Learning Objectives
1. State the rationale for the use of each of the following: sputum, lavage, throat culture, ABG, CXR, lung scan, lung perfusion scan, pulmonary angiography, PFT, and skin testing.
2. Demonstrate the positions of postural drainage.
3. Differentiate the following: thoracentesis, paracentesis, and thoracotomy.
4. Identify four nursing considerations related to closed water-seal chest drainage.
5. Identify five alterations in normal respiratory status.
6. Identify ten interventions that can assist the client who is in respiratory distress.
7. Differentiate the following infectious respiratory disorders: acute rhinitis, streptococcal throat infection, influenza, laryngitis, bronchitis, lung abscesses, pneumonia, pleurisy, histoplasmosis, tuberculosis, and empyema.
8. Compare and contrast the following chronic obstructive pulmonary diseases: asthma, bronchiectasis, chronic bronchitis, and emphysema.
9. Identify three nursing considerations for a client with ARDS.
10. State three common sources of trauma to the lungs, along with three nursing considerations for each.
11. Differentiate benign from malignant lung disorders.
12. Identify three common inflammatory disorders and four structural disorders of the nose.
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IMPORTANT TERMINOLOGY |
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anergic |
histoplasmosis |
pulmonary emphysema |
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asphyxiation |
hyperventilation |
rhinitis |
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asthma |
incentive spirometer |
rhinoplasty |
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atelectasis |
laryngectomy |
sinusitis |
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bronchiectasis |
lobectomy |
strangulation |
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bronchitis |
paracentesis |
suffocation |
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bronchoscopy |
pleurisy |
thoracentesis |
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empyema |
pneumonectomy |
thoracotomy |
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epistaxis |
pneumonia |
tracheostomy |
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eupnea |
pneumothorax |
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hemothorax |
postural drainage |
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Acronyms |
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ABG |
CT |
PFT |
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ARDS |
CXR |
PPD |
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BCG |
INH |
SOB |
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COLD |
IPPB |
SOBOE |
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COPD |
PaCO2 |
TB |
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CPAP |
PaO2 |
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CPT |
PCP |
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The respiratory system is vital to sustaining life. Respiration requires a patent (open) airway for oxygen to reach the lungs, and lungs that are physically capable of exchanging oxygen for carbon dioxide. Healthcare professionals may specialize in the field of respiratory care. A physician specializing in respiratory disorders is called a pulmonologist. A related field of respiratory care is respiratory therapy, which involves respiratory therapists and respiratory technicians.
The respiratory system consists of the upper respiratory tract (nose, sinuses, pharynx, and trachea) and the lower respiratory tract (bronchi and lungs).Because blood carries oxygen and carbon dioxide, both the cardiovascular system and the respiratory system must function for life to continue. A person can survive for only a few minutes without oxygen; it is the most vital, basic need of people and animals.
DIAGNOSTIC TESTS
Laboratory Tests
Sputum Specimen
Sputum specimens help determine the presence of organisms or blood in a person’s sputum. Specimens are best early in the morning, when they are most likely to contain sputum, rather than just saliva.
Nursing Alert Take precautions in the care and disposal of sputum. Wear gloves when collecting specimens and wash hands after contact with them. Wear a mask and eye shield if splashing is likely. Discard all used facial tissues as contaminated material.
Lavage Specimen
If the client is unable to cough up sputum, the physician may order that either the nurse or the respiratory therapist obtain a specimen by bronchoalveolar lavage. In this procedure, sterile saline is instilled into a bronchus. Then, cells and fluid from the bronchioles and alveoli are removed by endoscopy along with the saline. The cells are analyzed in the laboratory, most often to diagnose pulmonary tuberculosis (TB).
Throat Culture
A sample of both mucus and secretions from the back of the client’s throat can be obtained on a cotton-tipped applicator and applied to a slide or culture medium, which is then incubated in the laboratory to determine the presence of organisms. Drug sensitivity determinations may also be done by placing the specimen on solid media with different concentrations of medications, or in various liquid dilutions of medications to determine which medication is most effective against the organism. This procedure is called a culture and sensitivity (C&S) test or throat culture.
A full culture will determine all organisms present in the specimen. This test takes several days because the organisms must have time to grow. However, a culture may be done within a matter of hours to rule out the presence of streptococci. This test does not rule out any other organisms. A “quick strep” test is done in cases of suspected streptococcal infection so that appropriate antibiotic therapy can be initiated quickly.
Blood Gas Determinations
The best indicator of oxygen deficiency is the level of arterial blood gases (ABGs). The partial pressure of oxygen (PaO2) value is generally considered normal when it is between 80 and 100 mm Hg (millimeters of mercury). The laboratory can analyze an arterial blood sample and determine the Pao2, partial pressure of carbon dioxide (PaCO2), and hydrogen ion concentration (pH) of the blood. The physician, nurse, and respiratory therapist then evaluate the blood gas results and plan the most effective treatment for the client. A noninvasive method for continually or intermittently monitoring oxygen saturation of hemoglobin, without the use of a blood sample, is pulse oximetry.
