygen (low-flow)
• Chest physiotherapy
• Hydration
• Mucolytic agents
• Antibiotics
• Bronchodilators
• Cool mist vaporizer
• Surgery, such as a lobectomy
Did you know? The administration of oxygen, except in a very low concentration (24-28%)
could be fatal to residents with chronic pulmonary disease. This is because carbon dioxide
is retained in the blood and the chemoreceptors in the brain become less sensitive to high
blood levels of carbon dioxide. The resident can then become dependent on low oxygen
(hypoxia) to stimulate respriation. Therefore, if oxygen is given to correct the hypoxia, the
resident’s respiratory drive may be removed.
Emphysema
• The bronchi, bronchioles, and alveoli become inflamed as a result of chronic irritation
• Air becomes trapped in the alveoli during expiration, causing alveolar distention,
rupture, and scar tissue
• A main complication that can occur, “cor pulmonale” (right-sided congestive heart
failure due to pulmonary hypertension)
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Signs and Symptoms
• Dyspnea on exertion
• Sputum
• Barrel chest
• Chronic weight loss
• Emaciation
• Clubbing of fingers
• Oxygen (low-flow)
• Chest physiotherapy
• Bronchodilators
• Corticosteroids
• Antibiotics
• Diuretics
• Humidifier
• Pursed-lip breathing
• High-protein, high-calorie diet
Influenza
• Influenza, commonly referred to as the ‘flu’ is caused by the influenza virus, which
can be spread by coughing, sneezing or nasal secretions.
• Can occur at any time, but most occur from October through May.
Signs and Symptoms
• Fever
• Chills
• Cough
• Sore Throat
• Headache
• Muscle Aches
• Fatigue
• Runny or stuffy nose
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• Preventive:
Influenza vaccination annually
• Fluids
• Bedrest
• Analgesics
Legionnaire’s Disease
• Legionella pneumophila
• Thrives in water reservoirs
• Causes life-threatening pneumonia
• Leads to respiratory failure, renal failure, bacteremic shock, and ultimately death
Signs and Symptoms
• Headache
• Nonproductive cough
• Difficult and rapid respirations
• Crackles or wheezes
• Tachycardia
• Signs of shock
• Hematuria
• Oxygen
• Mechanical ventilation, if necessary
• IV therapy
• Antibiotics
• Antipyretics
• Vasopressors
October 2012
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Pertussis (Whooping Cough)
• Pertussis is commonly referred to as ‘Whooping Cough’
• Is an upper respiratory infection caused by the Bordetella pertussis or Bordetella
parapertussis bacteria
• Transmission of the disease can happen when an infected person sneezes or
coughs, tiny droplets containing the bacteria move through the air
• The infection usually lasts 6 weeks
• Causes severe coughing spells which can lead to difficulty breathing, vomiting and
disturbed sleep
• A deep "whooping" sound is often heard when the resident tries to take a breath
• Can lead to weight loss, incontinence, rib fractures and passing out from violent
coughing.
