“You never lose by
loving. You always
lose by holding
back.”
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Diagnostic Studies/Therapies
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Mantoux Test
Also known as the PPD (Purified Protein
Derivative) test
Intradermal
Read within 48 to 72 hours after injection
Positive: Induration of 10 mm or more;
signifies exposure to Mycobacterium
tubercle bacilli
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Chest X-ray
Radiographic visualization of the chest
Instruct the client to hold his breath and
remove metals from the chest
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Lung Scan
Measures blood perfusion through the
lungs.
Helps confirm pulmonary embolism or
other blood-flow abnormalities.
After an injection with a radioisotope,
scans are taken with a camera.
Remain still during the procedure.
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Lymph Node Biopsy
To assess lung cancer metastasis.
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Bronchography
Radiopaque medium is instilled directly to the
trachea or any part of the bronchial tree to be
visualized through x ray.
Nursing intervention before the procedure are:
Secure informed consent
Check for allergy to food, iodine, anesthesia
NPO for 6-8 hrs
Pre-op meds: Atropine SO4, Valium, topical
anesthesia and anesthesia to be injected into
the larynx
Secure O2, antispasmodic agents at bedside
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Nursing intervention after the procedure
are:
Side-lying position
NPO until cough, gag reflex return
Cough, deep breathing exercise
Low-grade fever is common
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Bronchoscopy
Direct inspection and observation of the
larynx, trachea and bronchi through
flexible or rigid scope
Diagnostic uses: to collect secretion, to
determine location of pathologic process
and collect specimen.
Therapeutic uses: remove foreign object
and excise lesions
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Nursing intervention before the
procedure:
1. Informed consent
2. Atropine, valium as premeds, topical &
local anesthesia
3. NPO for 6-8 hrs
4. Remove dentures, prosthesis, contact
lens
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Nursing intervention after the procedure:
Side lying position
Check for coughing, gag reflex prior to
oral intake
Watch for signs of perforation of the
bronchial tree: cyanosis, hypotension,
tachycardia, hemoptysis, dyspnea
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Sputum Exam
Sputum C & S
AFB staining
Early AM sputum
Rinse mouth with plain water
Use sterile container
Important: specimen for C & S is collected
before the first dose of antibiotic.
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Pulmonary Function Test
Volume Symbol Measurement
Tidal Volume (about TV Amount of air that moves into and out of the
500 ml at rest) lungs with each breath.
Inspiratory Reserve IRV Maximum amount of air that can be inhaled
Volume from the point of maximum inspiration.
(approximately 3000
ml)
Expiratory Reserve ERV Maximum volume of air that can be exhaled
Volume from the resting end-expiratory level.
(approximately 3000
ml)
Residual Volume RV Volume of air remaining in the lungs after
(approximately 1200 maximum expiration.
ml)
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Functional FRC • Volume of air remaining in the lungs at
Residual end-expiration.
Capacity • RV + ERV
(approximately
2300 ml)
Inspiratory IC IRV + TV
Capacity
Vital Capacity VC Maximum amount of air that can be
exhaled from the point of maximum
inspiration.
Total Lung TLC • Total amount of air that the lungs can
Capacity hold.
• The sum of all the volume components
after maximal inspiration.
• 20-25% less in females
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Thoracentesis
Aspiration of fluid or air from the pleural cavity
May be used for diagnosis or therapy
Nursing intervention before the procedure:
Secure consent
Take initial VS
Position: upright leaning on over bed table
Instruct to remain still during the procedure
Pressure sensation is felt upon needle
insertion
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Nursing intervention after the procedure:
Turn on unaffected side to prevent
leakage from the thoracic cavity
Bed rest
Check for expectoration of blood
Monitor VS
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Physiologic Responses to
Respiratory Dysfunction
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Hypoxia
Refers to inadequate cellular oxygenation
May result from:
Insufficient oxygen intake
Insufficient perfusion of oxygen in the
pulmonary system or in the peripheral organs
and tissues
Inability of blood to transport oxygen
Insufficient oxygen-carrying capacity of the
blood.
