TAFE NSW Training and Education Support Industry Skills Unit, Meadowbank HLTEN609A Practise in the respiratory nursing environment Version 1.0 Flexible Learning Resource Product Code: 2639 ISO 9001
HLTEN609A Practise in the respiratory nursing environment V1.0 i Acknowledgments TAFE NSW Training and Education Support, Industry Skills Unit, Meadowbank would like to acknowledge the support and assistance of the following people in the production of this resource package. Writer: Kylie Brennan Project Manager: Di Dawbin R/Education Programs Manager Training and Education Support, Industry Skills Unit, Meadowbank Acknowledgements are also given to all TAFE NSW teachers of the Enrolled Nurse Education Program. Enquiries: Enquiries about this and other publications can be made to: TAFE NSW Training and Education Support, Industry Skills Unit, Meadowbank Locked Bag No. 6 MEADOWBANK NSW 2114 Tel: 02-9942 3200 Fax: 02-9942 3257 The State of New South Wales, Department of Education and Training, TAFE NSW, Training and Education Support, Industry Skills Unit, Meadowbank, 2009. Copyright of this material is reserved to Training and Education Support, Industry Skills Unit, Meadowbank, TAFE NSW. Reproduction or transmittal in whole or in part, other than for the purposes of private study or research, and subject to the provisions of the Copyright Act, is prohibited without the written authority of Training and Education Support, Industry Skills Unit, Meadowbank. ISBN 978-0-7348-9047-4 ISO 9001
HLTEN609A Practise in the respiratory nursing environment V1.0 v TABLE OF CONTENTS INTRODUCTION... 1 LEARNER INFORMATION... 2 TOPIC 1 Apply pathophysiology of the respiratory system... 11 TOPIC 2 Determine respiratory health status... 21 TOPIC 3 Multidisciplinary health care team... 33 TOPIC 4 Nursing care plan... 35 TOPIC 5 Complex nursing interventions... 39 TOPIC 6 Pre-, intra- and post- care of respiratory diagnostic procedures... 51 TOPIC 7 Evaluate effectiveness of interventions... 57 Assessment requirements... 59 Resource List... 62 ISO 9001
HLTEN609A Practise in the respiratory nursing environment V1.0 11 TOPIC 1 Apply pathophysiology of the respiratory system In your study of the core unit HLTEN606A Assess clients and manage client care the learner was provided with an in-depth knowledge of the pathophysiology of the human body. It also provided the learner with the skills and knowledge to understand the development of diseases and the effect they have on the body. This unit will provide the learner with the skills knowledge and attitudes to practise in the respiratory nursing environment. Topic 1 will explore the pathophysiology of the respiratory system and will focus on the clinical manifestations and nursing care of common respiratory conditions. Please Note: You will require a human anatomy and physiology textbook to assist you in reviewing the anatomy and physiology of the human body. It is advised that the learner review the anatomy and physiology of the respiratory system by reading topic 1 In-depth understanding of pathophysiology of the human body in HLTEN606A Assess clients and manage client care. Pathophysiology is one way of discovering what happens inside the body when the normal functioning of the body is interrupted. A simple definition of pathophysiology is a change in function in an individual due to a disease. ACTIVITY 1 From the following list of disorders/conditions of the respiratory system choose five (5) and answer the following questions. You may use the internet or relevant textbook. Pneumonia Chronic obstructive pulmonary disease (COPD) Asthma Emphysema Lung cancer Cystic Fibrosis Haemo/pneumothorax Tuberculosis Pulmonary oedema Pulmonary embolism Sleep apnoea Acute respiratory distress syndrome ( ARDS) 1. Define the disease/condition 2. Describe the pathophysiology of the disease/condition 3. List the clinical manifestations of the disease/condition 4. Outline the treatment of the disease/condition The specific nursing care of these conditions will be reviewed in Topic 4.