Signs and Symptoms
• Initial symptoms are similar to the common cold and usually develop about a week
after exposure to the bacteria
• Severe episodes of coughing start about 10 to 12 days after exposure to the bacteria
• Has a distinctive ‘whoop’ noise at the end of the cough
• Runny nose
• Low grade fever
• Diarrhea
Complications:
• Pneumonia
• Convulsions
• Seizure disorder (permanent)
• Nose bleeds
• Ear infections
• Brain damage from lack of oxygen
• Cerebral hemorrhage
• Mental retardation
• Apnea
• Death
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• Prevention:
Vaccination
• Antibiotics, usually erythromycin, if started early enough
• Oxygen tent with high humidity
• Fluids, PO or IV, as indicated
• Sedatives to assist with sleep
• Cough expectorants and/or suppressants are usually not helpful and should NOT be
used
Pleural Effusion/Empyema
• An abnormal accumulation of fluid between visceral and parietal pleurae. There are
several factors that may predispose the resident:
Pre-existing fever, malaise or purulent sputum
History of cardiac, hepatic or renal disease
Recent drug therapy with Hydralazine, Methysergide, Nitrofurantoin or
Procainamide
Signs and Symptoms
• Dyspnea which may indicate minimal lung collapse
• Sharp, stabbing chest pain aggravated by coughing, deep breathing or exertion;
relieved by short, shallow breaths and splinting
• Pain that may mimic a heart attack since it can radiate to the neck, shoulders or
abdomen (due to the pain originating in the intercostal nerves)
• Shortness of breath
• Dull or flat percussion, especially over the area of effusion
• Absent or diminished breath sounds over affected areas
• Hypoxemia secondary to underlying respiratory disorders or lung compression
• Air hunger
• Absent or diminished voice sounds
• Displaced heart sounds which may indicate a mediastinal shift
• Gallop heart rhythms which may indicate heart failure (frequently causing or
accompanying effusion)
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• Cough and deep breathe; rrelax
elax the chest and abdominal muscles and make
mak
coughing less laborous; tthe
he best way to accomplish this is through the following
process:
When in bed, have the resident lie on the affected side; raise the head
of the bed
Encourage the resident to sit up, if possible
Show the resident how to splint the painful area when coughing or deep
breathing
• Thoracentesis
• Chest tube with closed water
water-seal drainage system
• Antibiotics
Pleurisy
• Inflammation of the visceral and parietal pleura
• Bacterial or viral
Signs and Symptoms
• Sharp inspiratory pain
• Dyspnea
• Cough
• Pleural friction rub
• Antibiotics
• Analgesics
• Antipyretics
• Oxygen
• Anesthetic block for intercostal nerves
Term Care Nurses
October 2012
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Pneumonia
Is best defined as a inflammation of the lung parenchyma, regardless of the
type of pneumonia
• This inflammatory process of the bronchioles and the alveolar spaces due to
infection
• The most common types of pneumonia found in the long-term setting are aspiration,
bacterial and viral
Aspiration pneumonia is the pathologic consequence of abnormal entry of
fluids, particulate matter or secretions in the lower airways
•
Signs and Symptoms
• Severe chills
• Increased heart rate
• Increased respiratory rate
• Dyspnea
• Myalgia
• Headache
• Mucopurulent sputum
• Oxygen
• Chest percussion and postural drainage
• Encourage to cough and deep-breathe
• Antibiotics
• Analgesics
• Expectorants
• Bronchodilators
• Nebulizer treatments
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Pneumothorax
• Is an accumulation of air or gas within the pleural cavity, causing the lung to collapse
Signs and Symptoms
• Sudden, sharp chest pain with dyspnea
• Diaphoresis
• Tachycardia
• Tachypnea
• No chest movement on affected side
• Sucking chest wound
• Chest tube to water-seal drainage system
• Oxygen
• Analgesics
• Encourage fluids
Pulmonary Edema
• An excessive accumulation of serous fluid within the interstitial tissue and alveoli
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Signs and Symptoms
• Dyspnea
• Cyanosis
• Tachypnea
• Tachycardia
• Pink or blood-tinged, frothy sputum
• Restlessness
• Agitation
• Wheezing
• Crackles
• Decreased urinary output
• Sudden weight gain
• Oxygen
• Mechanical ventilator (acute care setting, LTAC)
• Diuretics
• Narcotic analgesics
• Nipride (acute care setting only)
• Strict I&O
• Daily weight
• Low-sodium diet
Pulmonary Embolism
• A sudden lodgment of a foreign substance in a pulmonary artery with subsequent
obstruction of blood supply to the lung parenchyma
Blood clot, fat, air, or amniotic fluid
• The most common type of pulmonary embolus is a thrombus that usually has
migrated from a leg or pelvic vein
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Signs and Symptoms
• Sudden, unexplained dyspnea
• Tachypnea
• Hemoptysis
• Chest pain
• Increased white blood cells (WBCs)
• Oxygen
• Head of bed (HOB) elevated 30 degrees
• Anticoagulants
• Fibrinolytic agents
Tuberculosis
• Inhalation of tubercle bacillus (Mycobacterium tuberculosis)
• Infection versus active disease
• Presumptive diagnosis
Mantoux tuberculin skin test
Chest x-ray
Acid-fast bacilli smear x 3
• Confirmed diagnosis
Sputum culture; positive for TB bacilli
Signs and Symptoms
• Fever
• Weight loss
• Weakness
• Hemoptysis
• Chills and night sweats
October 2012
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• Tuberculosis isolation (acid fast bacilli [AFB])
• Multiple medications to which the organisms are susceptible
Recap of Nursing Interventions for the Respiratory Resident
Throughout the above listed respiratory disorders, various nursing interventions were utilized.
