RESPIRATORY TRACT Post -Procedure:

Primary Function: Diet: NPO until

- provides O2 for cells Time: 2 hrs after the procedure until gag
reflex returns
- removes CO2 as a waste
Assess: Ask the patient to swallow
Secondary Function
er NPO: Give fluids or Ice chips
> Sense of SMELL=CNI
Watch out for:
> Produces = speech and voice
Breathing/ airway: laryngospasm= Dec O2, Inc
> Maintains = Acid Base Balance
RR= Epinephrine
Inc. CO2 = Dec RR = Resp Acidosis
Circulation: Bleeding: blood tinged sputum vs hemoptysis
Dec CO2 = Inc RR = Respi Alkalosis Dec BP, Inc HR

DIAGNOSTICS AND LABORATORIES THORACENTESIS

CHEST XRAY Purpose:
Purpose; Dtermines Size, Contour, Location of Aspirate: Fluids/ Air from pleural space
Thoracic Organs
Instill: Medications into pleural space
Contraindication: Pregnant women
Duration: About 20 mins.
Unless: Lead Apron and 2nd-3rd Trimester
Preparations:
Assess: LMP and Sexual History
Diet: N/A
Preparations:
Medications given: Cough suppressants and
Materials: Remove dentures and other metallic sedative
objects
Medications withheld: Aspirin, Heparin,
Diet – N/A Warfarin
Medication – N/A
During: POST PROCEDURE: 1 hr post op
Position: Standing Position: Sitting side lying= unaffected
Instructions: Deep inhale and exhale; hold until WOF: Hypoxia/ Bleeding
images are larger
If pain: give analgesics
If nausea: Give antiemetics – to prevent inc pressure
BRONCHOSCOPY to promote healing
Purpose:
Direct visualization of Larynx, Trachea & During:
Bronchi
Positions of thoracentesis:
Obtain: Samples and Tissues
A. Orthopneic – expanded lungs
Diagnose: Bleeding SItes
- asthma
Bronchial washing: for secretions
- COPD
Removal of: Secretions
B. Sitting/ Straddling a chain
: Foreign Objects
C. Sidelying – lie on unaffected side
Preparation:
- used if pt is unconscious
Medications: - local anesthetic
- 30-45 degrees
- atropine SO4
- semifowler’s
Diet: NPO for 6-8hrs pre-op
Materials (at bedside):
Ask pt to avoid:
- Suctioning, mechanism vent
1. Coughing – anti cough is given
- remove dentures
2. Moving – sedative is given
- prepare epinephrine
3. Deep breathe
 Prevents: Aspiration
MANTOUX TEST OR PURIFIED PROTEIN Apply: 1st aid
DERIVATIVE (PPD) intradermal injection
5 to Pressure: Soft, Outer Portion
Purpose:
15 mins Provide: Tissue & emesis basin
Assess exposure to myobacterium tuberculosis
Medications: topical vasoconstrictors > dec blood flow
Results: to the wound = dec bleeding
Immunocompetent: (+) if wheal is >10mm To goblet cells = dec secretions
Immunocompromised: pregnant women, Nasal packing
cancer patients, old and young people
Duration: 3 – 5 days
: < 5mm = negative
Diet: Soft diet
: 5-8mm = inconclusive results
Avoid: Nose blowing = inc pressure
: > 8mm = positive
Home Instructions:
Responsibility:
Activity: Irritants = smoking
Patient: go back to 48-72 hrs after
: Vigorous Exercise Avoid
If itchy: do not rub
Foods: spicy/hot foods
To clean: room temp, h2O, mild soap
Do not: Cover
TONSILITIS / ADENOIDITIS
Nurse
Risk Factors:
Before results: Health education
Food: Sweet, cold
After results : report to PHCP
Temperature: Cold
Causative Agent: Group A-B Hemolytic Steptococcus
SPUTUM COLLECTION
Diagnostic Test: Throat swab/ Rapid Strep Test
Purpose: confirm infection through culture
S/Sx:
Preparation:
Throat: Sore
Diet: Gargle w/ water
Temperature: Fever
Procedure: deep breathing exercise & cough
Sleep: Snoring
deeply
Swalowing: Dysphagia/ Odynophagia
Materials: Sterile cup & mucus trap
Tonsils: Inflammed
During:
> Bacterial infection: antibiotic
Timing: early AM (5-6AM)
> Viral infection:
Meals: before meals
Avoid: oral care before procedure
Nursing Interventions:
Amount: 10-15ml (1tbsp)
Diet: Fluids, rest and vitamin C
If conscious: Cough deeply
Gargle: warm saline gargle
If unconscious: suction
Decreases swelling = osmosis
Post procedure
Osmosis: fluid movement
Viability: within 30 mins
From low concentration to high concentration
Properly (CLT): Collect, Label, Transport
Indications for tonsillectomy: Affects ADL’s / QOL
Oral Care: AFTER procedure
5-6x/yr
1. Airway Obstruction
2. ADL = OJA
EPISTAXIS / Nose Bleeding
3. QOL = Chronic O. Media
Types:
Anterior (common): due to trauma
Posterior (Fatal): due to Inc pressure in blood vessels
Positions: Upright; leaning forward
Preparations: Signs and symptoms: LATE
Report abnormal labs Skin color: Cyanotic
Lab findings that are risk for bleeding: Fingers: Clubbing
- low platelets and prolonged coagulation Nail beds: Cyanotic
parameters
Respi rate: Irregular, shallow
ABG: Respi Acidosis
POST- OPERATION:
Positions: semi fowler’s, side lying, prone =
Position: Orthopneic Position or Tripod position
promote drainage
Apply: cold collar, Inc comfort; small bleeding
Bronchial Asthma Pharmacology:
Activities: Avoid throat clearing to avoid
disrupting suture Medical Management (fast acting) – asthmatic attack
Watch out for: frequent swallowing, bright red  Short – acting beta agonists – triggers Beta
drooling receptors = broncho dilation
WOF: triggers B1 receptors = tachycardia >
Avoid: dysrhythmias

