Saturday, February 16, 2019

MANAGE NURSING CARE AT HOME, "Ch. 11 Respiratory System"

   How to Manage Nursing Care at Home

The nasal passages, pharynx, larynx, trachea, main bronchus and bronchial tubes, and lungs make up this system.  All these organs provide respiration, the exchange of gas, or air, between the environment and the body and the process of making it usable for the body.  The byproduct of respiration, carbon dioxide, is eliminated by exhaling.  Inhaling provides oxygen; it is then exchanged on a cellular level, via the alveoli, and transported to all cells via the blood pumped by the heart.  It is the alveoli, the main functioning cellular pieces of the respiratory system, along with the bronchial tubes and organs, which connect the inside of the body to the outside environment – and perform gas exchange providing pulmonary functionality.

A wide variety of illnesses and disorders are accompanied by problems with breathing. Often the need for respiratory intervention and assessment is what distinguishes patients who need skilled nursing care at home from those who do not. Some of the various respiratory systems conditions and care considerations are described below.

Chronic Obstructive Pulmonary Disease (COPD): is a long-term (chronic), debilitating, irreversible, and progressive group of lung diseases that results in air-flow resistance into and/or out of the lungs, noted by increased expiration time along with an abnormal decreased elasticity of the lungs further decreasing the air flow.   This group of pulmonary diseases includes chronic bronchitis and emphysema.  Asthma is also included in this group but will be addressed separately. 

Chronic Bronchitis is a widespread inflammation and/or infection of the lungs causing narrowing and blockage of the bronchial tubes due to increased mucous, and that is the hallmark of the disease:  airflow obstruction due to mucous.  While it can be acute, if increased mucous and cough are present over a period and occurs over consecutive years, it is classified as chronic bronchitis.   It is characterized by airway resistance affecting the smaller “limbs” or tubes of the bronchial tree.  It does not directly affect the smallest functioning units of the lungs, the alveoli – rather, it is mucous that blocks the smaller tubes, hampering receipt of oxygen to the cellular level, as well as blocking carbon dioxide exchange.  Because the airways are obstructed, oxygen transport to the body via the arterial blood system is reduced.    Patients with this condition often show productive (phlegm-producing) cough, cyanosis (blueness) of extremities due to decreased oxygenation, and hypoventilation (breathing in an unusually slow and shallow fashion) due to mucus production that blocks enough oxygen into airways.

Emphysema is very severe; it causes recurrent damage at the cellular level (the alveoli) rather than affecting the bronchial tubes.  It is characterized by permanent and abnormal gaps or spaces between alveoli due to alveolar wall destruction.  Without these walls, large air spaces (bullae) result, creating an inability for gas exchange to occur: the gaps are too large to permit efficient transport.  Ultimately, pulmonary functioning cannot be achieved.  Carbon dioxide cannot be released, and oxygen cannot be consumed and made useful.   Airflow obstruction is not from mucous, as is the case with chronic bronchitis, but from cellular tissue damage of the lung.  Patients with this condition show long and slow exhalation to get rid of trapped carbon dioxide.  They are often described as having “barrel-chests,” and they tend to use respiratory and abdominal muscles to force air out of their lungs.  These patients tend to hyperventilate (breathe especially deeply and rapidly) because they have trapped carbon dioxide and tend to be hypoxic (low on oxygen). 

Care Considerations for COPD (Chronic Obstructive Pulmonary Disease):
1) Muscle fatigue often occurs, due to trapped carbon dioxide that results in an inability to inhale oxygen.  This can result in “air hunger.”  To treat this condition, promote exhalation and inhalation.  Monitor for nasal flaring and use of accessory muscles.  Other signs are difficulty speaking and trouble breathing (dyspnea) during exertion or at rest. 
2) Position patient to ease in breathing.  Place in “tripod” position, where patient rests forearms on a high table and lean forward to expand chest.   When in bed, place head of bed to as upright a position as is tolerable, but ensure patient has ability to expand both diaphragm and abdominal muscles essential for deep breaths. 
3) Monitor respirations for rapid rate and shallowness, indicating hyperventilation.  Have patient perform pursed lip breathing to expel carbon dioxide:  breathe in through nose and exhale very slowly through pursed lips (lips drawn into a kissing position).  Avoid fatigue and faintness. 
4) Provide supplemental oxygen at the medically prescribed level only.  Too much oxygen can cause oxygen toxicity and resulting carbon dioxide toxicity.  (Oxygen is a drug to be maintained at prescribed levels.)
5) Monitor vital signs, such as percentage oxygen saturation, heart rate, and respiration rate.  These should be within normal range for your patient. 
6) Monitor for loss of appetite which could occur if mucous is being ingested and causing nausea. 
7) Promote fluids intake to decrease mucous thickness (and viscosity) and promote expelling mucous. 
8) Perform chest physiotherapy, including “cupping” of back to loosen secretions. 
9) Ensure medications are taken as prescribed; these may include bronchodilators, inhalation therapy, diuretics, antibiotics, or steroids.   Compliance with instructions is essential. 
10) Reassure the patient, who may mourn the difficulty in breathing and feel he can no longer participate in life, becoming hopeless.  To prevent the experiencing of a loss of self, encourage interaction with others.  
11) Obtain portable oxygen, if it’s needed all the time, to encourage leaving the home and combat isolation. 
12)  Provide assistance with care while promoting self-care as much as possible. 
13) Do activities in short bouts to decrease fatigue and allow periods of rest in between them.  Learn the signs of weariness and exhaustion. 

