• 20-40% 

• anestethsia
• tissue trauma

• Mucous plug/mucous
• infections/pain
• tissue trauma
• pneumonia vs. ashma
• trauma to brain stem

70 % of previous cases....

• return back to normal without any clinical signs

• become worse 3rd/4th day post op

• ↑ temp., HR, RR
• pulse ox <90*****
• vertigo
• syncope
• restlessness, anxiousness\
• chest xray
• abnormal breath sound/pattern
• cyanosis
• diaphoresis

how much do we normally breath?

• 400-500 ml/breath
• every 5-10 respirations we take a deep breath

• alveolar collapse

• give incentive spirometer, especially to immobile patient

• first TCDB
• ptnt need Abx
• chest clapping
• postural drainage
• mechanical venilation

• OBJECTIVE: fet maximum alveolar inflation & normal function
• FREQUENCY: 3-4x q8h to 10xh

• Breathing exercise method
• easiest and most cost effective**
• turn cough and deep breath**

• incentive sperometer
• goal oriented: normal 500-1000cc/breath

1. sit high as possible
2. normal exhale
3. slow/deep inhale
4. hold 3 seconds

how often to TCDB?**

• liquify/loosen thick secretions

• reduce inflammation in the airways

• metered dose inhaler
• delivers controlled dose w/ each compression

• hand held/ mask
• used til med. is gone

how to hold MDI**

• hold inhaler w/mouthpiece @ bottom

• 11/2 -2 (2-3 finger widths)  in front of mouth

• tilt head back
• gently breath out

breath in how long when inhaled?

How long you hold your breath**?

• slowly 3-5 seconds
• **hold breath 10 second to allow med. time to deposit into the airways

• (like airo chamber)
• device-helps deliver meds. to the airways of the lungs instead of the mouth
• lessens SE

pre-post treatment

• if albuterol: check pulse be-4 for & after
• when admn. steroids: have ptnt. rinse mouth to avoid thrush

What is and what do you need for postural drainage?**

• *It is* gravity  used to draind secretions from lungs into larger pulmonary branches where secreations can be coughed, drained, suctioned out.
• You need a DO

• do 2-4 x/day~ total time 20-30 min~ leave in each pos. up 2 5 min.
• do b-4 meals or 1-2 hrs after eating(prevent reflux/vomiting)
• if ptnt. dyspneic- may change angle of tilt

• dyspnea/exhaustion
• unstable HR or BP
• recent head injury
• acute MI
• obese
• no suction equipment if needed

• striking chest wall rhythmically w/cupped hand over segment to be drained to loosed pulmonary secretions
• need DO

• Clap over thoracic cavity
• 30-60 sec. over an area several times
• 3-5 min

• increased bronchospasme
• area of suspected carcinoma
• hemorrhage possible(surgery,rib fracture,↓ platlets)
• unresolved PE(pulm. emb.)
• risk of pneumothorax(tension)

position for CC/PD

• upper lobes: high fowlers
• middle lobes: on side w/ pillow under chest* do both sides
• lower lobes: position head lower than feet.

• viral infection(eg common cold)
• require only supportive care

• infection

• caused by coal, dust, smoke, soot inhalations

• ass. w/
  •  pneumococcal pneumonia
  • TB
  • blood present

• coughing up blood
• can be small streaks to large amounts

• ass w/ pulm. edema

indicates bacterial infection

• Have ptn rinse mouth before NOT eat/brush teeth
• us sterile container
• have ptnt. cough direct into container

low O2 content in blood

• inadequate amnt. of O2 available to cells

syncope

faint, light headed, brief loss of consiousness

• mist of meds. small enough to inhale

• bed rest
• post-op & not enough TCDB

• airway obstruction
• external compression
• disease causeing thickening of alveolar/capillary membrane( pneumonia, pulm. edema)

• CO2**
• hydrogen ions

• some cells die in 30 second
• irreversible in 4-6 min

psychological health affecting repitory function

• stress can cause sighing or hyperventilation
• anxiety"           " broncho-spasm/bronchial asthma

• dyspnea (most common)
• elevated B/P, RR, HR
• pale, cyanotic
• anxiety, restlessness,frightnened         DEPA

O2 : sources and measurement

• wall, tank, concentrator
• L/min

O2 amnt for COPD ptnts***

• 2L or less
• excess O2 decreases stimulant to breath

commonly used at 3 L or higher cuz o2 dries mucus membranes

• 24-44 % oxygen

• mask has tight seal to avoid leakage
• remove and dry skin Q 2-3h

30-60 %

Deliver no < than 6L/min

• 60-100% concentration, highest concentration O2 mask

• Wound healing

• Intermittent positive pressure breathing
• used if TCDB not working

• Continuous positive airway pressure
• Keeps airway open when sleeping(sleep apnea
• (DENNIS)

• Open airway PRIORITY
  • positioning
  • suctioning
  • coughing
• Equipment
  • Check
    • flow rate
    • Need 4 humidification/H20 level
    • tubing

