ABGsAbnormal Respiratory Assessment Findings Case Studies Diagnostic Tests Respiratory Modalities

Pulmonary assessmentWhat types of patients are at risk for pulmonary disease? What occupations & behaviors increase the risk of pulmonary disease? Weight, neck size and history of OSA?

CoughMost common symptom of respiratory dz Nonproductive cough: usually not a bacterial or viral problem White & clear sputum is usually not bacterial Mucoid and blood streaked = viral

SputumRusty, green or yellow: Bacterial Pink & Frothy: p. edema Bloody: Cancer, lung abscess, TB, p. embolus Large amounts of bloody clots: p. infarction

Chest PainHave patient stop any strenuous activity, sit down Place oxygen on the patient & assess the pain, take vs & O2 sat What would make you think it is pleuritic in nature?

PleurisyAbrupt onset at the site of inflammation Well localized Cutting, sharp pain Increases with cough, breathing & sneezing Splinting may decrease the pain

InspectionPeripheral cyanosis is unreliable: WHY? Vasoconstriction from the cold Dependent extremity Reduced blood flow Elevated hemoglobin levels

Peripheral cyanosis

Thoracic ConfigurationAbnormal chest configuration tells you: 1. Patient has other underlying health issues 2. Patient is at greater risk of developing pulmonary complications 3. Care with high levels of O2 in these patients!!

RespirationsA very sensitive indicator of patients condition Tachypnea: hypoxia, pain, anxiety, fear, fever, metabolic acidosis Bradypnea: drugs, respiratory center depression, metabolic alkalosis, loss of hypoxic drive in patients who are chronic CO2 retainers

RespirationsShallow: pain, ascites, pregnancy, abdominal distention, depressed respiratory center Deep: DKA, sleep, neurological disorders Irregular: metabolic or neurological disorders

DyspneaSOB Paroxysmal nocturnal dyspnea (PND) Orthopnea Are they SOB at rest, talking, walking or running?

Work Of Breathing (WOB)When does dyspnea occur (Running, rest)? What accessory muscles does the patient use? Abdominal Sternoclaidomastoids Intercostals Nasal flaring? Pursed lips?

Neck & TeethNeck size > 17 Top overbite = underdeveloped chin/mandible

Trachea MidlineOccurs in pleural effusion, atelectasis, pneumo/hemothorax Important to assess in ventilator, COPD and trauma patients & great vessels are shifting also

PalpationTactile fremitus: 99 vibration should be felt over entire chest but greatest in the major airways in pneumonia with airway obstruction/blockage

Pain & tendernessAssess when pt c/o CP, especially if it increases on inspiration Palpate gently May indicate rib fractures in trauma pts

CrepitusCrackling sensation that occurs when air enters the soft tissue of the chest Indicates subcutaneous emphysema Pneumothorax If patient has a chest tube, remove dressing to assure the tube is in the patient, re-dress and then mark with ink around the crepitus, alert md

Adventitious Lung SoundsCrackles inspiratory fluid filled alveoli Rhonchi continuous fluid in the larger airways- often clears with cough & suctioning Wheeze inspiratory +/or expiratory indicates bronchoconstriction Stridor - is a high pitched sound resulting from turbulent air flow in the upper airway.

StridorInspiratory: laryngeal problem Expiratory: lower airway problem Both I & E: tracheal problem Can be d/t: airway obstruction from epiglottitis, foreign body, or layngeal tumor Stridor is a 911 emergency! Tx with nebulized racemic adrenaline or nebulized Cocaine dexamethasone (Decadron) inhaled Heliox (70% helium, 30% oxygen)

AuscultationPleural friction rub: heard best on inspiration, have patient hold breath to r/o pericardial rub Diminished throughout: shallow respirations d/t pain, obesity, ascites, etc Absent breath sounds: pneumothorax, atelectasis, pleural effusion

Oxygen SaturationWhat is O2 saturation? Is it always reliable? What factors can affect it? Can a patient be 100% saturated and still be in trouble?

Pulse oximetryUsed to assess trends. nl > 92%, with anemia > 94% Does not replace ABGs Unreliable in vasoconstriction, anemia, polycythemia Will drop with hypotension

Oxygen SaturationDependent upon Hemoglobin levels Hgb = O2 Sat

Hgb =

O2 Sat

HIGH SATURATION DOES NOT MEAN WELL OXYGENATED !!!!!