Asthma: is a form of chronic obstructive pulmonary disease (COPD) but is often discussed separately from chronic bronchitis and emphysema because episodic symptoms often result from triggers or environmental stimuli and the patient may be asymptomatic between episodes.   Airway obstruction can be caused in three different ways, acting separately or collectively:  bronchospasms, mucus secretion, and mucosal edema. 
Bronchospasms are the narrowing of the bronchial tubes due to contractions of the muscles, causing coughing and wheezing. 
Increased mucus production is the result of inflammatory responses to allergic reactions due to outside allergens, causing the release of histamine (extrinsic reaction) or due to effects of non-allergic causes such as emotions or cold weather (intrinsic reaction). 
The thick over-production of mucus, along with edema (swelling due to fluid build-up) of the bronchial tube lining further constricts the opening of the bronchial tubes.  When the patient inhales, the bronchial lumen (space within the tube) is only partially open.  However, due to pressures within the body, the lumen closes when the patient exhales, trapping carbon dioxide, and gas exchange at the alveolar level is impaired.  Asthma triggers may include anything that causes an allergic reaction, such as dust, pollen, food allergies, as well as conditions including stress, fatigue, exercise, and temperature changes. 

Care Considerations for Asthma: 
1) Learn the triggers of the asthma attacks and limit the triggers as much as is possible.  While it is difficult to eliminate extrinsic triggers such as cold weather, minimizing contact, using scarves, or entering warm cars may discourage attacks.        
2) Proper use of medications, whether daily or for attacks, is essential.  Bronchodilators help to decrease the bronchial constriction and edema while promoting ventilation.  Corticosteroids act like bronchodilators but also help to decrease the inflammatory and immune response to the allergen. 
3) During attacks, supplemental oxygen may be necessary if the patient has difficulty breathing (dyspnea) or shows signs of insufficient oxygen intake with increased respiratory rate and depth.  Be sure to use proper amount of oxygen, as too much can be as detrimental as too little.  Beware of carbon dioxide air trapping. 
4) Pursue effective relaxation techniques, which could prove vital during an exacerbation.  Imagery, yoga, or focused breathing may help to calm patient and decrease anxiety and fear during an attack when he is unable to breathe.
5) Promote fluids, especially after an attack, to help thin secretions and help expel them. 
6) During an attack, position patient to assist in breathing.  He should sit upright and lean forward to promote chest expansion. 
7) Because attacks can be episodic, fear may be constant, especially if triggers are unknown or unable to be avoided.  Teach and reinforce that medications will assist.  As the time the patient has been enduring the disease increases, so will his ability to understand and recognize the early signs of an asthma attack. 

Sleep Apnea:  This is defined as temporary absence of breathing during sleep, absences that may last more than 10 seconds and occur thirty times or more in a seven-hour sleep period.  When breathing stops for a prolonged period, oxygenation decreases, and carbon dioxide levels increase.  Sleep is fragmented, and the patient often wakes many times a night.  In the morning, he feels he had unsatisfying sleep, may feel drowsy and fatigued, or suffer a morning headache.  It is a common condition, and partners are often the first to observe the situation.  There are three distinct types of sleep apnea: 
Obstructive sleep apnea is caused by an inability to keep the upper airway open (patent); the structures in and around the mouth and pharynx collapse or become obstructed.  This is usually accompanied by snoring, as the airways start to close, and snorting, which then opens them up. 
Central sleep apnea does not have sounds associated with it, because it is not due to obstruction but rather is from lack of nervous system communication.  This type of apnea strictly involves the part of the brain center that controls respiration and the respiratory muscles that perform the work of breathing.  Proper signals are not sent by the brain and thus not directing the muscles to act.  Simply stated, the brain has not told the muscles to breathe for the body.  This results in no breathing, no movement of the chest, and no breath sounds. This is further marked by excessive daytime sleepiness, such as falling asleep during meetings or while driving, as the body has been deprived of oxygen during these episodes. 
The last type is mixed apnea, the combination of the two types.

