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Health History
Reason the patient is seeking health care
Focuses on the physical and functional problemsCollects data on the causes/factors producing the
problem
Determines the duration of the problemImpact of the problem on the patients ability to
perform activities of daily living
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Signs and SymptomsDyspnea
CoughSputum production
Chest Pain
WheezingClubbing of fingers
Hemoptysis
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Thoracic PalpationRespiratory Excursion
Estimates thoracic expansion and may disclosesignificant info. About thoracic movement during
breathing.
Patient is instructed to inhale deeply while the thumbs
are placed along the costal margin on the anteriorchest wall.
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Tactile Fremitus
This is the detection of the resulting vibration on the
chest wall by touch.The vibrations are detected with the palmar surfaces
of the fingers and hands, or the ulnar aspect of the
extended hands, on the thorax.
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ThoracicPercussionThis determines whether the underlying tissue are
filled with air, fluid or solid material.
Ideally, the patient is in a sitting position with the
head flexed forward and the arms crossed on the lap.
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Thoracic Auscultation
This is useful in assessing the flow of air through the
bronchial tree and in evaluating the presence of fluidor solid obstruction in the lung.
Breath Soundsdistinguished by their location
Vesicular
Bronchovesicular
Bronchial
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Adventitious SoundsAbnormal condition that
affects the bronchial tree and alveoli.
Cracklesare discrete, noncontinous sounds that resultfrom delayed reopening of deflated airways.
Friction rubsresult from inflammation of the pleural
surfaces that induces a crackling, grating sound usually
heard in inspiration and expiration. Wheezes are commonly heard in patients with asthma,
chronic bronchitis and bronchiectasis.
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Pulmonary Function TestTo be able to assess respiratory function and to
determine the extent of dysfunction.They are useful for screening patients scheduled for
thoracic and upper abdominal surgery.
Trends of results provide information about disease
progression as well as patients response to therapy.
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Arterial Blood Gas StudiesThese aid in assessing
the ability of the lungs to provide adequate oxygen andremove carbon dioxide
the ability of the kidneys to reabsorb or excrete bicarbonate
ions to maintain normal pH
Obtained through an arterial puncture at the: Radial
brachial
femoral artery.
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Pulse OximetryA noninvasive method of continuously monitoring
the oxygen saturation of hemoglobin.
An effective tool to monitor for subtle or sudden
changes in oxygen saturation.
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Sputum StudiesObtained for analysis to identify pathogenic
organisms and determine whether malignant cells arepresent.
Expectoration is the usual method for collecting a
sputum specimen.
These are used
For diagnosis
Drug sensitivity testing
For guide treatment
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Imaging StudiesChest X-Ray
May reveal an extensive pathologic process in thelungs in the absence of symptoms.
Usually taken after full inspiration
Densities produced by fluid, tumors, foreign bodies,and other pathologic conditions can be detected by x-
ray examination.
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Computed Tomography
Images produced provide a cross sectional view of
the contrast.Can distinguish fine tissue density.
Contrast agents are useful when evaluating the
mediastinum and its contents
May be used to define pulmonary nodules and small
tumors adjacent to pleural surfaces
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Magnetic Resonance Imaging
Radiofrequency signals are used instead of a narrow-
beam x-ray.Much more detailed diagnostic image than CT scans.
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Fluoroscopic Studies
Used to assist with invasive procedures
Used to study the movement of the chest wall,mediastinum, heart, and diaphragm
To locate lung masses and detect diaphragm
paralysis.
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Pulmonary Angiography
The most commonly used to investigate
thromboembolic disease of the lungs.Involves rapid injection of a radiopaque agent into the
vasculature of the lungs for radiographic study of the
pulmonary vessels.
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Radioisotope Diagnostic ProcedureVentilation-Perfusion lung scan
Performed by injecting a radioactive agent into a peripheralvein.
Used to clinically measure the integrity of the pulmonary
vessels relative to blood flow and to evaluate blood flow
abnormalities.