> dark colored breverages = causes confusion  Anticholinergic agents: anti pns =SNS = dec
in bleeding assessment secretions

> dairy products = thick = stick to suture lines = Indication: cannot tolerate SABA’s
throat clearing  Corticosteroids: low immune response = dec
> soda / citrus - flavored drinks = throat inflammation
irritation = throat clearing Fast- acting: No, thru nebulization
Diet: Soft diet for 1-2 days post op Medical Management (long acting)
Medications: Give antiemetics  Long acting beta agonists
Mouth Care: Alkaline Mouthwash & warm salt - indication: s/sx of asthma at night
solution
 Corticosteroids PO
Avoid: Gargle and toothbrushing
Indication: dec inflammation = low immune
Cause: unknown system
Pathophysiologic mechanism WOF: s/sx of infection; cushing’s disease =
Inflammataion moonface buffalo hump = weight gain
Hyperactivity of immune system
Edema  Antileukotrienes
Mucus prod. – hyperactivity of goblet cells Indication: dec inflammation
Types: Timing: at night due to sedation
Intrinsic: dysfunctional adaptive mechanisms WOF: (Diet and activity)
(foods, temp, meds)
: operating machinery
Extrinsic: reactions to other biologic agents
(dander, molds, dust spores) Medical Management: Long Acting
Mixed:  Methylxanthines (phyllines)
Signs and symptoms: EARLY Indication: Bronchodilation
Reflex: Cough Therapeutic levels: 10-20 mcg/ml
O2 level: dec O= hypoxia Diet: Avoid Xanthine – containing diet
(chocolate, caffeine) > inc serum levels
Respi rate: Tachypnea
 Use of metered-dose inhaler
Resp depth: Dsypnea
Inhaler: shake vigorously
Breath sound: wheezing = during expiration
Patient: inhaler + deep breaths (hold breathe)
ABG: Respiratory Alkalosis
s/sx of oral
thrush
Aftercare: do oral care
SPACERS Preventions:
Indication: Pt with low dexterity • If with secretions and shallow breaths – Deep
Breathing exercise
Rationale: Inc absorption by suspension
• If smoking and alcoholic – smoking and
alcoholic cessation
Nursing Management: Prevent/Avoid triggers
• If immunocompromised – apply risk for
 Pillow and mattress covers: Wash with hot infection practices
water • If NPO or with ET tube – frequent oral hygiene
 House cleaning: remove dust, dandex, molds q 4hrs