Pulse OximetryYou must know your patients hemoglobin level to evaluate O2 sats !!!!! And the amount of O2 the patient is receiving

Arterial Blood GasesNormal ABGs: pH = 7.35 7.45 HCO3 = 22 26 PaCO2 = 35-45 PaO2 = 80-100

You MUST know the % O2 the patient is on to evaluate ABGs !!!!!

RespiratoryDetermined by PaCO2 levels (normal =3545) Hyperventilation ( RR) blows off CO2 thus lowering it (c/w respiratory alkalosis) Hypoventilation ( RR) causes CO2 to be retained, thus increasing CO2 levels (c/w respiratory acidosis)

MetabolicBicarb = HCO3 = the metabolic component (normal levels = 22-26) Too much HCO3 or too little acid is c/w metabolic alkalosis Too little HCO3 or too much acid is c/w metabolic acidosis

Acid-base ImbalancesUncompensated Partially Compensated Compensated

Uncompensated1. pH is abnormal 2. PaCO2 OR HCO3 abnormal Example: pH = 7.30, PaCO2 = 50, HCO3 = 26

Partially CompensatedpH, PaCO2 & HCO3 are all abnormal Example: pH = 7.34, PaCO2 = 48, HCO3 = 30

Compensated ABG1. pH is normal 2. CO2 & HCO3 are abnormal Example pH 7.35, PaCO2 = 33, HCO3 = 20

ROMEIf the problem is respiratory, the pH and PaCO2 will go in opposite directions of each other ie: Respiratory acidosis: pH = 7.29 PaCO2 = 58 Respiratory alkalosis: pH = 7.54 PaCO2 = 30

ROMEIf the problem is metabolic, the pH and HCO3 will go in the same (equal) direction ie Metabolic acidosis: pH = 7.31 HCO3 = 19 Metabolic alkalosis: pH = 7.51 HCO3 = 32

Case Study OneHistory of Present Illness: 31 y/o female presents with c/o n,v,abdominal pain. Began 9 pm last evening. No alleviating or aggravating factors She has not had her insulin in several days because she cant afford it.

Case Study OnePast Medical History: IDDM Past Surgical History: None Allergies: NKDA Current Medications: Lantus insulin

Case Study OneVital Signs: T = 96.6 P = 119 RR = 40, BP = 92/42

O2 Sat = 100% RA

Pain = 8/10

Case StudyFocused Assessment: Abdomen: Non-distended, soft with decreased BS x 4 Tender to palpation in the epigastric region and right upper quadrant without rigidity, rebound or guarding. No flank ecchymosis.

Case Study OneWhat is the following Acidbase imbalance?

pH PaCO2 PaO2 HCO3

6.91 29.2 140 31.8 13 97%

Why has it occurred?

Is it compensated, partially Hgb compensated or uncompensated?

O2 Sat on 28%

Case Study OneNa 131 * 6.8 * 98 5*

What is her anion Gap? How does it affect Treatment? What treatment do you expect her to receive?

K Cl CO2 Anion Gap BUN Cr Gl Ca PO4 Mg

22 * 1.4 * 546 * 7.8 * (Albumin 4. 9) 1.4 * 1.7 *

Anion GapNa (Cl + CO2) = Anion gap 131 (98 + 5) = 131 103 = 28 Anion gap is > 12

TreatmentIVF Insulin NaHCO3

What electrolyte imbalance is due to the acid-base imbalance?Acidosis increases serum ______

H+ inSerum

___ out CellSerum

Is she truly Hypocalcemic?Her albumin level is WNL, however: Acidosis increases ionized ______ and decreases serum ______.

H+ on

serum____ off & it

Albuminbecomes ionized _____

Hypocalcemic?When her acidosis is corrected, H+ will jump off the albumin and ionized calcium will jump on thus, H+ Ionized Ca

Albumin

Increasing serum _____.

HCO3 & CO2Venous CO2 represents the arterial HCO3

Clinically, the venous CO2 value has little direct use but when venous CO2 content is abnormal, it should alert the clinician to the need for obtaining arterial blood gas and pH values.