Gallium scan
Used to detect inflammatory conditions, abscesses,
adhesions and the presence, location and size of tumor.
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Radioisotope Diagnostic Procedure
Positron Emission Tomography
Used to evaluate lung nodules for malignancy
It can detect and display metabolic changes in tissue
It can distinguish normal tissue from tissues that are
diseased
Differentiate viable from dead or dying tissue
Show regional blood flow
Determine the distribution and fate of medication in the
body
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Endoscopic Procedures
Bronchoscopy
Is the direct inspection and examination of the larynx,trachea and bronchi through either a flexible fiberoptic
bronchoscope or a rigid bronchoscope.
Purposes:
To examine tissues or collect secretions
Determine the location and extent of the pathologic process and
obtain a tissues sample
Determine if the tumor can be resected surgically
To diagnose bleeding sites.
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Endoscopic ProceduresBronchoscopy
Used to:Remove foreign bodies from the tracheobronchial tree
Remove secretions of obstruction
Treat postoperative atelectasis
Destroy and excise lesions
Possible reactions of Bronchoscopy:
Reaction to the local anesthetic
Infection
Aspiration
Bronchospasm
Hypoxemia
Pnuemothorax
Bleeding
perforation
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Endoscopic ProceduresBronchoscopy
Nursing InterventionsSigned consent
NPO 6 hours prior
NPO after the procedure only if gag reflex is is still absent
Assess for confusion and lethargy post procedureReport any sign of shortness of breath or bleeding immediately.
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Endoscopic ProceduresThoracoscopy
Primarily indicated in the diagnostic evaluation of pleuraleffusions, pleural disease and tumor staging.
Small incisions are made into the pleural cavity in an
intercostal space
After the procedure, a chest tube may be inserted and thepleural cavity is drained by negative-pressure water seal
drainage.
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BiopsyPleural Biopsy
Accomplished by needle biopsy of the pleura or bypleuroscopy
Performed when there is pleural exudate of undetermined
origin and when there is a need to culture or stain the tissue
to identify tuberculosis or fungiLung Biopsy
Performed to obtain lung tissue for examination to identify
the nature of the lesion
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BiopsyLung Biopsy
Nonsurgical lung biopsy techniques
Transcatheter bronchial brushinga fiberoptic bronchoscope is
introduced into the bronchus under fluoroscopy.
This is useful for cytologic evaluations of lung lesions and for
the identification of pathogenic organismsTransbronchial lung biopsyuses biting or cutting forceps
introduced by a fiberoptic bronchoscope.
Percutaneous needle biopsyaccomplished with a cutting needle
or by aspiration with a spinal type needle that provides a tissue
specimen for histologic study.
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Biopsy
Lung Biopsy
Nursing Intervention
Monitor patient for shortness of breath, bleeding and infection
Report for pain, shortness of breath and bleeding to the puncture
site
Provide care and teaching to the patient
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Biopsy
Lymph Node Biopsy
A biopsy of these nodes may be performed to detect lymphnode spread of pulmonary disease and to establish a
diagnosis or prognosis.
Mediatinoscopy
The endoscopic examination of the mediastinum for explorationand biopsy of mediastinal lymph nodes that drain the lungs.
Valuable whether the pulmonary lesion is resectable
Anterior mediastinotomy
Provides better exposure and diagnostic possibilities
Incision is made in the second or third costal cartilage
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Oxygen Therapy
Indications
Patients respiratory rate or pattern Changes in the patients signs and symptoms
Long standing hypoxia producing fatigue, drowsiness,
apathy inattentiveness and delayed reaction time
Cautions in Oxygen Therapy
Oxygen toxicity may occur when too high a concentration
of oxygen is administered for an extended period
Administration of a high concentration of oxygen removes
the respiratory drive that has been created largely by the
patients chronic low oxygen tension.