In review, the following are the most common interventions utilized regardless of the cause of
the respiratory disorder:
• Frequent position changes
• Maintain position to facilitate ventilation (semi-fowler’s)
• Protect from infection
• Protect from sources of lung irritants
• Cool the environment
• Cough and deep breathing exercises
• Provide rest periods between activities of daily living
• Encourage the resident to use adaptive breathing techniques, such as pursed-lip
breathing
• Provide alternative method of communication if needed
• Encourage fluids
• Ensure good nutrition
• Provide good skin care
• Provide good oral care
• Bedrest as indicated
Emergency Treatment of the Respiratory Resident
Exacerbation of COPD
The resident is end stage COPD with a long history of home oxygen and nebulizer treatments.
He has a history of Prednisone use and is a DNR. Normal oxygen saturation readings are
89 – 90% with an apical heart rate 100.
The resident presents with complaints of tightness in the chest and increased difficulty
breathing, increased sputum production, oxygen saturation of 85%, respiratory rate of 30, apical
heart rate of 110 and is very anxious. The resident is insisting to return to the hospital.
Your first response is to give this resident a STAT nebulizer treatment while you reposition him
in an upright sitting position. You should talk to the resident in a calm and relaxing voice as you
encourage him to take slow, deep breaths; repeat as necessary. Give anti-anxiety medications
and cool the resident’s room temperature. Notify the physician and request CXR and weaning
process for Prednisone. Monitor frequently until the episode passes.
October 2012
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Tracheal Occulsion
The resident is a recent tracheostomy resident with complications due to surgery. The resident
has no previous respiratory history but is unable to wean from continuous oxygen to her trach at
this time. Oxygen is being delivered at 35% via tracheostomy mask.
You begin to suction her and notice that you cannot pass the suction catheter. Oxygen
saturations are falling and the resident is starting to utilize her accessory muscles.
Your first response is to remove the inner cannula and check for occlusion. You immediately
clean the inner cannula, remembering to increase oxygen levels for the resident as you clean).
Replace the inner cannula and increase humidity to the resident. Leave increased oxygen level
until the resident stabilizes. If the inner cannula was not occluded, check inflation of the cuff
and verify that it is deflated; deflate if indicated.
Your next response to this situation would be to lavage and suction the resident. Hyperoxygenate by using an ambu-bag hooked up to an oxygen source. Lavage, suction and hyperoxygenate the resident until the plug is dislodged. Repeat as necessary. Leave the resident on
the higher oxygen until she stabilizes. Check the humidification device and water levels.
Pulmonary Embolism
The resident has had recent repair of a hip fracture due to a fall. No previous respiratory history
is available. He complains suddenly of shortness of breath. Room air saturation is 97%. He
continues to complain of increased shortness of breath and room air saturation drops to 95%.
Your first response is to immediately place oxygen at 2 liters/minute per nasal cannula, place on
bedrest and notify the physician due to possible pulmonary embolism.
Aspiration of Tube Feeding in a Tracheostomy Resident
The resident is noted to have tube feeding coming from the trach site; she has no cough reflex.
Your first response is to immediately inflate trach cuff and suction resident. Airway is protected
by cuff inflation. Numerous suction attempts need to be performed to prevent pneumonia.
Lavage and suction your resident.
October 2012
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Glossary
Adventitious sound – an acquired (usually) abnormal sound superimposed over normal or
abnormal breath sounds.