Other CausesCardiac Arrest Hypoperfusion Renal Failure Diarrhea Starvation

Compensatory MechanismsRapid respirations (Kussmals) Decreased PaCO2 Urine pH will decrease to < 6 Hyperkalemia & increased ionized Ca++

How quickly will O2 be released from Hgb molecule ?

O2 DissociationO2 will _____ off the hemoglobin molecule in times of need such as: Exercise Acidosis Increased CO2 Fever

Possible Nursing DiagnosesDecreased cardiac output Risk for impaired sensory/perception Risk for injury Risk for fluid volume deficit

Case Study 2A 64 year old male long flight from California to Ohio. complaining of sudden onset of chest pain and SOB extremely anxious and afraid he is going to die. also complaining of lightheadedness and numbness and tingling in his extremities.

Case Study 2T = 99.2, HR = 121, RR = 38, BP = 156/88 O2 Sat = 81%, pain = 7/10 Hgb = 17 Why is he anxious? Activity level?

pH PCO2 PO2 HCO3 O2 Sat

7.51 22 52 26 81% on NRM

Case Study 2What is the initial concern and treatment for a client with c/o CP and SOB? What is this clients Acid-base imbalance? Is it compensated, partially compenstated or uncompensated? What medical problem do you suspect?

Case Study 2Why is the client c/o numbness and tingling?

H+ ions Ca

Albumin

ionized

Case Study 2What other electrolyte problems may he have and why?

H+ out

Cell

__ in

Case Study 2

What treatment will this client require?

What other conditions can cause this acid-base imbalance?

Hemoglobin & O2 SatsWhat effect will his Hgb of 17 have on his O2 Saturations?

Cells =

% Saturated with O2

Possible Nursing DiagnosesImpaired sensory/perception related to neurological deficits Impaired thought processes related to altered cerebral functioning Ineffective breathing pattern related to hyperventilation Risk for injury related to weakness, tetany and seizures

Case Study 354 year old male 2 PPD smoker with sleep apnea Very anxious and SOB Paramedics insert an IV catheter, place the client on a 100% non-rebreather mask (NRM) Upon arrival to the ED, he is no longer anxious but appears sleepy.

Case Study 3T = 100.3, HR = 102, RR = 8, BP = 146/88 O2 Sat = 99%, pain = 0/10

pH pCO2 pO2 HCO3 Hgb O2Sat

7.31 92 131 32 17 99% on 100% NRM

Case Study 31. What is this clients acid-base imbalance and why did it occur? 2. How does a client with hypoxia act? Hypercapnia? 3. Why would pulse oximetry be of limited use in determining this clients problem? 4. What actions should be taken?

Case Study 3Vasodilation: warm flushed skin, H/A, HR, papilledema CO2 Narcosis: ALOC, drowsiness progressing to coma, seizures Acidosis: dysrhythmias, decreased CO BP,

Case Study 3What other conditions can cause this problem? COPD CNS depressants Chest wall abnormalities Pneumonia Atelectasis

Respiratory muscle weakness Underventilation

Possible Nursing DiagnosesIneffective breathing pattern: hypoventilation Impaired gas exchange: alveolar hypoventilation Impaired sensory perception: acid-base alterations Anxiety: breathlessness Risk for injury: ALOC Risk for decreased cardiac output: dysrhythmias

Case Study 4Mrs. C undergoes an open cholecystectomy NGT to low wall suction with large amounts of drainage.pH pCO2 pO2 HCO3 Hgb O2Sat 7.51 46 96 35 9* 99% on RA

Case Study 4What is her acid-base imbalance and why has it occurred? What other electrolyte imbalance does she probably have and how will this imbalance contribute to her problem? What type of fluid should the nurse flush an NGT to LWS and why? What is the best treatment to increase this clients peristalsis?

