NCLEX: Respiratory disorders

Respiratory disorders: Treatments

Focus topic: Respiratory disorders

Through the nose

Focus topic: Respiratory disorders

Nasal CPAP has proved successful as a long-term treatment for obstructive sleep apnea. In this type of CPAP, high-flow compressed air is directed into a mask that covers only the patient’s nose. The pressure supplied through the mask serves as a back pressure splint, preventing the unstable upper airway from collapsing during inspiration. It also helps reduce other risks from sleep apnea.

Not so positive

Focus topic: Respiratory disorders

CPAP may cause gastric distress if the patient swallows air during the treatment (most common when CPAP is delivered without intubation). The patient may feel claustrophobic. Because mask CPAP can also cause nausea and vomiting, it shouldn’t be used in patients who are unresponsive or at risk for vomiting and aspiration. Rarely, CPAP causes barotrauma or lowers cardiac output.

Respiratory disorders

Patient preparation
If the patient is intubated or has a tracheostomy, you can accomplish CPAP with a mechanical ventilator by adjusting the settings. Assess vital signs and breath sounds during CPAP.
If CPAP is to be delivered through a mask, a respiratory therapist usually sets up the system and fits the mask. The mask should be transparent and lightweight, with a soft, pliable seal. A tight seal isn’t required as long as pressure can be maintained. Obtain ABG results and bedside pulmonary function studies to establish a baseline.

Monitoring and aftercare
After CPAP has begun, take these steps:
• Check for decreased cardiac output, which may result from increased intrathoracic pressure associated with CPAP.
• Watch closely for changes in respiratory rate and pattern. Uncoordinated breathing patterns may indicate severe respiratory muscle fatigue that CPAP can’t help. Report this to the practitioner; the patient may need mechanical ventilation.
• Check the CPAP system for pressure fluctuations.

• Keep in mind that high airway pressures increase the risk of pneumothorax, so monitor for chest pain and decreased breath sounds.
• Use oximetry, if possible, to monitor oxygen saturation, especially when you remove the CPAP mask to provide routine care.
• If the patient is stable, remove his mask briefly every 2 to 4 hours to provide mouth and skin care along with fluids. Don’t apply oils or lotions under the mask — they may react with the mask seal material. Increase the length of time the mask is off as the patient’s ability to maintain oxygenation without CPAP improves.
• Check closely for air leaks around the mask near the eyes (an area difficult to seal); escaping air can dry the eyes, causing conjunctivitis or other problems.
• If the patient is using a nasal CPAP device for sleep apnea, observe for decreased snoring and mouth breathing while he sleeps. If these signs don’t subside, notify the practitioner; either the system is leaking or the pressure is inadequate.

Home care instructions
CPAP for sleep apnea is the only treatment requiring instructions for home care.
• Have the patient demonstrate his ability to maintain the prescribed pressures without excess leakage in the system. Teach him how to clean the mask and change the air filter.
• Explain to the patient that he must use nasal CPAP every night, even when feeling better after initial treatments; apneic episodes will recur if CPAP isn’t used as directed. He should call his practitioner if symptoms recur despite consistent use.
• If the patient is obese, explain that CPAP treatments might be decreased or eliminated with weight loss.

Oxygen therapy
In oxygen therapy, oxygen is delivered by mask, nasal prongs, nasal catheter, or transtracheal catheter to prevent or reverse hypoxemia and reduce the work of breathing. Possible causes of hypoxemia include emphysema, pneumonia, Guillain-Barré syndrome, heart failure, and myocardial infarction (MI).

Fully equipped

Focus topic: Respiratory disorders

The equipment depends on the patient’s condition and the required fraction of inspired oxygen (FIO2). High-flow systems, such as a Venturi mask and ventilators, deliver a precisely controlled air-oxygen mixture. Low-flow systems, such as nasal prongs, a nasal catheter, a simple mask, a partial rebreather mask, and a nonrebreather mask, allow variation in the oxygen percentage delivered, based on the patient’s respiratory pattern.