Alveolus – one of the millions of very small, saclike lung structures where oxygen and carbon
dioxide exchange occurs.
Amplitude – magnitude or intensity of a sound.
Anatomical dead space – air that remains in the conducting airways during each breath and is
not involved in the oxygen and carbon dioxide exchange.
Apnea - temporary absence or cessation of breathing.
Aspiration – act of inhaling; usually refers to the act of breathing in foreign materials.
Atelectasis – incomplete expansion of the lung tissue usually casued by pressure from exudate,
fluid, tumor or an obstructed airway; may involve a lung segment or an entire lobe.
Attenuation – decrease in the intensity or loudness of a breath sound.
Auscultation – act of listening to sounds made by the body; usually performed with a
stethoscope.
Bell – cup-shaped portion of the stethoscope that is best suited for listening to low-pitched
sounds.
Bifurcate – to divid into two branches.
Bradypnea – abnormally slow rate of breathing, less than 12 breaths per minute.
Bronchiectasis – irreversible dilatation of the bronchi characterized by chronic cough and
sputum production and by fibrosed and atelectatic lung tissue surrounding the affected airways.
Bronchophony – voice sound auscultated over the chest wall that reveals exaggerated vocal
resonance.
Bronchospasm – smooth muscle contraction within the airway walls, which leads to airway
narrowing and reduced airflow.
Cheyne-Stokes – cyclic breathing marked by a gradual increase in the rapidity of respiration followed by
a gradual decrease and total cessation for from 5 to 50 seconds.
Cilia – motile, whiplike extensions from cell surfaces. Ciliated columnar epithelial cells line the
walls of the tracheobronchial tree.
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Conchae – shell-shaped turbinate bones in the nasal cavity that stimulate turbulent airflow
within the nasal passages. The dense mucus and capillary beds that line the burbinates’
surface encourage warming and humidification of inspired air.
Conducting airway – one of the airways beginning at the nose and ending at the terminal
bronchioles. These airways are responsible for transporting air during breathing but are not
involved with oxygen and carbon dioxide exchange.
Congestion – abnormal accumulation of fluid or blood in an organ or organ part.
Consolidation – inflammatory solidfication of lung tissue.
Crackle (formerly known as a rale) – short, explosive or popping sound usually heard during
inspiration; descrbed as coarse (loud and low in pitch) or fine (less intense and high in pitch).
Crepitation – crackling sound that resembles the sound made by rubbing hair between two
fingers.
Dampened – diminished sound intensity or amplitude; term used to describe sounds.
Diaphragm – primary muscle of respiration, which separates the thoracic and abdominal
cvaities. The part of the stethoscope used to auscultate high-pitched sounds.
Diffuse – widely distributed; not localized.
Duration – length of time that a sound is heard.
Dynamic airway compression – narrowing of the airways during expiration caused by properties
of intrapleural pressure, radial traction exerted by lung parenchyma and the loss of elastic recoil
within the lung.
Dyspnea – difficult, labored or uncomfortable breathing.
Edema – excessive accumulation of fluid in intercellular tissue spaces of the body.
Egophony – voice sound that has a nasal or bleating quality when ausculated over the chest
wall.
Elastic recoil – spontaneous contraction of lung parenchyma that occurs during expiration and
that helps move air out of the lungs.
Elastic tension – support and traction exerted on the airways because of the natural eleastic
recoil properties of the surrounding lung parenchyma.
Epiglottis – small elastic cartilage attached at the larynx that coves the opening to the trachea
during swallowing.
Exudate – inflammatory fluid leaked from body cells or tissues.
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Fibrosis – abnormal formation of fibrous connective tissue that usually occurs as a reparative or
reactive process within a tissue or organ.
Frequency – pitch of a breath sound measured in hertz.
Gas exchange surface – alveolar capillary surface that is actively involved in diffusing oxygen
and carbon dioxide.
Hemidiaphragm – one half of the diaphragm, either the right or left side.
Hila – medial lung aspects where the bronchi, nerves and vessels enter and leave.