 Pests: eliminate cockroaches • If advanced age – Give pneumococcal vaccine

q 5years
 Rooms: put dehumidifier
Difference with Tracheobronchitis = affects trachea
 Avoid adjunctive non allergic triggers: and bronchitis
- Smoke: Smoking Similarity with Tracheobronchitis
- Temp: Extremes If bacterial: administer antibiotics
- Humidity: Inc humidity If viral: provide fluids, rest and vit c
- Odors: strong odors
CHRONIC OBSTRUCTIVE PULMONARY
PNEUMONIA – inflammation of lungs parenchyma DISEASE

Classifications: Risk Factors:

A. Health care-associated pneumonia (HCAP) Sex: Males

Criteria: OPD patients with extensive Medical History: Asthma LUNG INFLAMMATION

healthcare contact Vice: Smoking also includes secondhand and

B. Community-acquired pneumonia: (CAP) thirdhand smoking

Criteria: Infection within the first 48 hours after Environmental: Air pollution or occupational
admission hazards

C. Hospital – acquired pneumonia: (HAP) Genetics: Alpha 1 Antitrypsin Deficiency

Criteria: after 48 hours since admission > no protection against elastase and collagenase

D. Ventilator - associated pneumonia (VAP)

Criteria: after 48hrs since intubation

Nursing Intervention:
A. Airway patency:
Fluids: 2-3L of fluids and ORS
Oxygen delivery: Humidified air and cool vapor
therapy
Exercises: coughing exercises, chest
physiotherapy, deep breathing exercises, incentive
spirometry
PRN: Suctioning
B. Activity: Promote rest and avoid over exertion
Position: semi fowler’s position (30-45 degrees CHRONIC BRONCHITIS
head of bed elevation) Mucus production that is trapped = chronic, productive
C. Diet: small, frequent feeding cough crackles, hypoxemia; respiratory acidosis

D. Psychosocial: health teaching to the patient and to Hypoxemia> cyanosis = blue boaters – Inc BMI
the family Hypoxemia> pulmonary vasoconstriction > inc
right ventricular workload= right sided heart failure =
cor pulmonale
Airway narrowing = wheezes; dyspnea
 meds = surgery ventilator
EMPHYSEMA • Closed pneumothorax: intact pleura
• Decreased airway compliance > narrowing = • Open pneumothorax: non-intact pleura
dyspnea, chronic cough
• Spontaneous pneumothorax: unknown cause
• Decreased lung compliance > lung distention = but related to ruptured bleb > High risk in
dyspnea > prolonged lung distention > barrel COPD
chest
• Tension pneumothorax: complication = High
• Loss of alveoli elasticity > alveoli distention = mmHg = accumulated air
hypoxia, hypercapnia > labored breathing >
increased blood to the face OPEN/CLOSED TENSION

- Hypoxia > polycythemia vera > Midline TRACHEA deviated

pinkish appearance = pink puffers (pursed lip Decreased EXPANSION May be fixed
breathing)
Decreased BREATH SOUNDS Decreased