Compare and contrast

Focus topic: Respiratory disorders

Nasal prongs deliver oxygen at flow rates from 0.5 to 6 L/minute. Inexpensive and easy to use, the prongs permit talking, eating, and suctioning — interfering less with the patient’s activities than other devices. Even so, the prongs may cause nasal drying and can’t deliver high oxygen concentrations. In contrast, a nasal catheter can deliver low-flow oxygen at somewhat higher concentrations, but it isn’t commonly used because of discomfort and drying of the mucous membranes. Masks deliver up to 100% oxygen concentrations but can’t be used to deliver controlled oxygen concentrations. Also, they may fit poorly, causing discomfort, and must be removed to eat. Transtracheal oxygen catheters, used for patients requiring chronic oxygen therapy, permit highly efficient oxygen delivery and increased mobility with portable oxygen systems and avoid the adverse effects of nasal delivery systems. Even so, they may become a source of infection and require close monitoring and follow-up after insertion as well as daily maintenance care.

Patient preparation
Before oxygen therapy begins, take these steps:
• Instruct the patient, his roommates, and visitors not to use improperly grounded radios, televisions, electric razors, or other equipment. Place an OXYGEN PRECAUTIONS sign on the outside of the patient’s door.
• Perform a cardiopulmonary assessment, and check that baseline ABG or oximetry values have been obtained.
• Check the patency of the patient’s nostrils (he may need a mask if they’re blocked). Consult the practitioner if the patient requires a change in administration route.

Some assembly required

Focus topic: Respiratory disorders

  • Assemble the equipment, check the connections, and turn on the oxygen source. Make sure the humidifier bubbles and oxygen flows through the prongs, catheter, or mask.
  • Set the flow rate as ordered. If necessary, have the respiratory care practitioner check the flow meter for accuracy.

Procedure
• When applying a nasal cannula, direct the curved prongs inward, following the nostrils’ natural curvature. Hook the tubing behind the patient’s ears and under his chin. Set the flow rate as ordered.
• If you’re inserting a nasal catheter, determine the length to insert by stretching one end of the catheter from the tip of the patient’s nose to his earlobe. Mark this spot. Then lubricate the catheter with sterile water or water-soluble lubricant and gently insert the catheter through the nostril into the nasopharynx to the pre-measured length. Use a flashlight and a tongue blade to check that the catheter is positioned correctly: It should be directly behind the uvula but not beyond it (misdirected airflow may cause gastric distention). If the catheter causes the patient to gag or choke, withdraw it slightly. Secure the catheter by taping it at the nose and cheek, and set the flow rate as ordered.
• When applying a mask, make sure the flow rate is at least 5 L/ minute. Lower flow rates won’t flush carbon dioxide from the mask. Place the mask over the patient’s nose, mouth, and chin and press the flexible metal strip so it fits the bridge of the patient’s nose. Use gauze padding to ensure comfort and proper fit.

To rebreathe or not to rebreathe?

Focus topic: Respiratory disorders

  • The partial rebreather mask has an attached reservoir bag that conserves the first portion of the patient’s exhalation and fills with 100% oxygen before the next breath. The mask delivers oxygen concentrations ranging from 40% at a flow rate of 8 L/minute to 60% at a flow rate of 15 L/minute and depends on the patient’s breathing pattern and rate. The nonrebreather mask also has a reservoir bag and can deliver oxygen concentrations ranging from 60% at a flow rate of 8 L/minute to 90% at a flow rate of 15 L/ minute. Set flow rates for these masks as ordered, but keep in mind that the reservoir bag should deflate only slightly during inspiration. If it deflates markedly or completely, increase the flow rate until only slight deflation occurs.
  • The Venturi mask, another alternative, delivers the most precise oxygen concentrations (to within 1% of the setting). When using this mask, make sure its air entrainment ports don’t become blocked or the patient’s FIO2 level could rise dangerously. Venturi masks are available with adapters that allow various oxygen concentrations ranging from 24% to 60%. Adjust oxygen flow to the rate indicated on the adapter.
  • If a transtracheal oxygen catheter will be used to deliver oxygen, the doctor will give the patient a local anesthetic before inserting this device into the patient’s trachea.

