Manage UsersNCLEX Study Guide

Article

Respiratory System

05/02/2011

Katrina
Member since: April 2011
(Boynton Beach,FL)

Pneumonia

Abrupt onset of fever with shaking and chills (not reliable in the elderly)
Elderly symptoms include

  • Confusion
  • Lethargy
  • Anorexia
  • Rapid respiratory rate

Fever can cause dehydration bc of excessive fluid loss due to diaphoresis.  Increase temp also increases metabolism and the demand for oxygen.
High risk for pneumonias

  • Any person who has an altered LOC
  • When feeding raise the head of the bed and position the client on their side, not back.

Bronchial breath sounds are heard over areas of density or consolidation.  Sound waves are easily transmitted over consolidated tissue.

Hydration

  • Enables liquefication of mucous
  • Essential for client experiencing fever
  • Important bc 300-400 ml of fluid are lost daily by the lungs thru evaporation

Irritability and restlessness are early signs of cerebral hypoxia; the client’s brain is not receiving enough oxygen.
Pneumonia preventatives

  • Elderly: flu shots; pneumonia immunizations; avoiding sources of infection and indoor pollutants; no smoking
  • Immunosuppressed and debilitated persons:  infection avoidance, sensible nutrition, adequate intake, balance of rest and activity

Chronic airflow limitation

Exposure to tobacco smoke is the primary cause of COPD in US
Compensation occurs over time in clients with chronic lung disease, and arterial blood gasses are altered.  It is imperative that baseline data be obtained in the client.
Productive cough and comfort can be facilitated by semi-fowler or high-fowler position, which lessen pressure on the diaphragm by abd organs.  Gastric distention becomes a priority in these clients bc it elevates the diaphragm and inhibits full lung expansion
Pink puffer:  barrel chest is indicative of emphysema and is caused by use of accessory muscles to breathe.  The person works harder to breathe, but the amt of O2 take in is adequate to oxygenate the tissues.
Blue bloater:  insufficient oxygenation occurs with chronic bronchitis and leads to generalized cyanosis and often right-sided heart failure (cor pulmonale).
Cells of the body depend on O2 to carry out their functions.  Inadequate arterial O2 is manifested by cyanosis and slow capillary refill (>3 sec).  a chronic sign is clubbing of the fingernails, and a late sign is clubbing of the fingers.
Caution must be used in administering O2 to a COPD client.  The stimulus to breathe is hypoxia (hypoxic drive), not the usual hypercapnia, which is the stimulus to breathe for healthy persons.  Therefore, if too much oxygen is given the client may stop breathing.
Eating consumes energy needed for breathing.  Offer mechanically soft diets, which do not require as much chewing and digestion.  Assist with feeding if needed. 
Prevent secondary infections; avoid crowds, contact with persons who have infectious diseases, and resp irritants (smoke).
Teach client to report any change in characteristics of sputum. 
Look and listen!  If breath sounds are clear, but the client is cyanotic and lethargic, adequate O2 is not occurring.
Watch of RN questions that deal with O2 delivery:

  • In adults, O2 must bubble thru some type of water solution so it can be humidified if given at >4 L/min or delivered directly to the trachea.  If given at 1-4 L or by mask or nasal prongs, the oropharynx and nasal pharynx provide adequate humidification.

Cancer of the larynx

Neoplasm occurring in the larynx, most commonly squamous cell.

  • Prolonged use of alcohol and tobacco is directly related
    • Vocal straining
    • Chronic laryngitis
    • Family hx
    • Industrial exposure
    • Nutritional deficiencies
  • Men  ages of 55-70
  • Laryngectomy

With cancer of the larynx, the tongue and mouth often appear white, gray, dark brown or black, and may appear patchy.
Refer to speech pathologist & utilize planned alternative communication alternatives.
Keep laryngeal airway humidified at all times.
Trach care involves cleaning the inner cannula, suctioning, and applying clean dressings.
A laryngectomy tube has a larger lumen and is shorter than the trach tube.  Observe client for any signs of bleeding occlusion, which are greatest immediate postoperative risks.

Fear of choking is very real for laryngectomy clients.  They cannot cough as before bc the glottis is gone.  Teach the glottal stop technique to remove secretions (take a deep breath, momentarily occlude the trach tube, cough, and simultaneously remove the finger form the tube).

Tuberculosis

Symptoms:

  • Fever with night sweats
  • Anorexia, weight loss
  • Malaise, fatigue
  • Pleuritic chest pain with inspiration

A positive TB skin test is exhibited by and induration 10mm or greater in diameter 48 hrs after skin test.  Anyone who has received BCG vaccine will have a positive skin test and must be evaluated by a chest x-ray.
Take all prescribed meds daily for 9-12 months.
Client may return to work after three negative cultures.
Rifampin:  reduces effectiveness of oral contraceptives; client should use other birth control methods during treatment; gives body fluids orange tinge; stains soft contact lenses.
Isoniazid (INH): increased dilantin levels
Ethambutol:  vision check before starting therapy, may have to take for 1-2 yrs.

Lung Cancer

Leading cause of cancer-related deaths in the US and has a 5 yr survival rate.
Symptoms:

  • Dry, hacking cough early then productive as disease progresses.
  • Hoarseness
  • Hemoptysis; rust-colored or purulent sputum.

Pneumonectomy – position client on operative side or back.  Chest tubes are not usually used because it is helpful if the mediastinal cavity, where the lung used to be fills with fluid.  This fluid helps to prevent the shift of the remaining chest organs to fill the empty space.
If a chest tube becomes disconnected, do not clamp!  Immediately place the end of the tube in a container of sterile saline or water until a new drainage system can be connected.
If the chest tube is accidentally removed from the client, the nurse should apply pressure immediately with an occlusive dressing and notify the MD.
Fluctuations (tidaling) in the fluid will occur if there is no external suction.  When external suction is applied, the fluctuations cease.
With radiation, avoid use of powders and creams on radiation site unless specified by the radiologist & wear soft cotton garments only.