Hypercapnia – the physical condition of having the presence of an abnormally high level of
carbon dioxide in the circulating blood; symptoms are a headache, dizziness, confusion,
unconsciousness, twitching, hypertension, sweating and flushed face.
Hyperinflation – overinflation of the lung that occurs with the air trapping in obstructive lung
diseases, such as emphysema.
Hyperpnea – an increase in the volume of air breathed per minute caused by an increase in
depth and/or respiratory rate.
Hypertrophy – enlargement of an organ resulting from an increase in the size of its constituent
cells.
Hypoxemia – abnormally low oxygen tension in arterial blood.
Hypoxia – is a condition that causes restlessness, confusion, impaired motor function,
hypotension, cyanosis and tachycardia.
Idiopathic – of unknown cause.
Inspiratory-Expiratory ratio (I:E) – numerical expression of the duration of inspiration in relation
to the duration of expiration.
Intensity – strength or loudness of a sound.
Intercostal muscle – one of the muscles found between the ribs. Internal and external
intercostal muscles help stablize and expand or lower the rib cage with ventilation.
Intersitium – small gap in an organ or a tissue; in lung parenchyma, the space between the
alveolar and capilarry membranes.
Intrapleural pressure – relative pressure that occurs between the pleurae. Negative pressure
occurs during inspiration and positive pressure occurs during expiration.
Intrapulmonary pressure – pressure within the lung. Negative pressure causes air to flow
inward and positive pressure causes air to move outward.
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Larynx – cartilaginous organ located between the pharynx and the trache that houses the vocal
cords and allows for voice production.
Left mainstem bronchus – one of two main branches extending from the trache that supples air
to the left lung. It leaves the trache at a sharper angle than the right mainstem bronchus and
passes under the aortic arch before entering the lung.
Left ventricular heart failure – inability of the left ventricle to pump blood adequately, causing
decreased cardiac output, which results in pulmonary congestion and edema.
Lobar – referring to or involving any lung lobe.
Lower airway – see Tracheobronchial tree
Low-pitched wheeze (formerly known as sonorous rhonchus or sonorous rale) – continuous,
low-pitched sound that resembles snoring.
Mainstem bronchi breath sound – harsh, tubular (hollow) breath sound heard over a mainstem
bronchus.
Mean airflow velocity – airflow rates occurring within an airway during the middle part of
exhalation.
Mechanical ventilation – breathing that is assisted or controlled by a ventilator.
Mediastinum – area that acts as a medium partition of the thoracic cavity. It contains all the
thoracic viscera and structures, such as the heart, great vessels and central airways.
Monophonic – having one distinct musical sound or tone; used to describe selected wheezes.
Mucus – serous, watery liquid secreted by bronchial glands and goblet cells within the airways.
Normal breath sound – sound auscultated over chest wall areas of a healthy person.
Oscillation – vibration, fluctuation.
Parenchyma – function cells of an organ that distinguish or determine the primary organ
function.
Perfusion – blood flow to or through an organ or tissue supplied by the blood vessels.
Peripheral – toward the outer boundary or perimeter; not central.
Pharynx – musculomembranous passage between the posterior nares, larynx and esophagus;
commonly referred to as the throat. It serves as a joint conduit for food and air.
Phonation – production of vocal sounds.
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Pitch – a tone’s vibration or frequency, measured in cyclers per second as sound amplitude;
subjectively described as high, medium or low.
Pleurae – ting, serous membranes that surround the lungs (visceral pleura) and line the thoracic
cavity’s inner walls (paretal pleura).
Pleural crackle (pleural friction rub) – loud, grating sound caused by inflamed or damaged
pleurae.
Pleural friction rub – see Pleural crackle
Polyphonic – having multiple distinct musical sounds or tones; used to describe selected
wheezes.
Pulmonary circulation – blood pumped by the right ventricle into the pulmonary artery that
circulates through the pulmonary capillary beds, where gas exchange occurs. The oxygenated
blood is carried to the left atrium via the pulmonary veins.
Pulmonary function – decreased vital capacity, minute volume and functional residual capacity;
increased pulmonary shunting.
Pulmonary vein – principle vein that carries oxygenated blood into the left atrium.
