Nursing Care for patients with Respiratory Dysfunction Nancy Finch May 22, 2003ReviewAnatomy of upper respiratory tractAnatomy of lower respiratory tractFunction of the respiratory system-- ventilation-- diffusion/perfusionAge changes pages 372-382Assessment Health HistoryChief complaint--reason for seeking healthcarecc…dyspnea, cough, hemoptysis, sputum production, pain, fatigue, weaknessAssess--respiratory signs/symptomsclubbing of the fingers, cyanosis, chest pain, cough,wheezing, dyspnea pages 382-393AssessmentRisk factors…smoking, family hx, personal hx, occupation, allergens/environmental pollutants, recreational exposurePsychosocial factors….-strategies used for coping-signs of anxiety, anger, withdrawal, isolation, noncompliance, denial-support sys…family, friends, communityPhysical ExamInspectionPalpationPercussionAuscultationAdventitious breath sounds…..crackles, wheezes, friction rubsDiagnostic Evaluationculturessputum studiespulmonary function test... PFTsarterial blood gas…. ABGspulse oximetryimaging…..CXR CT scansDiagnostic Evaluationfluoroscopic studies….ba swallow, angiolung scansbronchoscopythoracoscopythoracentesisbiopsy….pleural, lung, lymph nodespages 393-400Nursing management Pre/Post invasive procedureseducation…dec fear/anxietyNPO...6 hr before test (risk of aspiration re: cough reflex blocked)informed consentpre meds (atropine, sedation, opioids)conscious sedationpost--awake, alert, oriented, +cough reflex, +swallow, monitor resp status, vsNursing Interventions caring for pts resp dysfunctionFacilitate ventilationpromote removal of secretionsprovide supplemental O2decrease work of breathingeducate for self-careUpper airway infectionsCommon cold--nasal congestion, sore throat, coughrhinitis, pharyngitis, laryngitis, chest coldcontagiousrhinovirus---40% all coldsSx last 5 days---2 weeksTx symptomsUpper airway infectionsCold sores--- “herpes simplex virus”incubation period 2-12 daystransmitted by direct contactmay subside spontaneously 10-14 dysTx--Acyclovir (antiviral agent)Prevention URIIdentify strategies to prevent infectionhand washingavoid crowds/ individuals with known illnessflu vaccine, esp the elderlypractice good health habitsavoid allergensHome Care Teaching Checklist p. 403Upper airway infectionsAcute sinusitisaffects-- 32 million USSx--pressure, pain over sinus, purulent nasal secretionsTx- infection, shrink nasal mucosa, relieve painAmoxcillin, Bactrim DS, Septra DS, decongestantsnursing mng-- teach self-careChronic sinusitisSx persist for more than 8 weeks/adultetiology-- narrowing/obstruction of the sinuses that drain into the middle meatusblockage due to infect, allergy, structural abnormalityclinical--impaired mucociliary clearance, ventilation, cough, postnasal drip, chronic hoarseness, periorbital headaches,facial painfatigue, nasal stuffiness, decrease taste/smellMedical/Nsg managementTx--antimicrobial agents, Ceftin, Suprax, Biaxin, Cefzil, Zithromax, LorabidSurgery--correct structural deformities, excise/cauterize nasal polyps, I&D sinuses, correct deviated septum, remove tumorsNursing care--teach self-carepromote sinus drainage, increase humidity (steam bath, hot shower, facial sauna)inc fluid intake, compliance to medsAcute pharyngitisfebrile inflammation of the throatcaused by a virus---70%A streptococci = strep throatcomplications if not treated (otitis media, abscess, rheumatic fever, mastoiditis, nephritisclinical--fiery-red pharyngeal membrane/tonsils, lymphoid follicles swollen with exudate, enlarged tender cervical lymph nodes, fever, malaise, sore throatMedical/Nsg managementTx- antibiotics for at least 10 days, PCN, Erythromycin, cephalosporins, macrolidesanalgesics for pain, Tylenolantitussive meds with Codeine (Robitussin DM, Hycodan)Nursing care-- tx fever, rest, obs skin for rash, saline gargles, ice collar, compliance to meds, liquid/soft diet, oral fluidsChronic pharyngitisCommon in adults who work or live in dusty places, use the voice to excess, suffer from chronic cough, habitually use alcohol and tobaccoclinical--c/o of constant sense of irritation or fullness in the throat from mucus, dysphagiamedical mng--relieve sx, avoid exposure to irritants, correct resp conditions that may contribute to chronic coughTx--nasal spray, antihistamine decongestants, pain meds---ASA, TylenolNursing managementTeach--self-careprevent spread of infectionavoid contact with others until fever subsidesavoid alcohol, tobacco, second hand smoke, environment/occupational pollutants, cold exposure, wear face masks,fluids, saline gargle, lozenges, medsTonsilitis/adenoiditisTonsils--lymphatic tissue on either side of the oropharynx. site of acute infectionsAdenoids--abnormally large lymphoid tissue mass near center of nasopharynxClinical--sore throat, fever, snoring, dysphagia, mouth breathing, earaches, freq colds, bronchitis, bad breath, voice impairmentClinical--infect, nasal obstruction, mastoiditis, otitis mediaMedical managementTonsillectomy for recurrent infections, severe hypertrophy or peritonsillar abscess, obstruction endangering the airwayenlargement alone not an indicationusually T/A/adenoidectomy performed togetherantibiotics prior to surgery if infectedantibiotics for 7 days after surgery, PCN, amoxicillin, erythromycinNursing managementRisk of hemorrhage immediate post op/recoveryprone position with head to the sideobs for swallow reflex to returnice collar for comfortmonitor expectoration of mucus/bloodbright red bleeding/vomitus with bloodincreased pulse, temp, restlessnessreturn surgery--suture/ligation of bld vesselNursing managementPost op T/A--continuous observationice chips, water to drinkteach self-care--usually short hosp stay, make sure pt/family know s/s hemorrhage, usu hemm in the first 12-24 hours, notify MD of bleedingmonitor breathing/rest rate/airwaymonitor s/s infection, fevercompliance to meds, antibioticsNursing managementpain managementactivity/rest/sleepnutrition--liquid/semi-liquid diet, avoid spicy food, may restrict milk/productsoral hygiene--alkaline mouthwash, warm saline solutions to rinse mouthCare of the pt with upper airway infectionnursing process---assessment, nsg dx, plansnursing interventions--maintain patent airway--promote comfort--promote communication--encourage fluid intake--teach pt self-care—compliance, vaccine, avoid exposureprevention strategies--continuing care –home health referral, f/u primary care healthcare provider, MD, NPObstruction and trauma of
or
We will never post anything without your permission.
Don't have an account? Sign up