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Oxygen Therapy
Intermittent Positive-Pressure Breathing
A form of assisted or controlled respiration produced byventilatory apparatus in which compressed gas is delivered
under positive pressure into a persons airways until a
preset pressure is reached
Indications:Difficulty in raising respiratory secretions,
Reduced vital capacity with ineffective deep breathing and
coughing
Unsuccessful trials of simpler and less costly methods for loosening
secretions, delivering aerosol, or expanding the lungs.
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Oxygen Therapy Complications:
Pneumothorax
Mucosal drying
Increased intracranial pressure
hemoptysis
Gastric distentionVomiting with possible aspiration
Psychological dependency
Hyperventilation
Excessive oxygen administration
Cardiovascular problems
Mini-Nebulizer Therapy
A hand-held apparatus that disperses a moisturizing agent
or medication
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Oxygen Therapy Indications:
Usually for patients with COPD to dispense inhaled medications
Commonly used at home on a long-term basis
Incentive Spirometry (Sustained Maximal
Inspiration)
A method of deep breathing that provides visual feedbackto help the patient inhale slowly and deeply to maximize
lung inflation and prevent or reduce atelectasis.
Indications:
Used post-surgery, especially thoracic and abdominal surgery To promote the expansion of the alveoli
To prevent or treat atelectasis
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Chest PhysiotherapyPostural Drainage ( Segmented Bronchial Drainage)
Uses specific position that allow the force of gravity toassist in the removal of bronchial secretions
Patient remains in each position for 10-15 minutes
Instructed to breathe in slowly through the nose and then
breathe out slowly through pursed lipsTo help keep the airways open so that secretions can drain while in
each position
Usually performed two to four times daily before meals and
at bedtimeTo prevent
Nausea
Vomiting
Aspiration
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Chest PhysiotherapyChest Percussion
Carried out by cupping the hands and lightly striking the
chest wall in a rhythmic fashion over the lung segment to
be drained.
Performed cautiously in the elderly
Vibration The technique of applying manual compression and tremor
to the chest wall during the exhalation phase of respiration.
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Airway ManagementEmergency Management of Upper Airway
Obstruction
Causes:
Food particles
Vomitus
Blood clots
Any particle that enters and obstructs the larynx or trachea
Enlargement of tissue in the wall of the airway
Pressure on the walls of the airway
Altered level of consciousness
Nurse should assess for:Inspection
Palpation
Auscultation
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Airway ManagementEndotracheal Intubation
Provides a patent airway when the patient is havingrespiratory distress that cannot be treated with simpler
methods.
Method of choice in emergency care
A means of providing an airway for patients who cannotmaintain an adequate airway on their own
Cautions:
The cuff around the tube should be inflated
Low cuff pressure can cause: Risk for aspiration pneumonia
High cuff pressure can cause:
Tracheal bleeding
Ischemia
Pressure necrosis
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Airway ManagementEndotracheal Intubation
Disadvantages:Causes discomfort
Cough reflex is depressed
Depressed swallowing reflex
May develop ulceration and stricture of the larynx or trachea
Inability to talk or communicate
Nursing Alert:
Inadvertent removal of an endotracheal tube can cause laryngeal
swelling, hypoxemia, bradycardia, hypotension, and even death.
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Airway Management
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Airway ManagementTracheostomy
A surgical procedure in which an opening is made into the
trachea.
May either be temporary of permanent
Uses:
To bypass upper airway obstruction
Allow removal of tracheobronchial secretions
Permit long-term use of mechanical ventilation
Prevent aspiration of oral or gastirc secretions in the unconscious or
paralyzed patient
Replace an endotracheal tube
Ai M t
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Airway ManagementTracheostomy
Complications:
Early complications Bleeding pneumothorax
Air embolism
Aspiration
Subcutaneous or mediastinal emhysema
Recurrent laryngeal nerve damage
Posterior wall penetration
Long term complications
Airway obstruction from accumulation of secretions or protrusion of cuff over
the opening of the tube
Infection
Rupture of the innominate artery Dysphagia
Tracheophageal fistula
Tracheal dilation
Tracheal ischemia
Necrosis
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