DiffusionH2O K+Stomach

K+

AnemiaFalsely increases O2 saturations Look for s/s hypoxia as O2 sats are unreliable in anemia & polycythemia: restlessness confusion dysrhythmias

Other causesVomiting Diuretic therapy Hypokalemia Licorice Excessive antacids or mineralocorticoids (ie. aldosterone)

Clinical ManifestationsCompensatory: RR & urine pH > 6

CNS: Muscle cramps, hyperreflexia, tetany, paresthesias, seizures GI: anorexia, nausea, vomiting, paralytic ileus

Nursing DiagnosesDeficient fluid volume: GI loss Decreased CO: FVD & altered conduction d/t hypokalemia & alkalosis Knowledge deficit: potassium-wasting diuretics & antacids Risk for impaired gas exchange: hypoventilation Risk for injury: FVD

QuestionsInterventions to correct respiratory acidosis would first include: 1. 2. 3. 4. Administering morphine sulfate IVP Giving sodium bicarbonate IV push Increasing supplemental O2 levels Correcting the cause of hypoventilation

QuestionWhich of the following can cause a respiratory alkalosis? 1. 2. 3. 4. Oversedation Heart rate < 60 bpm Intractable pain High PaO2

QuestionWhich of the following ABG findings indicate the presence of acute uncompensated respiratory acidosis? 1. 2. 3. 4. PCO2 increased, HCO3 normal PCO2 decreased, HCO3 normal PCO2 increased, HCO3 increased PCO2 decreased, HCO3 decreased

QuestionWhich of the following ABG findings is most consistent with a metabolic acidosis? 1. 2. 3. 4. Increased PCO2 Decreased PCO2 Increased HCO3 Decreased HCO3

QuestionABGs on a client with pneumonia indicate the client is in respiratory acidosis. In order to best improve this acid-base imbalance, the nurse implements which of the following interventions? Select all that apply.

Answers1. Restrict oral fluid intake to H2O only 2. Ambulate client in the hall twice a shift 3. Assist the client to cough & deep breathe 4. Give a non-opiate pain med prn for intercostal muscle pain 5. Give Magnesium rider IVPB

CXRUsed to determine lung pathology & line placement to r/o pneumothorax Portable CXR can be done in emergency conditions, pts with Chest tubes, etcFor excellent tutorials on diagnostic tests: http://www.nlm.nih.gov/medlineplus/tutorials/

Normal CXR

Acute MVR

Right pneumo

CHF Pretx

RML Pneumonia

Lg Right Pleural effusion

Right Hemothorax

ARDS

CT Chest: w/wo contrast

CT ScansNPO 4 hours prior if possible* Assess Patients ability to cooperate & lie flat for the procedure May require IV contrast Be alert to allergies & pts with HTN & DM

Bronchoscopy: Tumor

Pre-procedureObtain signed consent Postural drainage Sedation if ordered

Patient TeachingPre-procedure:NPO 6-12 hr Hold anticoagulants, anti-plt meds* Alert MD to any allergies, pregnancy

Procedure:Local anesthetic & sedation Slow, deep breaths Make high pitched sounds to pass larynx Takes 30-60 minutes Bx

Patient TeachingPost-procedure:Someone else drives home Rest the remainder of the day Lozenges & warm salt water for soreness Drink H2O first & carefully

Call MD if:SOB T > 100.4 x 24 hr > 2 Tbsp blood

ComplicationsAspiration: Check gag reflex PTA any foods or liquids Bleeding Infection Bronchial perforation Bronchospasm (Ambu) or laryngospasm (Solumedrol) Pneumothorax - air becomes trapped in the pleural space causing the lung to collapse

Post-bronchoscopy Nursing ActionsInstruct the client NOT to swallow oral secretions Save expectorated sputum and observe for frank bleeding NPO until gag reflex returns Observe for subcutaneous emphysema & dyspnea Apply ice collar to reduce throat discomfort

Angiography: Pulmonary Embolus

Pulmonary Function Studies

Thoracentesis

Pre-procedure ActionsObtain signed consent PT, PTT & CXR Position in high-fowlers or sitting up on the edge of the bed with feet supported on a chair. Lean over table If unable to sit up, turn on the unaffected side

ComplicationsBleeding (vitals, ck site) Infection Pneumothorax (Ck BBS, CXR)

Post ThoracentesisObtain VS & auscultate BBS Evaluate for signs of shock, especially if > 1 liter of fluid removed Assess for pain, cyanosis, increased RR & WOB, pallor Obtain PCXR Note color, characteristics and amount of fluid removed, patient tolerance and post procedure condition & record

Respiratory TreatmentsPulmonary Medications & Oxygen

Pulmonary MedicationsBronchodilators Relieves bronchospasm Increases HR & CO Increases O2 demand Diuretic effect SE: Nervousness, anxiety, arrhythmias Hold if severely tachycardic

Evaluating the effectiveness of bronchodilatorsRR, WOB, wheezing, restlessness

Improved ABGs

BBS

Diuretics: LasixDecreases edema in CHF, renal failure, P. edema Decreases preload ( CVP) Decreases BP SE: Hypokalemia, metabolic alkalosis, BP, Polycythemia, DVT, thirst, tachycardia, hyperglycemia, increased BUN

LasixUsually 10-40 mg but can be much higher Comes supplied 40 mg in 4 mL or 100 mg in 10 mL Administer slowly to avoid ototoxicity How many mLs will you draw up to administer 20 mg?