Resonant > hyper PERCUSSION hyperesonant

Diagnosis: Pulmonary function test
Results: decreased forced expiratory volume
(FEV) PLEURAL EFFUSION
Nursing Interventions: • Hemothorax: blood
• Smoking: STAM Smoking cessation • Pyothorax / empyema: PUS
• Coughing: direct, controlled coughing • Hyrdrothorax: Serous Fluid
• Breathing: DBE and pursed- lip breathing
SIGNS AND SYMPTOMS:
• Diet:
• LOC: Restless/ Agitated
- Meals (timing and composition) = Soft, small
frequent feeding, high calories and protein • Respiratory rhythm:Dyspnea
- Fluids: High OFI • Respiratory rate: tachypnea
• Exercise: promote rest but with ADL • Breath sounds: Decreased/ absent
participation
• Fremitus: Decreased/ Absent
Programs: Graded exercises
• Chest contour: unequal explansion
During exercise: Deep Breathing Exercise
• Oxygen therapy: low flow O2 therapy (1-3LPM) • Percussion: Dull/ Hyper resonant
Mode: Venturi Mask (blue) via nasal cannula • Serum LDH: Increase 0.6
• Medications: Bronchodilators/ corticosteroids Lactate Dehydrogenase
Diuretics: Low O2 demand = Low blood Sanguineous: RED
volume
Serosanguineous: clear + red = pink
Vaccination: Influenza / annual &
pneumococcal every 5 years Serous: Clear
• Environment: Avoid risk factors DIAGNOSTIC PROCEDURES:
• Chest X-ray: used mostly in recovery
PNEUMOTHORAX • Lung ultrasound: measure amount of
• Breached pleural space > exposure to positive air/fluid in pleural space
pressure > accumulation of air in the
intrathoracic cavity > decreased lung • Thoracentesis:
expansion > atelectasis Remove: Air/Fluid
• Cause: Puncture injury (direct/indirect)
Obtain: Sample
RIB FRACTURE FLAIL CHEST
Relieve: Dyspnea
One rib RIBS Multiple ribs
Chest drainage system: returns negative pressure
Severe pain PAIN Severe pain
• Drainage chamber: collects air/fluid
Pain mngmnt PRIORITY O2 therapy
• Water seal chamber: prevents air to go
Immobility + pain MANAGEMENT Mechanical
 back to lungs
• Suction chamber: maintains the negative
pressure– and
Pleural effusion promotes
chest drainagedrainage
system • If nurse suspects recovery
NURSING INTERVENTION Report to physician > anticipate chest x
ray
• Ensure patencsy: no kinking, coiling,
obstruction; no milking and excessive If lungs are not yet expanded:
clamping continue system
• Monitor drainage If lungs are expanded: pt has
recovered
Expected: serosanguineous; <100ml/hr
Patient: Perform Valsalva =
Too much: sanguineous; more or equal
prevent air entry
100ml/hr
Dressing: occlusive dressing taped
Recovered: <50ml/hr+breath sounds
at 4 sides
present

• Monitor water seal chamber

Expected: intermittent bubbling
Abnormal: continuous bubbling
Recovered: no bubbling
Depth of tube: 2-3cm

• Monitor suction control chamber

Expected
Dry: no bubbling
Wet: continuous bubbling
Abnormal: no bubbling
• Paient position: High-fowler’s
• Proper placement of the chest tube: 2-3 ft
below the patient
• Keep at bedside:
Clamp: Dislodgement from bottle: only
with doctor’s order
Non-occlusive dressing: Disconnection
from patient, taped at 3 sides
Bottle of sterile water: dislodgement from
bottle – maintain water seal
Bandage Scissors: in case of the tube
contamination
 • Promote: rest but with ADL participation
• Diet (GLORY W): green, leafy veg.;
HEMATOLOGIC DISORDERS • FEROUS
Legumes;SULFATE SUPPLEMENTATION
organ meat; raisins; yolk;
TABLET INSTRUCTIONS
whole grains
Increases absorption: without meals with
IRON DEFICIENCY ANEMIA = LOW
vitamin c
RBCS = LOW IRON LEVELS
If with GI upset: with meals
Why iron? Production of RBCs
Decreases absorption (C-MALT): coffee,
milk, alcohol antacis, laxatives, tea
RISK FACTORS FOR IDA
What time to take? 2-3 hours
• In women: Pregnant women before/ after
• Diet: Low iron or malnutrition
• Bleeding through: Trauma /GIT FERROUS SULFATE LIQUID
• Vices: Alchoholism. Low absorption
INSTRUCTIONS

