RESPIRATORY PROCEDURESI. ARTERIAL BLOOD GAS (ABG)

Purposeso detect acid-base balanceo assess ventilation o monitor client’s response to O2

treatment Allen’s Test

o If ABG is to be monitored to assess circulation of ulnar (hand) blood supply

Radial Arteryo common site to withdraw arterial blood

specimen Nursing Alert!

o Avoid suctioning client prior drawing blood specimen

Nursing Care o Assess site for bleeding or hematomao Apply firm pressure for 5 – 10 minuteso 10 ml pre-heparanized syringe to

prevent clotting of specimen o Place specimen on ice to prevent

hemolysis of specimeno Client with diarrhea – observe

metabolic acidosiso Client with vomiting – observe

metabolic alkalosisABG Component Normal Values

pH 7.35 – 7.45pCO 35 – 45 mmHgHCO 22 – 26 mEq/L

O2 Sat >90%PO2 >60 mmHg

II. BRONCHOSCOPY Purpose

o direct inspection of larynx, trachea, and bronchi using lighted bronchoscope

Diagnostic Useso collect secretionso determine location of pathology and

collect specimen for biopsy Therapeutic Uses

o remove aspirated foreign objectso excise lesions

Pre-op Interventionso Verify Informed Consento NPO– to prevent vomiting and aspirationo Atropine Sulfate to decrease secretionso Valium to relieve anxiety o Position: Supine w/ hyper extended neck

Post – Op Interventionso NPO o Position: Side-lying (to promote drainage

from mouth) or Semi-Fowlero Check return of cough and gag reflex o Prepare suction equipment @ bedsideo Notify Physician if fever or DOB occurs

after procedure

III. CHEST – XRAY (CXR) Radiographic exam of lungs Non – invasive, minimal radiation Purpose

o detect abnormalities of thoracic organs Nursing Care

o Rule out pregnancy firsto Instruct to remove metals (jewelries)o Instruct client to hold breath and do

deep breathing

IV. FLUORSOCOPY Purpose: test for lung and chest in motion

V. MANTOUX TEST / SKIN TEST (PPD – PURIFIED PROTEIN DERIVATIVE) Purpose

o determine exposure to MYCOBACTERIUM TUBERCULOSIS

ID injection – inner aspect of lower arm 4 inches below antecubital space

Positive Resultso 10mm or more for children <4 y/oo 5mm or more

– client with HIV positive– client with healed TB– had contact with a client with

active TB Nursing Care

o BCG vaccine may cause FALSE (+) resulto Result is read after 48 – 72 hours o Assess client if with history of TB and

report history to Physician

VI. SPUTUM EXAM Purposes

o Gross Appearanceo Sputum C & S – to detect actual microbes

causing infection; collected prior 1st dose of antimicrobial

o AFB staining – collected 3 consecutive mornings; assist in dx of TB

o Cytologic Exam / Papanicolaou exam – to detect CA cells

Nursing Careo Early morning sputum specimen

(expectoration or suctioned)o Rinse mouth with plain water. o Use sterile containero Instruct client to take several deep

breaths then cough deeply

VII. PULSE OXIMETER Purposes

o Non – invasive procedureo determines amount of oxyhemoglobin

saturation of arterial bloodo also measures Pulse Rate

Indications

o Patients receiving O2 therapy or home oxygen therapy

o Risk for hypoxiao Post operativeo Unstable patient who may experience

sudden changes in blood 02 levels Nursing Alerts

o This does not replace ABG Probe or sensor is attached to:

o fingertipo foot of infantso earlobeo bridge of nose

SpO2 Resultso Normal: 95% - 100% o If <85% - tissues not receiving enough

o2 Results unreliable in

o Cardiac arresto Shocko Severe Anemiao High Carbon Monoxide levelo Use of dyes or vasoconstrictors

VIII. LUNG SCAN Purpose

o to determine lung perfusion when pulmonary embolism and infarction are suspected

Nursing Alerto Verify consento Involves injection of radioactive

isotope, scans taken via scintillation camera

Nursing Careo Assess for allergies to dye, iodine, and

sea food.o Remove jewelries from chest areao Administer sedatives as prescribedo Wear clean gloves when urine is being

discarded within 24h after procedure.