Rale – see Crackle
Resistance – force that hinders motion; hindrance or impedance.
Resonance – sound quality produced by percussing structures or cavities that radiate sound
vibrations and energy.
Respiratory cycle – one complete cycle of inspiration and expiration.
Respiratory distress – a condition that can exhibit nasal flaring, chest wall retractions, tachypnea
or bradypnea, decreased chest wall movement and labored breathing.
Rhonchus – see Low-pitched wheeze
Right mainstem bronchus – one of two main branches extending from the trachea that supplies
air to the right lung. It leaves the trachea at a less-acute angle than the left mainstem bronchus.
Scapula (shoulder blade) – triangular flat bone that makes up part of the shoulder girdle.
Segmental bronchus – airway that branches from a lobar bronchus and conducts air to a lung
segment.
Serous – having a watery consistency.
Silent chest – absence of breath sounds during auscultation; usually associated with severe
bronchospasm and insufficient airflow to produce sounds.
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Status asthmaticus – severe asthma that is resistant to treatment; characterized by respiratory
insufficiency or failure, wheezing and severe dyspnea.
Stenosis – narrowing or stricture of a bodily passage, such as an airway.
Stethoscope – instrument used in auscultation; usually consists of a diaphragm and a bell,
which are connected to one or two tubes leading to a binaural headpiece and earpieces.
Stridor – noisy, high-pitched sound that can usually be heard at a distance from the resident.
Caused by a laryngeal spasm and mucosal swelling, which contract the vocal cords and narrow
the airway.
Surfactant – active surface agent that acts to decrease surface tension, thereby allowing easier
ventilation of the alveoli.
Tachypnea – abnormally fast rate of breathing, more than 20 breaths per minute.
Terminal respiratory bronchioles – final part of the conducting airways.
Thoracic cavity – space within the rib cage that begins at the clavicle and ends at the
diaphragm.
Thorax – bony structure that enclosed the thoracic cavity, protecting the heart, lungs and great
vessels.
Tracheal breath sound – loud, tubular (hollow) breath sound ausculated over the trachea that is
audible during inspiration and expiration.
Tracheobronchial tree (lower airway) – portion of the airway that begins at the larynx and ends
at the terminal bronchioles.
Tubular breath sound – loud, hollow sound heard over the trachea and mainstem bronchi.
Turbulence – disturbed or irregular airflow; can be caused by rapid flow rates or variations in air
pressures and velocities.
Ventilation – movement of air in and out of the lungs.
Vesicular sounds – normal breath sounds ausculated over most of the chest wall.
Vocal cord – one of two membranous structures in the larynx responsible for phonation.
Vocal fremitus – sensation of sound vibrations produced when the resident speaks.
Wheeze – continuous, high-pitched sound that has a musical quality.
Whispered pectoriloquy – high-frequency whispered voice sound ausculated over consolidated
or atelecdtatic areas.\
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Bibliography
2013 Lippincott’s Nursing Drug Guide; Lippincott Williams & Wilkins, Wolters Kluwer Company.
Rochester, NY. June, 2012.
Braman SS. Postinfectious cough: ACCP evidence-based clinical practice guidelines. Chest.
2006;129(1):138S-146S.
Centers for Disease Control and Prevention. Vaccination Information Sheets (VIS).
http://www.cdc.gov/; Accessed October, 2012.
Cleveland Clinic, www.clevelandclinic.org; accessed October, 2012
Lippincott Manual of Nursing Practice, Ninth Edition; Lippincott Williams & Wilkins, Wolters
Kluwer Company. Rochester, NY. 2010
Littmann Education; http://solutions.3m.com/wps/portal/3M/en_US/3MLittmann/stethoscope/littmann-learning-institute/heart-lung-sounds/. Accessed October, 2012.
Merck Manual of Diagnosis and Therapy, Nineteenth Edition; Merck Research Laboratories,
Division of Merck & Co., Inc. Whitehouse Station, NJ: July, 2011.