Evaluating the effectiveness of diuretic therapyHR, RR, BP, CVP, PAP, PCWP, edema, JVD, crackles, SOB, WOB No further S3 UOP, O2 Saturation, PaO2 Make sure you know how to calculate I & Os, change weights to mLs or Liters 1 kilogram = 1 liter 1 lb = approximately 500 mL

Nursing PrecautionsALWAYS obtain BP & K before giving Hold if SBP < 100, (CVP 2.0 is toxic Increased risk of toxicity with hypokalemia S/S toxicity = Brady-tachy syndrome, green halos, nausea & vomiting

DigoxinGiven loading dose IV initially (0.5 mg) Later 0.125 0.25 mg Supplied 0.5 mg in 2 mL Calculate how many mLs will you give if you need to administer 0.125 mg

QuestionWhy do you need to take an apical heart rate when administering digoxin OR when the heart rate is irregular? What will you do if the patients K+ level is < 3.5 or < 4.0 with lasix administration?

QuestionWhat if a patient has order for lasix but does not have an order for potassium? Renal function is WNL Labs: Day 1 Day 2 Today K = 5.4 K = 4.8 K = 3.7

Steroids: Solucortef/SolumedrolGiven to reduce inflammation Glucose, Na & H2O retention, risk of GI bleeding Causes immunosuppression ( WBC counts & fever are not always seen with infection) You need to look for other s/s of infection) Must be weaned to prevent Adrenal Insufficiency

SteroidsAvailable in different strengths 125 mg in 2 mL Need to administer 90 mg. How many mLs will you administer?

Nursing PrecautionsMonitor glucose levels Hemoccult stools/gastric secretions Daily weights Observe for s/s infection Anti-ulcer medication

Vasodilator therapyNitroglycerin or Ace Inhibitors (pril) NTG decreases preload > afterload Tx: ACS & CHF Work of

Ace inhibitors decrease afterload by causing arterial dilation thus increases CO decreasing pulmonary congestion and LVHF

Nursing PrecautionsObtain BP prior to administering Standard of Practice is to hold meds that decrease BP if the SBP is < 100 You will need a physicians order to administer these medications if the SBP is < 100 mmHg

AntibioticsOften given board-spectrum ATB until organism is identified or infection is r/o At risk for infection d/t: steroids, decreased immune response, debilitated health & cross contamination from health care providers

Obtain cultures first if possible & note allergies Monitor serum drug levels if appropriate (Call MD if < or > than therapeutic PTA)

Gram Stain will tell if organism is + or -

Gram + vs Gram -

C & S: MRSA Vancomycin = S

OxygenIs considered a drug Anything > 4 L/m via NC should be humidified >60 % O2 over 36 hours or 100% over 24 hours can result in O2 toxicity Can result in Acute Respiratory Distress Syndrome (ARDS)

Nursing PrecautionsGive the lowest amount of O2 necessary to maintain a normal PaO2 or O2 Sat S/S O2 toxicity: tickling in the throat, cough, burning of the trachea/bronchus (early) DOE, n, v, h/a (late) Monitor for improvement or tolerance to weaning

WeaningDescribes the process of allowing the patient to breath with less oxygen Greater success with weaning if well nourished and has normal PO4 levels

WeaningShould begin in early hours of the day Explain procedure to patient Sit them up in bed Monitor patient closely for signs of intolerance to weaning

Readiness CriteriaHemodynamically stable SaO2 > 92% on 40% FiO2 or less CXR, ABGs, lytes WNL for patient Hematocrit > 25%

Stop weaning & obtain ABGs if:RR > 35 bpm, HR > 20% higher than baseline, SBP > 180 mmHg or < 90 mmHg SaO2 < 90% (higher if anemic) Rapid, shallow respirations, increased use of accessory muscles, nasal flarring Labored breathing, anxiety, restlessness, diaphoresis, arrhythmias

Rule of ThumbIf a client becomes unstable after you have adjusted something.. Return the client to the last settings where they were stable.