12 HLTEN609A Practise in the respiratory nursing environment V1.0 Suggested websites for each disease/condition Pneumonia http://science.jrank.org/pages/5358/pneumonia-pathophysiology-pneumonia.html http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/pneumonia_explained?opendocument http://www.virtualrespiratorycentre.com/diseases.asp?did=38 http://www.health.nsw.gov.au/topics/pneum.html COPD http://www.virtualrespiratorycentre.com/diseases.asp?did=17 http://www.nlm.nih.gov/medlineplus/copdchronicobstructivepulmonarydisease.html Asthma http://www.nationalasthma.org.au/html/home/index.asp http://www.nlm.nih.gov/medlineplus/asthma.html Emphysema http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/emphysema_explained?open http://www.virtualrespiratorycentre.com/diseases.asp?did=18 Lung cancer http://findarticles.com/p/articles/mi_m0fss/is_4_15/ai_n17214425 http://www.medsurgnursing.net/ceonline/2008/article08231235.pdf http://www.health.nsw.gov.au/topics/lungcancer.html Cystic Fibrosis http://www.cysticfibrosis.org.au/ http://www.nlm.nih.gov/medlineplus/cysticfibrosis.html http://www.drugdigest.org/dd/hc/treatment/0,4047,851,00.html http://www.medicinenet.com/cystic_fibrosis/page5.htm http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/cystic_fibrosis Haemo/pneumothorax http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=8351 http://www.virtualrespiratorycentre.com/diseases.asp?did=8 Tuberculosis http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/tuberculosis_treatment?opendocument http://www.virtualinfectioncentre.com/diseases.asp?did=40#progression http://www.virtualinfectioncentre.com/diseases.asp?did=40 http://www.healthinfonet.ecu.edu.au/html/html_health/specific_aspects/infectious/tuberculosis/tuberculosis_inde x.htm http://www.public.health.wa.gov.au/cproot/1001/2/hp%207901%20january%202007web.pdf http://www.health.nsw.gov.au/factsheets/infectious/tuberculosis.html Pulmonary oedema http://www.virtualrespiratorycentre.com/diseases.asp?did=23 http://www.allhealth.com.au/html/s02_article/article_view.asp?keyword=pulmonary-oedema Pulmonary embolism http://www.virtualbloodcentre.com/diseases.asp?did=21 http://jcsmr.anu.edu.au/technegas/diagnosis_and_managementof_pulmo.htm http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/deep_vein_thrombosis?opendocument http://www.australiandoctor.com.au/news/94/0c027f94.asp http://www.mja.com.au/public/issues/182_11_060605/lee10890_fm.html
HLTEN609A Practise in the respiratory nursing environment V1.0 13 Sleep apnoea http://www.lungnet.com.au/content/view/91/96/ http://www.healthinsite.gov.au/content/external/page.cfm?objid=0008f3c4-fdd0-1d2b- BE8883032BFA006D&PID=6089 Acute respiratory distress syndrome ( ARDS) http://www.virtualrespiratorycentre.com/diseases.asp?did=26 http://intensivecare.hsnet.nsw.gov.au/current/community/conditions/ards#3
HLTEN609A Practise in the respiratory nursing environment V1.0 21 TOPIC 2 Determine respiratory health status In determining a client s respiratory heath status the nurse is performing the first stage of the nursing process: assessment. This assessment will include an interview with the client (and significant other) and a physical examination. This will enable the nurse to identify the needs of the client and implement appropriate nursing interventions. By conducting a client interview the nurse will be able to obtain vital information that will assist in determining the client s respiratory health status. This information should include the client s past history such as recent surgery, coexisting conditions, allergies and current medications. The client s family medical history should also be ascertained as well as their occupational and social history. The nurse should also question the client about the presence of a cough, dyspnoea, chest pain, wheezing or haemoptysis. If any of these clinical manifestations are present the nurse should further question the client about the nature and extent of these problems. If the client has complained about dyspnoea the nurse should grade this according to the table below. Grade Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 (Bruck, L and Brenna, HM 2005) ACTIVITY 1 Description Not troubled with breathlessness except with strenuous exercise Troubled by breathlessness when walking up a slight hill Has to stop to catch their breath when walking at the client s normal pace on a level path Stops to breath after walking 100 metres Breathless when dressing or undressing What questions would you ask the client if, during a respiratory assessment, they complained of a wheeze and cough? During the client assessment it is important that the client and significant other s knowledge is assessed regarding the respiratory condition, management of the condition and individual treatment regimes (if already established) should be reviewed. Initially when an assessment on a client is conducted to determine their respiratory health status the nurse should conduct a physical examination. A physical examination of a client involves an investigation of the body to determine its state of health using any or all of the techniques of inspection, palpation, auscultation, percussion and smell (Anderson, DM, Keith, J, Novak, PD and Elliot, MA 2006). The assessment also involves the taking and recording of vital signs, height and weight.
22 HLTEN609A Practise in the respiratory nursing environment V1.0 Inspection is the first step in a physical examination and involves a visual examination of the client. This skill is used to assess colour, rashes, scars, body shape, facial expression and body structures and is an active process rather than a passive one. When conducting a respiratory assessment, the nurse should examine: the nares for flaring how the client is breathing - open mouthed or through the nose skin colour (cyanosis) clubbing of fingers chest symmetry The client fingers are checked for clubbing to assess for chronic tissue hypoxia. To assess the client s chest symmetry the nurse should place their hands on the chest wall with thumbs together at the second intercostal space. The client is directed to breathe in and as this is happening the nurse is watching the movement of their thumbs. The thumbs should separate simultaneously and equally to a distance several centimetres away from the sternum. This should be repeated at the 5 th intercostal space. (Bruck, L & Brenna, H.M., 2005) ACTIVITY 2 2008 A.D.A.M., Inc. What conditions would cause the client s chest to rise asymmetrically? Chest abnormalities can also be identified during inspection. Four chest abnormalities are: Barrel chest Pectus carinatum (pigeon chest) Pectus excavatum Thoracic kyphoscoliosis