Care Considerations for Sleep Apnea: 
1) Diagnosis is made in a formal sleep study lab.  Encourage participation.  Fear of positive diagnosis or embarrassment may prevent patient from undergoing study. 
2) If apnea is due to obstruction, surgical remedy may be available.  Help patient understand the ramifications of surgery, the potential benefits or curative possibility (whether partial or complete).  Learn post-surgical complications and healing actions.  Provide honest feedback of results. 
3) Many sleep apnea patients are obese, causing or increasing the incidents of the apnea.  Encourage weight loss.  Promote healthy foods, increased non-caloric fluids, and exercise.  In addition, changes in some underlying conditions, such as type-2 diabetes or hypertension may occur. Prior to initiating, discuss with physician. 
4) After confirming diagnosis and weight loss does not remedy the condition, treatment may be obtained using a continuous positive airway pressure (CPAP) machine.  Used at night, this machine, with a device that covers the nose and/or mouth, provides a constant mild stream of air that forces the airway to remain open.  Ensure that face apparatus fits properly and comfortably, has ample tubing, is set correctly, and functions optimally. 
5) If patient is using a CPAP machine, he may be uncomfortable initially.  Provide support but do not pressure usage.  Encourage use by noting positive benefits such as increased energy in morning and during the day, as well as enhanced mood and disposition due to getting a restful night’s sleep.

Respiratory Treatments and Therapies:  Effective respiration occurs at the cellular level when carbon dioxide and other wastes are exchanged for oxygen via the blood.  For this to happen, inhaled oxygen from the environment proceeds within the lung structure comprised of increasingly smaller tubes (the bronchial tree) to the smallest functional unit in the lungs (the alveolus), where gas exchange takes place and transported via the venous system.  If there is an inadequate amount of oxygen available in the blood (hypoxemia), then there will be insufficient oxygen to meet the needs of tissues and cells (hypoxia).  Any blockage or obstruction, such as mucus, inflammation or infection, prohibits this from happening, and, therefore, decreases pulmonary function.  Forms of treatments and therapies to promote respiration include suctioning, eliminating mucus plugs, lavage, chest percussion, and controlled coughing and positioning.

Suctioning is used to eliminate excess secretions from a part of the respiratory system to maintain an open airway.  Secretions that could cause obstruction may be thin and watery or thick and tenacious.  This will vary dependent on location and underlying disease and ventilation assistance that the patient may have.  All types of suctioning require attachment to a suction machine via long tubing.

Oropharyngeal suctioning uses a rigid plastic catheter with openings, often called a Yankauer suction catheter, to remove oral secretions.  It is inserted into the mouth to remove excess liquid; it is often required for patients who have inefficient gag reflexes and an inability to swallow these secretions.  Yankauer suctioning removes saliva and mucus that could enter the lungs.  Depending on the awareness of the patient, this suction can be done directly by him, as it is much like handling a toothbrush. 

Nasotracheal suctioning is used to clear secretions from the trachea and lower airways when a patient cannot do so himself.  It requires a sterile technique even though the airway access is obtained from the nose.    Secretions can range from as thin as saliva to being much thicker in nature. 

Endotracheal and tracheostomy suctioning is used when there is a direct access to the lower airways, either by intubation or permanent placement of a tracheostomy tube, respectively.  This type of ventilation and suction completely bypasses the respiratory system above the trachea.  Strict sterile technique is necessary, and often a closed suction tubing suctioning system is used to promote sterility, as well as not requiring the patient be disconnected from a ventilator.

Care Considerations for Suctioning: 
1) Sterile technique is essential for all suctioning, except oropharyngeal, as the area below the pharynx is a sterile area.  Patients requiring suctioning usually have compromised pulmonary systems and are at risk for respiratory infections. 
2) Ensure proper technique is used.  Insert catheter into airway until resistance is felt or the patient coughs.  Pull back slightly and then apply intermittent suction until the catheter is removed.  Never apply suction while inserting the catheter. 
3) Patient should be well oxygenated prior to suctioning, especially if a closed suction system is not used.

Mucus Plugs are merely accumulations of mucus, tissues, cells, and dirt that block or obstruct an airway or tube.  Patients with artificial airways are more susceptible, because the tubes can stimulate or cause stasis of secretions. In addition, air bypasses the usual defenses, filtration, and humidification of normal airways.  However, replacing equipment, such as an inner cannula, or carrying out lower airway suction, often relieves the obstruction.  Removing plugs in patients with natural airways are difficult and requires strong forceful coughing, abdominal thrusts, and suctioning.  Regardless of the type of airway, mucus plugs must be removed.