Oxygen TherapyNasal cannula (NC) Venimask (VM) Partial Nonrebreather (PNRM) Nonrebreather (NRM) BiPAP & CPAP Endotracheal tube (ETT) Tracheostomy tube (Trach) Trach collar (TC)

Nasal Cannula (NC) Estimation of FIO2can be made by the formula (Liter Flow x 4)+20= FIO2 Effective Simple Delivers 24-44% at 4-6 liters/min Difficult to keep In place unless Pt is very Cooperative Requires humidification If > 4 L/m

Venturi Mask (VM)Effective 24-40 % O2 Masks & nasal cannulas can cause skin breakdown

Face MaskDelivers 35-60% About 1/3 of exhaled air is rebreathed Reservoir contains mostly O2 from previous inhalation

Non-rebreathing MaskHas 1 way valve prevents client from exhaling back into bag Delivers 100% O2 at flow rate of 10-12 L/min

Noninvasive Positive-Pressure VentilationNPPV Can use nasal or full face Improves alveolar ventilation Decreases WOB Preserves the ability to swallow speak & cough normally

Bi-pap vs C-PAP

BiPAP vs CPAPBi-level positive airway pressure: delivers a higher pressure on inspiration than exhalation. Can be used to ventilate pt Continuous positive airway pressure: delivers the same pressure during inspiration & expiration which helps re-expand and stabilize the alveoli. The pt must have spontaneous respirations.

Swallow Precautionsa. oral motor weakness/facial droop/decreased sensation b. food/liquid leaking from mouth, inability to control oral secretions or pocketing of food c. dysarthria (slurred speech), wet" vocal quality (gurgle) or coughing or choking during fluid intake or during meals d. feeding tube e. history of aspiration pneumonia or of dysphagia f. decrease LOC or recent anesthetic

Airway MaintenanceNever give anything by mouth to a person who has ALOC or questionable swallow reflex Anyone with the potential for dysphagia should have suction set up at the bedside Unless contra-indicated elevate the HOB

Airway MaintenanceCheck residuals for tube feedings and hold per policy Maintain peristalsis Obtain swallow study when needed

Airway MaintenanceOral Airway Use in unconscious patients only 1. Use tongue blade to depress tongue and insert directly into mouth 2. Position curved end toward the roof of the mouth and rotate 180 degrees

Suctioning Equipment

Airway Maintenance: SuctioningHyper- oxygenate with 100% O2 for 2 to prevent hypoxia Insert catheter as far as possible without applying suction Apply intermittent suction while withdrawing & rotating catheter over less than 10 seconds

WarningAlways observe heart monitor when suctioning for: Arrhythmias: PVCs (hypoxia) Bradycardia (vagal stimulation) O2 saturation Stop suctioning and give 100% O2, if prolonged then treat with DOC

Other Nursing InterventionsMouth care Q 1-2 hours in NPO patients & q shift in others: Pneumonia Empty H2O from oxygen tubing: Pseudomonas Pneumonia Remember pulmonary hygiene, force fluids* & early/frequent ambulation

Postural Drainage Positions:Lower lobes: anterior basal segment

Postural Drainage Positions:Lower lobes: superior segments

Postural Drainage Positions:Lower lobes: lateral basal segment

Postural Drainage Positions:Upper lobes: anterior segment

Postural Drainage Positions:Upper lobes: posterior segments

Postural Drainage Positions:Upper lobes: apical segment

Percussion and Vibration

High-Frequency Chest Wall Oscillation Vest

Chest (Thorocotomy) TubesUsed to restore negative intrathoracic pressure or to remove drainage Anterior CT: remove air and are inserted at the 2nd ICS, MCL Posterior CT: remove fluid and are inserted in the 5th or 6th ICS, mid axilla

Chest tubes: ComponentsCollection receptacle Water seal Suction Air leaks in the system will show up as bubbling in the water seal chamber