• GI disease: Malabsorption or GIT

Drink with: straw/ spoon directed
at back of mouth
After: perform oral care
LABORATORY MANIFESTATIONS:
Rationale: can stain teeth
• Serum iron: low
• Ferritin (iron stores): low
FERROUS SULFATE IM (DEXTRAIN)
• RBC: Low mature rbcs INSTRUCTIONS
• Reticulocytes: Low (immature) Best route: 90 degree thru z track method
• Mean corpuscular volume: (cell size) low Rationale: 1. Promote absorption
• Hemoglobin: low 2. prevent SQ discoloration
• Hematocrit: low
• Transferrin (delivers iron): high Implications of iron in GUIAC tests:
(FOBT) false positive
Signs and symptoms:
• Skin color: Pallor APLASTIC ANEMIA
• Breathing: dyspnea Autoimmune disorder where there is a
• Energy levels: fatigue hypoplastic (low development) bone
marrow > produces low WBC, RBC,
• Head: headache Platelets
• Attention span: poor Low RBCs = anemina
• Hair: Brittle Low WBCs = risk for infection
• Tongue/gums: red, smooth Low platelets= risk for bleeding
• Nails: spoon-shaped = Koilynochia • Diagnostic procedure: Bone marrow
• Lips: chapped side lips: Cheilosis • Medical procedure: bone marrow
• Diet: PICA transplant
• Medication: Cyclosporine
Nursing care for patients with anemia MOA: prevent Tcells from attacking BM
• Daily activity/schedule: In respect to meals: w/ meals, juice, milk
• During activity: deep breathing exercises Timing: exactly as prescribed
 Avoid: grapefruit = high serum level Pressure: positive pressure
ventilation
WOF: low BP, seizures
Nursing Interventions:
Activities:
• Fatigue interventions: low RBCs =
PRBCs: 4 hrs Avoid: crowded places, injuries
Daily activity/schedule: spaced schedule Promote: non-contact sports,
solitary play, isometric exercise
During activity: Deep breathing exercise
Diet: everything should be cooked
Promote: Rest with ADL participation
• Bleeding precautions: low platelets
<platelet concentrates = 20-30 mins POLYCYTHEMIA VERA
Food Proliferation of myeloiod stem cells > Hyperplastic
bone marrow
Consistency: Soft
Signs and Symptoms:
Temperature: Room temp & warm
• Due to increased RBCs: reddish / ruddy
Shaving: electrical or razor: use electric
appearance
razor
• Due to increased histamine related to
increased WBCs: pruritis
Nursing Interventions:
• Due to increased platelets:
• Bleeding precautions
• Due to increased uric acid levels related to
Avoid nursing procedures such as RBC turnover: signs and symptoms of
IV: anything that punctures skin: gouty arthritis (painful extremities)

1. Sterikle dressing • Laboratory:

2. Apply pressure Hemoglobin: > 20 q/dL

for 15 mins. Hematocrit: > 60%
Rectal SET: suppositories, Enemas, • Diagnostic tests: Bone marrow aspiration
Thermometer
Nose: Avoid nose blowing
Medical Management:
Oral hygiene
• Main procedure: therapeutic phlebotomy
Avoid: Alcohol, dental floss
How many ML: 250-500ml
Use: alkaline mouthwash – soft
• Medications:
brizzled toothbrush
For increased uric acid: Allopurinol
Sports: avoid contact sports
To inhibit clotting: dipyridamole
Stools: avoid constipation
For antiplatelet aggregation: Anagrelide
Promote: High fluids, fiber
As a bone marrow suppressant:
Medications: Avoid risk for bleeding meds.
hydroxiurea
to relieve pruritus: Antihistamines: h1
Nursing Interventions: reception antagonist
• Infection precautions; risk for infection Nursing Management:
Assess: Skin, respiratory system, GI • Activity: continue usual ADLs but dec rest
system
Rationale: Risk for DVT
Isolation protocol: reverse isolation=
• Skin: NO scratching, direct sunlight,
protect the patient
hot/cold applications
Room characteristic: private room
Wear: long sleeves, wide brim hats
High risk
for injury
 Rationale: pruritis and fragile skin = Nursing Intervention:
• Instruction for follow up: • Promote: safety
Every:90 – 120 days > Quarterly phlebotomy • Refer to: PT/OT
MEGALOBLASTIC ANEMIA • Diet: soft, bland diet
= low vit b12/ folic acid Rationale: sore tongue
• Avoid: hot/ cold applications
Why vitamin b12 and folic acid? Rationale: low sensation = high risk for
injury
= For maturation of RBCS