Monitoring and aftercare
After the oxygen delivery system is in place, take these steps:
• Periodically perform a cardiopulmonary assessment on the patient receiving any form of oxygen therapy.

Bed restless

Focus topic: Respiratory disorders

  • If the patient is on bed rest, change his position frequently to ensure adequate ventilation and circulation.
  • Provide good skin care to prevent irritation and breakdown caused by the tubing, prongs, or mask.
  • Humidify oxygen flow exceeding 3 L/minute to help prevent drying of mucous membranes. However, keep in mind that humidity isn’t added with Venturi masks because water can block the Venturi jets.
  • Assess for signs of hypoxia, including decreased level of consciousness (LOC), tachycardia, arrhythmias, diaphoresis, restlessness, altered blood pressure or respiratory rate, clammy skin, and cyanosis. If these occur, notify the practitioner, obtain a pulse oximetry reading, and check the oxygen delivery equipment to see if it’s malfunctioning. Be especially alert for changes in respiratory status when you change or discontinue oxygen therapy.
  • If your patient has COPD, monitor him closely. High oxygen levels may decrease respiratory drive in such patients, causing high carbon dioxide levels and respiratory depression.
  • If your patient is using a nonrebreather mask, periodically check the valves to see if they’re functioning properly. If the valves stick closed, the patient will reinhale carbon dioxide and not receive adequate oxygen. Replace the mask if necessary.

Oxygen high

Focus topic: Respiratory disorders

  • If the patient receives high oxygen concentrations (exceeding 50%) for more than 24 hours, ask about signs and symptoms of oxygen toxicity, such as dyspnea, dry cough, and burning, substernal chest pain. Atelectasis and pulmonary edema may also occur. Encourage coughing and deep breathing to help prevent atelectasis. Monitor ABG levels frequently and reduce oxygen concentrations as soon as ABG results indicate this is feasible.
  • se a low flow rate if your patient has chronic pulmonary disease. However, don’t use a simple face mask because low flow rates won’t flush carbon dioxide from the mask, and the patient will rebreathe carbon dioxide. Watch for alterations in LOC, heart rate, and respiratory rate, which may signal carbon dioxide narcosis or worsening hypoxemia.

Home care instructions
If the patient needs oxygen at home, the practitioner will order the flow rate, the number of hours per day to be used, and the conditions of use. Several types of delivery systems are available, including a tank, concentrator, and liquid oxygen system. Choose the system based on the patient’s needs and the system’s availability and cost. Make sure the patient can use the prescribed system safely and effectively. He’ll need regular follow-up care to evaluate his response to therapy.

Respiratory disorders

Respiratory disorders: Chest physiotherapy

Focus topic: Respiratory disorders

Chest physiotherapy is usually performed with other treatments, such as suctioning, incentive spirometry, and administration of such medications as small-volume nebulizer aerosol treatments and expectorants. Recent studies indicate that percussional vibration isn’t an effective treatment for most diseases; exceptions include cystic fibrosis and bronchiectasis. Improved breath sounds, increased PaO2, sputum production, and improved airflow suggest successful treatment.

Patient preparation
Before chest physiotherapy begins, take these steps:
• Administer pain medication before the treatment as ordered, and teach the patient to splint his incision.
• Auscultate the lungs to determine baseline status, and check the doctor’s order to determine which lung areas require treatment.
• Obtain pillows and a tilt board if necessary.
• Don’t schedule therapy immediately after a meal; wait 2 to 3 hours to reduce the risk of nausea and vomiting.
• Make sure the patient is adequately hydrated to promote secretion removal.
• If ordered, administer bronchodilator and mist therapies before the treatment.
• Provide tissues, an emesis basin, and a cup for sputum.
• Set up suction equipment if the patient doesn’t have an adequate cough to clear secretions.
• If he needs oxygen therapy or is borderline hypoxemic without it, provide adequate flow rates of oxygen during therapy.