InsertionCheck PT, PTT, Plts Explain procedure Gather equipment Informed consent & pain med* Place in semi or high fowlers Support patient emotionally Once MD inserts tube, hold connecting tubing & tape connections and to floor Connect to suction if required, Assist with dressing PCXR, resp assessment Tape connections and tape to floor

DocumentCardio-pulmonary assessments before & after CT insertion CT size & insertion site, amount of suction* Drainage, amount, color Tolerance & meds given Results of CXR

Nursing ReportInformation you want to give to the oncoming nurse: 1. Left or right, anterior or posterior 2. H2O seal vs suction, how much? 3. Drainage, amount, color, or 4. Air leak? How much? Is MD aware? 5. Respiratory assessment, CXR

Assessments Q 4 hours& lungs Insertion site for crepitus/infection/oscillation in tubing with breathing, cough Dressing c/d/I, amount of suction, air leaks No dependent loops or occlusions Color, character & amount of drainage

DressingDressing should be dry and intact If crepitus is present, mark with pen around crepitus then remove dressing and check to see if any of the drainage eyelets have been pulled out of the pleural space. If no eyelets are visible redress & call MD If eyelets, call MD for repositioning of tube

Nursing CareMaintain sterile water, 4x4s, tape, occlusive dressing & clamps at bedside CDB q 2 hours Pain meds & splinting Turn q 2 hours ROM to affected arm & shoulder q 4 hrs (Frozen shoulder)

Technique for Supporting Incision While a Patient Coughs

Arm and Shoulder Exercises

I&ORecord q shift* (Q 1 hr post op) mark on the pleuravac the time Notify MD if excessive output Position affects drainage, dont be surprised if there is an increase in drainage when the patient sits up the first time (Posterior tubes)

Sudden cessation of drainage, or lack of movement of fluid = Clots postoperativelyCan cause tension pneumothorax (thoracotomy tube) or cardiac tampanode (mediastinal tube) Reposition the patient If you can see the clot, straighten & raise the tubing to facilitate drainage Milk the tube gently to remove the clot Stripping the tube = increase intra-thoracic pressure and should be done ONLY if blood clotting is leading to pleural/cardiac tampanode. It requires and MD order

Bubbling = Air LeakCheck all connections Clamp BRIEFLY starting at the patient: if bubbling stops, the pleural space is leaking air or there is a leak at the insertion site: this bubbling is usually intermittent, varying with respirations Should resolve as lung expands Reinforce dressing, if still bubbling, call MD

Bubbling = air leakConstant bubbling = air leak in the system Check all connections Disconnect from suction Use padded hemostats to check the system

Padded HemostatsIf bubbling persists, clamp briefly along the tubing starting at the patient and working your way to the water seal Bubbling will stop when you clamp between the air leak and water seal If you still cant find the leak change the chest drainage unit (CDU)

Other problemsCDU is knocked over: clamp briefly and change the CDU CT is pulled out: Cover with dry, sterile dressing If you hear air leaking, tape on 3 sides only Have someone else call MD stat & get equipment to insert new CT Watch for tension pneumothorax

Other problemsCT becomes disconnected from the CDU: Submerge the CT in 1 inch of sterile NaCL or H2O in a sterile container until a new CDU can be set up There should be a bottle of sterile water, 4 x 4s, tape and padded hemostats in any room with a CT tube

The only time you clampTo assess for leaks Stimulate chest tube removal To change out the CDU Connect or disconnect an in-line autotransfusion bag Only briefly !!! Prolonged clamping can lead to tension pneumothorax

PrecautionsAssure there are no kinks or dependent loops in tubing Never raise the CDU over the chest level of the patient Order daily PORTABLE CXR

PrecautionsStop suction QS to assess fluid level in the water seal chamber. Add sterile H2O if necessary Medicate for pain prior to discontinuing CT Observe tolerance to removal of suction, discontinuation of CT

Criteria for CT removalOne day after cessation of air leak Drainage of less than 50-100 mL day 1-3 days post Cardiac surgery 2-6 days post pulmonary surgery Obliteration of empyema cavity Serosanguineous drainage around the CT insertion site

Incentive Spirometry

Incentive SpirometryExhale slowly Place mouthpiece between teeth and close the lips Take in a slow deep breath and hold for 5 seconds Remove spirometer and exhale Relax for a while Perform 10 times per hour while awake