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Cyanosis
Bluish discoloration of the skin indicating
hypoxia; it results when oxygenation
does not occur and carbon dioxide does
not leave blood.
Dyspnea
Difficult breathing
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Increased work of breathing
Occurs when energy expenditure for
respirations is excessive and great effort
is required for breathing
Tachypnea
Rapid breathing with respiratory rates
more than 20 cpm.
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Cough
If effective, it allows the body to expel
excess mucus, keeping the airway clear.
If ineffective, in compromises airway
clearance by preventing mucus from
being expelled.
Along with mucociliary system, cough is
a defense mechanism of the respiratory
system.
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Adventitious breath sounds
These are abnormal breath sounds:
Rales (crackles) - fluid is heard
Rhonchi (gurgles) – mucus is heard
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Clubbing of Fingers
Clubbing is an increase in the normal
angle between the nail and its base (from
160 to 180 degrees or more)
Accompanied by softening of nail base
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Fatigue
Feelings of tiredness and exhaustion that
usually result when energy requirements
for breathing become excessive
Pain
May or may not be present
Due to rib-cage injury, infection or chest
surgery
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Hypoventilation
Refers to a ventilation rate that is insufficient
to meet the body’s metabolic needs
May result in respiratory acidosis because
Carbon Dioxide are not expelled off
Hyperventilation
Refers to a ventilation rate that exceeds the
body’s metabolic needs
May result in respiratory alkalosis because
excessive Carbon Dioxide is being expelled
off. 29
ALTERATIONS
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Epistaxis
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Causes:
Trauma, HPN, cancer, foreign body
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Nursing interventions:
Sit-up, lean forward, head tipped
Pressure application for 5 min
Cold compress or ice pack
Liquid, then soft diet
Avoid oral temp taking
Do not blow nose for 2 days after removal
of nasal pack
Notify MD if epistaxis is persistent or
recurrent
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Sinusitis
(Acute/Chronic)
URTI, cigarette smoking, allergic rhinitis
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Assessment
Pain
1. Maxillary – cheek, upper teeth
2. Frontal – above eyebrows
3. Ethmoid – in & around eyes
4. Sphenoid – behind eye, occiput, top of
head
General body malaise
Stuffy nose headache
Post nasal drip
Persistent cough
Fever 35
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Nursing Intervention
Rest
Increase oral fluid intake
Hot wet packs
Codeine, avoid ASA – increase risk for
bleeding
Antibiotics (acute: 7 days, chronic: 21
days)
Nasal decongestant – use for 72 hrs
Irrigation of maxillary sinus with warm 37
Tonsillitis
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Assessment:
Sore throat
Fever
Snoring
Dysphagia
Mouth breathing
Earache
Frequent head colds
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Bronchitis
Halitosis
Voice impairment
Noisy respiration
Draining ears
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Nursing Intervention:
Promote rest
Increase oral fluid intake
Warm saline gargle
Analgesics as ordered
Antimicrobial as ordered
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Pre op Care:
Assess for URTI, coughing &
sneezing may cause bleeding
Check prothrombin Time
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Post op Care:
Prone, head turned to side or lateral position
(awake: semi-fowlers)
Oral airway until swallowing reflex returns
Monitor for hemorrhage
1. Frequent swallowing
2. Bright red vomitus
3. Increased PR
Promote comfort
Ice collar
acetaminophen
Foods & fluids
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Client Education:
Avoid clearing of throat
Avoid coughing, clearing of throat for 2 wks
2-3 L of fluids until mouth odor disappears
Avoid hard scratchy food until throat is
healed
Reports signs of bleeding
Throat discomfort on the 4-8 post op day is
normal
Stool may be black/dark for few days due to
swallowed blood.
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“It’s all right letting
yourself go, as long
as you can get
yourself back.”
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