Mosby, Inc., an affiliate of Elsevier, Inc.; StatRef!. 2012
Radiopaedia, http://radiopaedia.org/encyclopaedia/. Accessed October, 2012
Sharma, S. Acute respiratory distress syndrome. British Medical Journal. 2009.
http://clinicalevidence.bmj.com/ceweb/conditions/rda/1511/1511.jsp. Accessed October, 2012
Taber’s Cyclopedic Medical Dictionary, Edition 21; F.A. Davis Company. Philadelphia, PA: 2005
US Food and Drug Administration. First Combination Vaccine Approved to Help Protect
Adolescents Against Whooping Cough. Rockville, MD: National Press Office; May 3, 2005. Talk
Paper T05-17.
Wark, P. Acute bronchitis. British Medical Journal 15:1996-2005. Revised 2007.
http://clinicalevidence.bmj.com/ceweb/conditions/rda/1508/1508.jsp. Accessed October, 2012
October 2012
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Appendix A: Instructions for the Oxygen Concentrator
Introduction:
The oxyen concentrator takes in room air and by removing nitrogen, provides a greater percent of oxygen concentration
to the patient. *Please take the time to read the operating instructions on the front or side of the concentrator.
How to Use the Concentrator:
•
Fill the humidifer bottle half-way with distilled water. Screw the humidifier bottle to the plastic adaptor on the
concentrator (see picture 1). Make sure the lid is properly secured onto the bottle before screwing it unto the
adaptor on the concentrator.
•
Plug the concentrator into a grounded outlet. Do not use an extension strip.
•
Turn concentrator on by pushing the power button. The initial beeping is normal.
•
Set the flow meter by turning the knob on the flow meter. Turn clockwise to increase the flow. Turn counterclockwise to decrease the flow.
•
Attach the nasal cannula to the humidifer bottle. At the top of the humidifer bottle you will see a protruding
end and feel air coming out of it, this is where the cannual is attached.
***For more detailed information see instructions below.***
Picture 1
Warnings & Precautions:
•
Do not smoke while using oxygen.
•
Always keep the oxygen concentrator in a well ventilated area about 3 to 4 inches from the wall or drapes. Never put inside a closet
or enclosed area.
•
Clean the filter on a weekly basis, otherwise motor failure may occur.
•
Keep oxygen at least 10 feet away from open flames or fire.
•
During an electrical storm, the concentrator should be turned off and unplugged. The back-up tank is then to be used.
•
Do not change the liter flow from what your physician has prescribed.
•
Do not leave the oxygen on when not in use.
Care & Maintenance:
The concentrator filters must be cleaned on a weekly basis. The filter(s) are located on the sides of the concentrator
(see picture 2). The Puritan-Bennett concentrator also has a panel where the reset button and the 9 volt battery are found.
•
To clean the filter, remove it from the side of the concentrator. Gently pull it off and run it under
warm water. Do this for both sides of the filter for about 10 seconds.
•
Squeeze the filter in your hand to remove excess water.
•
Place the filter back onto the sides of the concentrator.
•
Change the nasal cannula every 2 weeks. Change the oxygen tubing every 6 weeks.
•
Wipe down the concentrator with a damp cloth to remove dust. Make sure you unplug the concentrator first.
Picture 2
Humidifer Bottle:
•
The humidifer bottle moistens the air coming out of the concentrator. This will help to prevent nasal dryness associated with
prolonged use.
•
Remove the top of the bottle and fill with distilled water to the half-way mark on the bottle. Although distilled water is highly
recommended in order to prevent mineral build-up, you may also use regular tap water.
•
Always check that the lid is screwed on securely and that the bottle is securely tightened to the plastic adaptor on the concentrator.
Nasal Cannula:
Once you have filled the bottle half-way and screwed it onto the concentrator (see picture 1), the nasal cannula is then attached to the
humidifer bottle to the protruding piece located on the top of the bottle. If you have the concentrator on, you will feel air coming out of this
protruding end-piece. Mke sure the cannula is securely in place.
How to connect a cannula without using a humidifer bottle:
You may connect directly onto the concentrator without the use of a humidifer bottle. Simply locate the protruding
end piece. On the front of the concentrator and place your cannula onto it. (See picture 3).