Care Considerations for Treating Mucus Plugs: 
1) Maintenance of and compliance to scheduled equipment usage is vital to optimal functioning, filtering, and minimizing buildup of secretions. 
2) Increased hydration and humidification may assist in keeping mucus from hardening.  Use caution to prevent fluid overload. 
3) Suctioning, as prescribed, eliminates the stasis (pooling) of secretions, which minimizes the formation of a mucus plug. 
4) Lavage may (or may not) help to loosen secretions.  (Strictly follow physician’s and/or pulmonologist’s guidelines.)

Lavage (washing out) is a treatment that is not universally recommended and not definitely a commonplace, accepted practice. During lavage, a small amount of normal saline is instilled to stimulate a cough.  Once the fluid is delivered, the patient is suctioned.  The thought behind lavage is that instilling a small amount of sterile, normal saline into the bronchial tubes will loosen secretions, thereby making them easier to suction and prevent mucus plugs.  However, research has not indicated whether this is true.  Some theories suggest that instilling fluid, while loosening secretions, may disperse bacteria throughout the lung.  Alternatively, more humidification and hydration may relieve the mucous plug condition.

Care Considerations for Lavage: 
Consult your medical professionals and follow their guidelines.  Inquire about humidification and hydration for the patient.  Follow recommendations concerning care of the equipment.

Chest Percussion, also known as Chest Physiotherapy is done to loosen and help remove secretions that accumulate in the lungs especially in the bases.  It involves using numerous techniques. 
Clapping, or percussion, is performed by thumping the hands, held in a cup-like position, against the patient’s back.  After clapping, postural drainage is then utilized.  To achieve this, the patient’s body is tilted so his head is lower than his lungs.  This aids in the drainage of secretions due to gravity.  If a patient is unable to be tilted, suctioning would then be performed. 

Care Considerations for Chest Percussion: 
1) When cupping, ensure clapping is not too forceful.  The thumping should be strong but should not cause pain or discomfort.  Massaging the back with lotion in an upward motion after cupping also aids in movement of secretion as well as provides comfort after the procedure. 
2) Use caution when placing a patient in a head-first downward angle.  Depending on quality of his oxygen status, the patient may be at risk for dizziness and fainting.  The angle of the body does not need to be great for adequate postural drainage.

Controlled Coughing and Positioning:  Correct positioning helps to keep airways clear by promoting ability to expand chest, breathe deeply, and use muscles.  While the patient is sitting, the head of the bed should be at a 45- to 60-degree angle (semi-Fowlers) to a 90-degree angle (high Fowler’s position).  This enables chest expansion, full use of the diaphragm muscle and other respiratory and abdominal muscles.  If the patient is standing, and having difficulty breathing, support his body against a wall.  This will provide safety as well as support for his back to promote chest expansion.  If the patient is lying in bed on his back (supine position), use two or more pillows or raise the head of the bed to a 30-degree angle to promote deep breathing.  This is often a better position for patients who have a large abdominal girth. 

Controlled coughing is an exercise and technique to clear secretions and maximize the coughing effort.  Coughing that does not expel secretions is not effective, causing additional coughing ultimately leading to discomfort and fatigue.  Position the patient in a Fowler’s position.  Often it is more comfortable for the patient to support his abdomen with a pillow.  He then takes two slow, deep breaths in through the nose and exhaled through the mouth.  At the third breath, inhale through the nose and hold the breath, count to three, then without inhaling between, cough deeply two or three times pushing the air out of the lungs.

Care Considerations for Controlled Coughing and Positioning: 
1) Ensure patient safety at times.  If the patient is not mobile, ensure turning and positioning is done every two hours to decrease risk of pressure sores. 
2) Be mindful of patient comfort.  When in discomfort, less effective breathing is performed and is exhibited by shallow breaths, increased or decreased rate, and ultimately a decrease in oxygen saturation. 
3) Monitor oxygen saturation to provide actual verification of the effectiveness of the position. 
4) Encourage ingestion of fluids to thin secretions for ease in their expulsion. 
5) Practice controlled coughing exercises.  Count the repetitions and advise patient on steps to perform technique.  Support and encourage practice, even if immediate results are not seen. 
6) Observe for correct use of incentive spirometer.  The goal is to maximize exhalation – not inhalation.  Patient should take a deep breath in through the nose, and then exhale though the mouth of the machine to make the device’s indicator rise.  The higher rise of the indicator demonstrates that a deeper exhalation was accomplished.


Contact information:
Diane R. Beggin, RN
40 Sycamore Drive
Montgomery, NY 12549

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