Respiratory disorders

Monitoring and aftercare
After therapy, take these steps:
• Evaluate the patient’s tolerance for therapy and make adjustments as needed. Watch for fatigue and remember that the patient’s ability to cough and breathe deeply diminishes as he tires.
• Assess for difficulty expectorating secretions. Use suction if the patient has an ineffective cough or a diminished gag reflex.
• Provide oral hygiene after therapy; secretions may taste foul or have an unpleasant odor.
• Be aware that postural drainage positions can cause nausea, dizziness, dyspnea, and hypoxemia.

Home care instructions
The patient with chronic bronchitis, bronchiectasis, or cystic fibrosis may need chest physiotherapy at home. Teach him and his family the appropriate techniques and positions. Arrange for the patient to get a mechanical percussion and vibration device if necessary.

Respiratory disorders: Nursing diagnoses

Focus topic: Respiratory disorders

After completing your assessment, you’re ready to analyze the findings and select nursing diagnoses. Below you’ll find nursing diagnoses commonly used in patients with respiratory problems. For each diagnosis, you’ll also find nursing interventions along with rationales.

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Respiratory disorders: Ineffective breathing pattern

Focus topic: Respiratory disorders

Related to decreased energy or increased fatigue, Ineffective breathing pattern is commonly associated with such conditions as COPD and pulmonary embolus.

Expected outcomes
• Patient reports feeling comfortable when breathing.
• Patient achieves maximum lung expansion with adequate ventilation.
• Patient’s respiratory rate remains within 5 breaths/minute of baseline.
• Patient’s oxygen level remains within acceptable limits.

Nursing interventions and rationales
• Auscultate breath sounds at least every 4 hours to detect decreased or adventitious breath sounds.
• Assess adequacy of ventilation to detect early signs of respiratory compromise.
• Teach breathing techniques to help the patient improve ventilation.
• Teach relaxation techniques to help reduce the patient’s anxiety and enhance his feeling of self-control.
• Administer bronchodilators to help relieve bronchospasm and wheezing.
• Administer oxygen as ordered to help relieve hypoxemia and respiratory distress.

Respiratory disorders: Ineffective airway clearance

Focus topic: Respiratory disorders

Related to the presence of tracheobronchial secretions or obstruction, Ineffective airway clearance commonly accompanies such conditions as asthma, COPD, interstitial lung disease, cystic fibrosis, and pneumonia.

Expected outcomes
• Patient coughs effectively.
• Patient’s airway remains patent.
• Adventitious breath sounds are absent.

Nursing interventions and rationales
• Teach coughing techniques to promote chest expansion and ventilation, enhance clearance of secretions from airways, and involve the patient in his own care.
• Perform postural drainage, percussion, and vibration to promote secretion movement.
• Encourage fluids to ensure adequate hydration and liquefy secretions.
• Give expectorants and mucolytics as ordered to enhance airway clearance.
• Provide an artificial airway as needed to maintain airway patency.

Respiratory disorders: Impaired gas exchange

Focus topic: Respiratory disorders

Related to altered oxygen supply or oxygen-carrying capacity of the blood, Impaired gas exchange can occur with acute respiratory failure (ARF), COPD, pneumonia, pulmonary embolism, and other respiratory problems.

Expected outcomes
• Patient’s respiratory rate remains within 5 breaths/minute of baseline.
• Patient has normal breath sounds.
• Patient’s ABG levels return to baseline.

Nursing interventions and rationales
• Give antibiotics as ordered, and monitor their effectiveness in treating infection and improving alveolar expansion.
• Teach deep breathing and incentive spirometry to enhance lung expansion and ventilation.

• Monitor ABG values and notify the practitioner immediately if PaO2 drops or PaCO2 rises. If needed, start mechanical ventilation to improve ventilation.
• Provide CPAP or positive end-expiratory pressure (PEEP) as needed to improve the driving pressure of oxygen across the alveolocapillary membrane, enhance arterial blood oxygenation, and increase lung compliance.

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