ΤΓ Key Concept Hypoxemia is considered a Pa02 of less than 60 to 70 mm Hg on ABGs or a hemoglobin oxygen saturation of less than 90% on pulse oximetry Always consider the client’s actual clinical condition, which may not accurately reflect any relative mechanical value.
X-ray and Fluoroscopy Examinations
Chest X-ray
The chest x-ray (CXR) examination is no longer done routinely for all clients who are admitted to acute care facilities. It is ordered to determine lung or heart abnormalities. Abnormalities that can be observed on x-ray study include lung tumors or other growths, lung abscesses, pulmonary tuberculosis (TB), foreign objects in the lungs, pneumonia (inflammation of the lung), or an enlarged heart.
Computed Tomography Scan
The computed tomography (CT) scan is a series of x-ray films taken to provide a cross-sectional view of the chest or other body part. CT scanning is valuable in the diagnosis of TB, lung abscesses, or tumors.
Lung Scan
After a radioactive medication is introduced into the system by injection or inhalation, a lung scan (scintiscan) is done. This test yields a two-dimensional map of various organs and tissues. Disorders are revealed as a difference in density from normal tissue. After the client inhales a special gas, this scan is called a ventilation scan.
Lung Perfusion Scan
Albumin tagged with a radioactive material is injected intravenously. These particles pass through the client’s venous system and heart, but when they reach the lungs they lodge in the capillaries. The lung perfusion scan illustrates different views through which lesions, pneumonia, and other disorders can be located.
Pulmonary Angiography
Pulmonary angiography involves injection of radiopaque dye into the pulmonary blood vessels to determine pathology (see Box 47-2 for signs and symptoms of dye-related problems).
Other Diagnostic Tests
Magnetic Resonance Imaging
As with many other body systems, magnetic resonance imaging (MRI) can be used to diagnose disorders in the lungs and bronchi. This noninvasive nuclear procedure can produce images of tissues with high fat and water content, which often cannot be seen with conventional x-ray study. Thus, MRI is useful in the diagnosis of lung disorders. It allows the physician to distinguish among cancerous, trauma-induced, and normal tissues because it gives information about their chemical composition.
Pulmonary Function Test
The pulmonary function test (PFT) measures how much air a client inhales (inspiration) and exhales (expiration) in one breath and assesses the client’s general respiratory status. Many large hospitals have pulmonary function laboratories for this purpose.
The PFT measures total lung capacity, vital capacity (amount of air that is forcibly exhaled after a maximum breath), and residual volume (amount of air remaining in the lung after forced exhalation). PFT also measures tidal volume (volume of air in an average breath), inspiratory volume, and expiratory volume. The ratios between specific measurements can be determined. The machine used for these tests is the spirometer.
Key Concept Do not confuse the spirometer and the incentive spirometerThe spirometer measures pulmonary function. The incentive spirometer also measures pulmonary function, in a sense, but it is used by the client. The incentive spirometer helps the client, such as after surgery to perform respiratory exercises to maintain lung function.
The PFT is used to diagnose disorders and to assess effectiveness of therapy. The test helps in determining pulmonary pathology at an early stage and indicates whether the person has a cardiac or a respiratory disease. The test can evaluate the effectiveness of respiratory therapies and bronchodilator medications and can indicate the surgical risk involved in many cases. When administering this test, encourage the client to breathe as deeply as possible or to follow other instructions.
Bronchoscopy
Bronchoscopy is an invasive procedure in which a bronchoscope (a lighted endoscope) is advanced through the pharynx into the trachea and bronchi. The purpose of this test may be to observe lung tissue, obtain a biopsy or bronchial washings, remove mucous plugs or foreign objects, or determine the location and extent of a mass (tumor). Photographs may be taken. Two types of bronchoscopes are used: the rigid and the fiberoptic. The fiberoptic scope is smaller and more flexible, making it more comfortable for the client and allowing the physician better visualization of the lung within the smaller airways (Fig. 86-1).
FIGURE 86-1 · Fiberoptic bronchoscopy
Before the test, the person’s throat is anesthetized and medications (e.g., midazolam [Versed]) are administered intravenously (IV) to promote relaxation. These medications may cause a client to experience amnesia about the test. Alert the client to this possibility before the test to prevent concern later.
Food and fluids are withheld for 6 to 8 hours before a bronchoscopy. Give mouth care immediately before the procedure. Explain the procedure to the client, who will most likely remain awake. Be sure that any dentures are removed. Note any loose natural teeth because the bronchoscope may loosen or dislodge a tooth, which could lead to aspiration.
After bronchoscopy, the client takes nothing by mouth (NPO) until the gag reflex returns. The anesthetic numbs the throat, so reflexes are not functional and do not allow the person to cough out secretions. Position the client on his or her side. Rationale: Doing so keeps the airway open and helps to prevent choking and aspiration. The side-lying position also helps to facilitate drainage. Note any edema of the throat, bleeding, or dyspnea because if the airway becomes obstructed, an emergency tracheostomy (opening into the trachea) may be needed. A sterile endotracheal tube is kept at the bedside until the client is fully awake and reflexes return. In a respiratory emergency, the endotracheal tube can be inserted to assist in keeping the airway open temporarily.