SICKLE CELL ANEMIA

Vitamin b12 absorption: Diet with Vit b12 >
stomach > Intrinsic Factor + Vit b12 > Ileum Inheritance of HGbS = cause sickling during low
absorption O2
Diagnosed at: 5-6 moths after birth: low fetal
hemoglobin
RISK FACTORS:
Aggravating factors:
Nutrition: malnutrition
• Low blood volume: dehydration = high
Vices: Alcoholism
Low absorption HCT
GI disorders: malabsoption
In women: pregnant women: low folic acid • Vasoconstriction: cold temp = High o2
Surgeries: Gastrectomy demand = low O2 levels

Diet: low meat = low vit b12; low veg = low folic • Due to reactions to foreign substances:
acid infection = high body stress
• Due to thinning air and low oxygen: high
altitudes
SIGNS AND SYMPTOMS: general to anemia
• Sensation: Paresthesias/ numbing
Signs and symptoms (without sickling):
• LOC: confusion
• Due to elimination of HgbS by the spleen:
• Loss of: proprioception high bilirubin = jaundice
• Tongue: red, beefy tongue • To compensate: High reticulocytes
• Results of chronic anemia: Dyspnea,
SCHILLING’S TEST = determine vit b12 fatigue
absorption Bones: enlargement of skull= frontal
• Given to the patient: PO and IM vit b12 bossing

• Specimen collected: 24hr urine collection Heart rate: tachycardia

• Results: Heart sounds: cardiac murmurs

> 10% of B12 in urine: normal Heart size: cardiomegaly

< 10% of B12 in urine: decreased Heart rhythm: dysrhythmias > arrythmias
absorption
MEDICAL MANAGEMENT: Signs and symptoms (if sickling is present):
• Initial: dietary management> • Blood vessel obstruction:
Pernicious = high meat Sensation: Pain
Folic acid = High vegetables O2 levels: dec O2
• Medication: supplements • In the lungs/ heart: chest pain = MI
 • In the brain: stroke/ CVA
• In the kidneys: pre-renal acute renal
failure
• In the eyes:
LABORATORY vision eyes
MANIFESTATIONS:
•• In the penis: and
Hemoglobin priapism
hematocrit: LOW
• WBC and platelets: High due to Chronic
inflammation
• In blood smear: Normal
• Hemoglobin Electrophoresis: identify
hemoglobin S
MEDICAL MANAGEMENT:
• Main: blood transfusion, bone marrow
transplant
• Medication: hydroxyurea
MOA: High Hgb size > prevent sickling
Supplementation: folic acid
supplementation
• Others: Stem cell transplant

NURSING MANAGEMENT (during a crisis)

• Priority: hydration (2-3L of fluids)
• Provide O2
• To reduce pain: NSAIDS, opiod analgesics
= patient contolled analgesia
Position: elevate extremity = dec swelling
Techniques and exercises: non-
pharmacologic pain management
NURSING MANAGEMENT (prevent crisis)
• Environment: avoid cold and high altitude
• Following pain episodes: early ambulation
• Prevent infection: take antivbiotics and
secure Vaccines
• Diet: High OFI
• Schedule: spaced
• Clothing: loose