RESPIRATORY NOTES II

Thoracentesis

-needle is inserted in chest wall into the pleural space to obtain specimen for diagnostic purposes, removal of accumulated fluid or air & instill medication into pleural space (instructed to roll about to have the medication coat the entire pleural space

Nursing care:-informed consent -do not cough/speak during procedure

-position: side of the bed with upper torso supported on overhead table

-post-procedure: -apply pressure to the site

-watch out for pneumothorax, shock, respiratory arrest, leakage of air from pleural cavity=SQ EMPHYSEMA

Bronchoscopy

-insertion of a fiberscope into bronchi for diagnosis, biopsy & removal of foreign body

-uses local anesthetic spray to minimize gagging while inserting the bronchoscope

Nursing Care:-informed consent -position: supine with head hyper-extended

-NPO for 6-12 hours prior to procedure -NO dentures; maintain good oral hygiene

Post-Procedure:-position: side or semi fowler's

-NPO till gag returns then start with ice chips àsips of wateràsoft dietàregular

-ice bags to throat -minimize talking, coughing, laughing

-warm saline gargles -assess for respiratory distress

Mechanical Ventilation

-ventilation by mechanical means in a person unable to maintain normal levels of oxygen & CO2, eq.

-COPD -thoracic trauma -ARDS -neuromuscular diseases

Indications: a. inadequate ventilation b. hypoxemia

Types:

a. Positive Pressure-Cycled

-push air into the lungs until a predetermined PRESSURE is reached in the tracheo- bronchial tree

b. Volume-Cycled-deliver air into lungs till a predetermined TIDAL VOLUME is reached till termination

c. Time-Cycled-delivers air into lungs till a predetermined PRESET TIME reached & inspiration is terminated

Modes:

a. Assist/Control Mode-client's inspiratory effort triggers ventilation

b. Intermittent Mandatory Ventilation-client breath at own rate & IMV delivered under positive pressure

-popular in weaning client mechanical ventilator

c. Positive-End Expiratory Pressure -delivers positive pressure at the end of expiration

-helps keep alveoli open enlarging the surface area for oxygenation

d. Continuous Positive Airway Pressure-done on adults on T-piece, same as PEEP

Nursing Care:

-monitor for barotraumas

-assess ventilator setting every 3-4 hours

-assess breath sounds every 2 hours

-physical exam every shift

-WOF: GI problems such as stress ulcers

ALARMS:

a. High-Pressure Alarms -->OBSTRUCTION

-client biting on the tube -ventilator tubing is kinked

-bronchospasm -mucus plug-->suction

-there is water in tubing -px is breathing against an incoming

mechanical breath

b.Low-Pressure Alarms-->LEAK

-disconnected tubing -there is cuff leak

c.Minute Ventilation Alarms-something wrong with RR

d.Oxygen Alarms-oxygen amount

Chest Tubes/Water Seal Drainage

"Closed Chest Drainage"

-insertion of catheter into intrapleural space to maintain constant (-) pressure when air or fluid has accumulated

Purpose:

a. foster & permit drainage of air & serosanguinous fluid from pleural space

b. help re-expand remaining lung tissue by re-establishing normal negative pressure

c. prevent mediastinal shift & lung collapse

DRAINAGE SYSTEM

A.ONE-BOTTE SYSTEM

-serves as both collection chamber & water seal

-USE: Empyema

B.TWO-BOTTLE SYSTEM

-drainage collection

-water seal

-USE: after a thoracic surgery, pneumothorax

C.3-BOTTLE SYSTEM

-drainage collection chamber

-water seal

-suction control bottle

-USE: after a thoracic surgery, pneumothorax

D.COMMERCIAL UNITS

*PLEUR-EVAC-most popular

-lightweight & disposable

-function like 3 pay bottle

Principles Used:

GRAVITY

-fluid and air flow from higher level to lower level

-->keep below level of client's chest

WATER SEAL

-water acts as a seal; provides barrier between atmospheric air & subatmospheric intrapleural pressure

-must be AIRTIGHT

-leak can go back into the pleural space=(+) pressure

-must have AIRVENT

-provides escape route for air, prevent builds up in water seal chamber

SUCTION

-applied if air leaking in the pleural space is faster than it can be removed by water seal apparatus

-speeds up removal of air from pleural space

Nursing Care:

a.drainage should be lower than the chest

b.examine the entire system for air tightness & absence of obstruction

c.measure & document amount & character of drainage coming out; during first 24 hours-->500- 1000 ml is expected, excessive needs further evaluation

d.note for oscillation/fluctuations/ tidalling of fluid level within the water seal tube

-->means that system is patent & functioning properly

-->IF IT STOP!!>obstruction or re-expanded lungs

e.observe for INTERMITTENT BUBBLING ---normal in water seal

f. assess suction apparatus : normal=CONTINOUOS BUBBLING

g. have the ff at BEDSIDE

-rubber-shod clamps

-vaselinized gauze

-extra bottle with sterile water

h. make sure a chest XRay is requested to assess proper placement

i. maintain dry, sterile, occlusive dressing

j. WOF:respiratory distress from air or fluid accumulation