After the client’s gag reflex returns, offer clear liquids and monitor the client’s ability to tolerate them. Gradually increase the client’s diet to soft foods. Encourage the client to rest and to eat soft foods for 24 hours after this procedure.
Because most bronchoscopy procedures are done on an outpatient basis, be sure to teach the client and family to be alert for possible complications, especially the following:
• Swelling of the throat
• Difficulty swallowing
• Difficulty breathing
• Bleeding
Be sure to document all teaching completely.
NCLEX Alert Testing of various respiratory functions is commonly done as inpatient or outpatient procedures. It is important that you are aware of nursing actions for these procedures, including pre- and postprocedure teaching and reactions to emergency situations.
Skin and blood tests
Skin tests are commonly used to determine if a person has been exposed to tuberculosis or other disorders, such as histoplasmosis. The procedure is the same as that for administering tests to determine allergies to medications or other allergens. Blood testing may be available for some diseases.
Skin Tests
The purified protein derivative (PPD) tuberculin test, also known as the Mantoux tuberculin skin test, indicates whether a person has ever been exposed to the tubercle bacillus. Approximately 0.1 mL tuberculin serum (PPD) is injected intradermally, with a syringe and needle in the lower part of the arm. The injection site is examined for edema with induration (firmness) and redness (erythema) 2 to 3 days (48-72 hours) after the injection. Erythema alone does not indicate a positive reaction; the degrees of positive readings are based on the area of induration, sometimes combined with erythema. If the client’s test results are not read within the appropriate time frame, the test must be repeated.
Special Considerations :LIFESPAN
PPD Tests
Persons older than 65 years may be anergic because of immune system failure (not an immunodeficiency disease). If an elderly person tests PPD negative, other tests may be necessary to confirm a diagnosis of TB (sputum culture, chest x-ray examination, or two-step PPD test).
Another method of tuberculin skin testing is the tine test, which is simply a different method of injecting the tuberculin serum. It is often used in mass screening. A sterile stainless steel disk with four tines (sharp prongs) is impregnated with PPD; the tines are pressed into the person’s skin. The disks are packaged individually and are disposable; thus, they offer a practical advantage when testing a large group of people.
Candida and mumps antigen sera may be injected at the same time as the PPD to determine a person’s ability to respond to any foreign agent (antigen). Persons with a healthy immune system should respond to candida or mumps or both. In the immunosuppressed individual, this often does not occur. The term used is anergy, and the person is considered anergic (unable to respond to the foreign agent). In this case, the PPD may have been mistakenly read as negative. In other words, in the anergic individual, the PPD appears to be negative because the person’s body cannot appropriately respond to any antigen. This does not mean that the person has not been exposed to TB. If the person is judged to be anergic, a two-step PPD test may be necessary. The two-step PPD test involves doing two PPD tests, 1 or 2 weeks apart. This method attempts to boost the person’s immune system to respond appropriately to the antigen. Many public health departments now do the two-step test routinely.
Positive results on skin tests indicate only that the client has been exposed to TB; they do not differentiate between active or latent TB. A positive test simply means that the person has been exposed to the bacillus at some time, or that he or she has TB antibodies present. A person who is a positive reactor usually remains so for life. Thus, once positive, the PPD test is usually not repeated. If a person has a positive reaction to the testing, a CXR and a sputum culture should be done to determine if the lungs are affected. In addition, some individuals may develop a severe allergic reaction to the test.
Blood Tests
Blood testing is another way of testing for the TB antigen. Three tests are available: QuantiFERON®-TB Gold test (QFT-G), QuantiFERON®-TB Gold In-Tube test (GFT-GIT), and T-SPOT®. Results from blood testing are generally available within 24 to 48 hours. As with skin testing, a positive result on blood testing only indicates exposure.
COMMON MEDICAL TREATMENTS
Postural Drainage
Postural drainage uses position and gravity to drain secretions and mucus from the individual’s lungs. This procedure is not often done by licensed vocational nurses or licensed practical nurses (LVN/LPNs) or registered nurses (RNs), but rather by respiratory therapists (Fig. 86-2). The procedures are commonly taught to family members for home care.
The person adopts a head-downward position, which allows the secretions to run far enough into the trachea from the bronchi so that they can be coughed out. The client’s exact position will depend on the portion of the lung to be drained. Treatments generally last about 15 to 20 minutes. The procedure is called chest physiotherapy (CPT). The nurse must receive specific instructions from a respiratory therapist, physical therapist, or pulmonary physician before performing this procedure (In Practice: Nursing Care Guidelines 86-1).
Often postural bronchial drainage is done in combination with other respiratory treatments, such as inhalations, to loosen and bring up secretions from the lungs and to prevent respiratory complications.