IX. LUNG BIOPSY Purposes: to detect CA cells

o Transbronchoscopic biopsy – done during bronchoscopy

o Percutaneous needle biopsyo Open lung biopsy

Pre-op Nursing Careo NPOo Verify consent

Post-op Nursing Careo Observe signs of pneumothorax, air

embolism and RDSo check for hemoptysis and hemorrhageo check site for bleeding

X. LYMPH NODE BIOPSY Purpose: to assess metastasis of lung CA

XI. PULMONARY FUNCTION TEST Non – invasive test Document bronchodilators or narcotics used

prior test Purpose: To measure lung volume and airflow Tidal Volume – volume of air inhaled and

exhaled – 500ml Inspiratory Reserve Volume (IRV) – max

volume inhaled Expiratory Reserve Volume (ERV) – max

volume exhaled Residual Volume – volume of air remains in

lungs after forceful exhalation, 1200ml Vital Capacity – IRV + ERV + TV; maximum

volume of air that can be exhaled after maximum inhalation

Functional Residual Capacity – ERV + RV

XII. THORACENTESIS Purposes

o To aspirate pleural fluid and/or air from pleural space

Preop Nursing Careo Verify consent o Position: Sitting on the side of bed with feet

on chair, leaning over a bedside table o Note that no > 1200 ml of fluid should be

removed at a time o Avoid to cough, breathe deeply, or move

during procedure Postop Nursing Care

o Apply pressure to puncture site to prevent bleeding

o Position: SEMI-FOWLER or ensure PUNCTURE SITE IS UP (LIE ON UNAFFACTED SIDE)- to prevent leakage of fluid in thoracic cavity

o Bed Rest until V/S stable to prevent orthostatic hypotension

o Check for complications and notify physician– expectoration of blood –

indicates trauma– hypotension – indicates

hypovolemic shock– shock– pneumothorax– respiratory arrest– subcutaneous emphysema

CHEST TUBES (CLOSED CHEST DRAINAGE) / CTT / THORACOTOMY TUBE Purposes

o to remove air and/or fluids from pleural space

o to restore negative pressure within thoracic cavity and reexpand lungs

Nursing Alerto Anterior chest tube – to drain airo Posterior chest tube – to drain fluids

One – Way Bottle System serves as drainage bottle and water –seal

bottle immerse tip of tube in 2-3cm NSS to create

water – seal keep bottle 2 – 3 ft below chest level to allow

drainage from pleura by gravity never raise bottle above chest level to prevent

reflux of air or fluid Assess patency of device

o observe fluctuation of fluid along tube o observe intermittent bubbling of fluid o If continuous, rapid bubbling verify

presence of air leak in the system – TAPE THE LEAK!

Absence of fluctuation o Check obstruction of deviceo Check for Kinks along tubingo Milk tubing towards bottle o Auscultate breath soundso If no obstruction, Notify Physician, lung

may have reexpand – validated by CXR

TWO-WAY BOTTLE SYSTEM Not connected to suction apparatus

o 1st bottle – drainage bottleo 2nd bottle – water – seal bottleo check fluctuation and intermittent

bubbling Connected to suction apparatus

o 1st bottle – drainage and water-seal bottle

o 2nd bottle – suction control bottleo N: intermittent fluctuation and bubbling

in water – seal bottleo N: expect continuous bubbling in suction

control bottle * If absent bubbling, adjust the amount of suction control bottle within prescribed level until gentle, continuous bubbling occur

o Immerse tip of tube in 1st bottle in 2-3cm of NSS

o Immerse tip of tube of suction control bottle in 15-20cm NSS to stabilize pressure in lungs and prevent trauma in pleura

THREE-WAY BOTTLE SYSTEM 1ST bottle – drainage bottle 2nd bottle – water seal bottle; check

intermittent fluctuation and bubbling 3rd bottle – suction control bottle; check

continuous bubblingo excessive suction pressure results in

excessive bubblingo a pressure of 15-20cm of NSS is used to

ensure suction is adequate

Note: Broken bottle / Broken drainage system

o clamp end part of tube ORo insert tubing into sterile h20 until bottle

can be replaced Chest tube accidentally removed by client

o If in client’s room – apply VASELINIZED GAUZE

o If outside client’s room – apply cleanest material available to prevent entry of air in lungs

Encourage client deep breathing, coughing exercises, and ambulation to promote drainage (if tolerated and depending on condition)

ROM of exercises of arms Always mark the amount of drainage at

regular intervals Avoid frequent milking and clamping of tube

to prevent tension pneumothorax Removal of tube done by Physician

* Semi-fowler’s* CXR done after tube is removed* assess complications: emphysema and RD