Some models do not have a protruding end piece that is attachable to a cannula. To remedy this, you will need to
use a green “Christmas Tree Adaptor” shown below.
Simply screw the adaptor onto the black 90 degree adaptor located on the front of the
concentrator, then attach the nasal cannula directly onto it. You are now ready to use
the concentrator without the use of a humidifier bottle.
October 2012
Picture 3
58
Appendix B: Pursed-lip Breathing
Pursed-lip
lip breathing is one of the simplest ways to control shortness of breath. It provides a
quick and easy way to slow your pace of breathing, making each breath more effective.
Pursed-lip breathing:
• Improves ventilation
• Releases trapped air in the lungs
• Keeps
eps the airways open longer and decreases the work of breathing
• Prolongs exhalation to slow the breathing rate
• Improves breathing patterns by moving old air out of the lungs and allowing for new
• Relieves shortness of breath
• Relieves shortness of breath
• Causes general relaxation
Pursed-lip
lip breathing should be the technique used during the difficult part of any activity, such
as bending, lifting or stair climbing. Practice this technique 4-5
5 times a day at first so you can
get the correct breathing pattern.
Pursed-lip Breathing Technique::
1. Relax your neck and shoulder muscles.
2. Breathe in (inhale) slowly through your nose for two counts, keeping your mouth closed.
Don't take a deep breath; a normal breath will do. It may help to count to yourself: inhale,
one, two. (See Figure A)
3. Pucker or "purse" your lips as if you were going to whistle or gently flicker the flame of a
candle. (See Figure B)
4. Breathe out (exhale) slowly and gently through your pursed-lips
s while counting to four. It
may help to count to yourself: exhale, one, two, three, four. (See Figure C)
5. With regular practice, this technique will seem natural to you.
A
Term Care Nurses
October 2012
B
C
59
Appendix C: Diaphragmatic Breathing
The diaphragm is the most efficient muscle of breathing. It is a large, domeshaped muscle located at the base of the
lungs. Your abdominal muscles help move the diaphragm and give you more power to empty your lungs.
Diaphragmatic breathing is intended to help you use the diaphragm correctly while breathing to:
•
Strengthen the diaphragm
•
Decrease the work of breathing by slowing your breathing rate
•
Decrease oxygen demand
•
Use less effort and energy to breathe
Diaphragmatic breathing technique:
1.
Lie on your back on a flat surface or in bed, with your knees bent and your head supported. You can use a
pillow under your knees to support your legs. Place one hand on your upper chest and the other just below
your rib cage. This will allow you to feel your diaphragm move as you breathe.
2.
Breathe in slowly through your nose so that your stomach moves out against your hand. The hand on your
chest should remain as still as possible.
3.
Tighten your stomach muscles, letting them fall inward as you exhale through pursed-lips. The hand on your
upper chest must remain as still as possible.
4.
When you first learn the diaphragmatic breathing technique, it may be easier for you to follow the
instructions lying down. As you gain more practice, you can try the diaphragmatic breathing technique while
sitting in a chair, as shown below.
To perform this exercise while sitting in a chair:
1.
Sit comfortably, with your knees bent and your shoulders, head and neck relaxed.
2.
Place one hand on your upper chest and the other just below your rib cage.
3.
This will allow you to feel your diaphragm move as you breathe. Tighten your stomach
muscles, letting them fall inward as you exhale through pursed-lips. The hand on your
upper chest must remain as still as possible.
Note: You may notice an increased effort will be needed to use the diaphragm correctly. At first, you'll probably get
tired while doing this exercise. But keep at it, because with continued practice, diaphragmatic breathing will
become easy and automatic.
How often should I practice this exercise?
At first, practice this exercise 5-10 minutes about 3-4 times per day. Gradually increase the amount of time you spend
doing this exercise, and perhaps even increase the effort of the exercise by placing a book on your abdomen.
October 2012
60
Appendix D: Asthma Triggers
October 2012
61

Respiratory Therapy Training Manual

Transcription

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