• Frequent oral care_fluids if can
• Observe safety and skin
• pulse ox
• document: what thearpy, o2 sat., response

• 95-98%*

because of spring tension on pulse ox do what:**

• change spring Q2h
• (4-8 if taped)

• Use lowest amnt. of O2 possible
• COPD'ers have normal sat in 80's
• keep ambubag @ bed side

• Impaired gas exchange
• altered breathing pattern
• activity intolerance
• sleep pattern disturbance
• altered tissue perfusion
• anxiety

• Remains in place in trachea
• cuffed and uncuffed

• Prevent aspiration
• seals against air leakage
• permits mechanical ventilation

• needed for excessive secreations or difficutly clearing secreations
• disposable & nondisposable

• Remove and clean with hydrogen peroxide
• then replace

1. airway for comatos
2. mechanical ventilation for porlonged intubation
3. by-pass upper airway obstruction
4. facilitate removal of tracheobronchial secretions

• For emergency resperatory conditions
  • severe allergic reaction
  • trauma
  • infection

• Neurological damage to brain or resp.center
• crushing injury of larynx
• encroaching tumors

• aspiration
• airway obstruction (mucous plug;dried secretions)
• hemorrhage
• accidental extubation>keep spare @ bedside

• Overinflated cuff: tracheal necrosis
• most low pressure
• should deflate every 2hr and for eating

• Cardiac arrythmias

• Pre-oxygenate : be-4,during, after suctioning
• dont suction for >8-10 sec. per pass
• rarely > 3passes..may need to do more if strong cough

• air in subQ tissue( from ruptured airway)
• crepitus sound, dry crackle (rice krispies)
• mark to see if ↑ or ↓

• oxygenation
• skin color
• LOC
• mental status
• breathsounds
• pulse ox
• check equipment
• airway clearance
• clean trach q8h
• observe for S&S of infection(cough,angina,redness, swelling,fever, purulent sputum, increase WBC's)
• oral care
• nutrition
• hydration

• Humidifed O2*
• keep secretions liquified to cough up
• keeps mucous membranes intact

• Extra trach set
• obturator
• working suction machine and kits
• trach cleaning kits
• sterile H20 or saline(24 hr expiration)
• Hydrogen peroxide for cleaning trach

• Device
• first inside cannula
• blocks end to make insertion easier

• time
• reason
• nature/amnt. of secretions(color,consistency)
• character of respirations(before ,during,after)
• lung sounds             "                             "
• apical pulse( before and after)

Oro/naso-pharyngeal suctioning**

• Measure distance from earlobe to nose(tube)
• Suction 10-15 seconds
• Flush catheter with saline and repeat PRN**
• Need sterile catheter for nasopharyngeal not oropharyngeal

• New_may need suctioned Q15-30min
• suction as little as possible
• suction increases mucous

• Strict aseptic technique*
• INsert 4-5 inches*
• dont suction>8-10 sec*
• Preoxygenate be-4,during,after*(hyperoxygenate)
• Do not suction on way in(can cause mucosal damage)*
• Wall unit _100-120 mmHg*
• Portable unit- 10-15 mmHg*

cleaining inner cannula & skin are procedure

• To prevent wound infection & skin irratation
• Acute care: q4-8hr
• longterm:Q24 hr
• Use hydrogen peroxide

CT

• Chest tube
• goes in pleural space
• removes fluid/air &allows lung to reexpand

• R: 3 lobes
• L: 2 lobes

• free air/gas in pleural cavity*
• increased pressure with ventilation can increase reisk

• Puts all three bottle in on plastice unit
• can leave to gravity or add suction
• Only 2 connections
• may see rise in water seal chamber when take off suction and left to water seal
• amnt of water controls amount of suction
• may have transfusable set-up

• Mark on drainage chamber Q8H & add to output for shift
• Change system when full
• disconnect from suction close to unit
• dispose in biohazard

• tidaling
• if working_ should see rises & fall in fluid**
• If absent_could indicate lung reinflated or tubing kinked/plugged

• water seal chamber means leak in system*

• Air is leaking around the chest tube
• mark it if able
• report

• Nutrition given via IV

• Gastrostomy tube
• feeding tube
• goes through abdn wall to stomach

With levine gastric tube:

If to suction**

• Must be intermittent

• Kind of gastric tube
• clear plastic W/ double lumen
• one for feeding/drainage other for air vent

• with CXR

• minimum risk of infection/aspiration

• Dumping syndrome can occur from pyloric valve being bypassed*

When inserting NG tube If possible:

*

• aspirate and check pH of gastrice secretions

• intermittent check pH between feedings to indicate placement

• assess bowel sounds q shift
• check tube position(always before feeding,meds etc) to make sure not slipped out

Check residual from

• Used to detect aspiration in pulmonary secretions

Monitor what with TF:**

• Presence of complications of high carbohydrtate load from the feeding
• can affect insulin levels in blood*

• Check tube placement*

• Change ptnt. position,
• put HOB higher

• med dissoved and given separatly
• follow with 10 cc of h20