MEDICAL SURGICAL NURSING 1 TASK: BRONCHOSCOPY, LARYNGOSCOPY, CHEST INTUBATION, INCENTIVE, Summaries of Surgical Pathology

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DEPARTMENT OF NURSING

UNIT TITLE: MEDICAL SURGICAL NURSING 1

TASK: BRONCHOSCOPY, LARYNGOSCOPY, CHEST

INTUBATION, INCENTIVES, TRACHEOSTOMY &

SPIROMETRY.

Table of Contents

Introduction

Medical procedures such as laryngoscopy, bronchoscopy, tracheostomy, chest intubation, and incentives are day to day procedures in the health et up. This paper provides a clear concise overview of each procedure, explaining its purpose techniques involved and any associated risks or complications

Bronchoscopy

A bronchoscopy is an endoscopic medical procedure that is used to look inside the airways and the lungs. It involves inserting a bronchoscope which is a narrow tube that has a light and a camera on one end through the nose or mouth and guiding it down through the truck here in order to get an interval view of the respiratory system. It may be done to diagnosis or condition such as lung cancer or infection or to treat a medical problems such as a foreign object that slowly in the airways.

How the Test is Performed

A bronchoscope is a device used to see the inside of the airways and lungs. The scope can be flexible or rigid. A flexible scope is almost always used. It is a tube less than one half inch ( centimeter) wide and about 2 feet (60 centimeters) long. In rare cases, a rigid bronchoscope is used.

i. Medicines are administered through a vein (IV, or intravenously) to help the patient relax. Or, they may be asleep under general anesthesia, especially if a rigid scope is used. ii. A numbing drug (anesthetic) will be sprayed in the patients mouth and throat. If bronchoscopy is done through the nose, numbing jelly will be placed in the nostril the tube goes through. iii. The scope is gently inserted. It will likely make the patient cough at first. The coughing will stop as the numbing drug begins to work. iv. The health care provider may send saline solution through the tube. This washes the lungs and allows the health care provider to collect samples of lung cells, fluids, microbes and other materials inside the air sacs. This part of the procedure is called a lavage.

v. Sometimes, tiny brushes, needles, or forceps may be passed through the bronchoscope to take very small tissue samples (biopsies) from your lungs. vi. The health care provider can also place a stent in the airway or view the lungs with ultrasound during the procedure. A stent is a small tube-like medical device. Ultrasound is a painless imaging method that allows your provider to see inside your body. vii. Sometimes ultrasound is used to see the lymph nodes and tissues around the airways, and small needles can be inserted there to obtain tissue and make certain diagnoses. viii. At the end of the procedure, the scope is removed.

How to Prepare for bronchoscopy

For the patient, they are : i. Not to eat or drink anything for 6 to 12 hours before the test. ii. Not to take aspirin, ibuprofen, or other blood-thinning drugs before the procedure. Ask the provider who will do the bronchoscopy if and when to stop taking these drugs. iii. Arrange for a ride to and from the hospital. iv. Arrange for help with work, child care, or other tasks, as they will likely need to rest the next day. v. The test is most often done as an outpatient procedure, and they will go home the same day. Rarely, some people may need to stay overnight in the hospital. For the nurse: Ahead of the bronchoscopy procedure, the nurse’s role involves providing information on what to expect and what to avoid, helping relieve anxiety. The patient must be given a full explanation of the procedure, including risks, benefits and alternatives, as well as the preparation required. Other important tasks for nurses before the procedure include the following: i. Ensuring informed consent has been signed. ii. Collecting medical history, noting any known allergies. iii. Checking NPO status to reduce risk of aspiration. iv. Monitoring vital signs, including heart rate, blood pressure, respiratory rate and oxygen saturation. v. Instructing on oral hygiene and remove dentures if appropriate.

ii. To biopsy lymph nodes near the lungs. iii. To see why a patient is coughing up blood. iv. To explain shortness of breath or low oxygen levels. v. To see if there is a foreign object in airway. vi. If a patient has a cough that has lasted more than 3 months without any clear cause. vii. If there is an infection in the lungs and major airways (bronchi) that cannot be diagnosed any other way or need a certain type of diagnosis. viii. If inhaled a toxic gas or chemical. ix. To see if a lung rejection after a lung transplant is occurring. x. To treat a lung or airway problem. For example, it may be done to: xi. Remove fluid or mucus plugs from your airways xii. Remove a foreign object from your airways xiii. Widen (dilate) an airway that is blocked or narrowed xiv. Drain an abscess xv. Treat cancer using a number of different techniques xvi. Wash out an airway

Results for Bronchoscopy

Normal results; Normal results mean normal cells and fluids are found. No foreign substances or blockages are seen. Abnormal results; i. Many disorders can be diagnosed with bronchoscopy, including: ii. Infections from bacteria, viruses, fungi, parasites, or tuberculosis. iii. Lung damage related to allergic-type reactions. iv. Lung disorders in which the deep lung tissues become inflamed due to the immune system response, and then damaged. For example, changes from sarcoidosis or rheumatoid arthritis may be found. v. Lung cancer, or cancer in the area between the lungs. vi. Narrowing (stenosis) of the trachea or bronchi. vii. Acute rejection or infection after a lung transplant.

Risks of the test

Main risks of bronchoscopy are:

i) Bleeding from biopsy sites (most dangerous complication in very rare occasions) ii) Infection

There is also a small risk for:

i. Abnormal heart rhythms ii. Breathing difficulties iii. Fever iv. Heart attack, in people with existing heart disease v. Low blood oxygen vi. Collapsed lung vii. Sore throat

Risks when general anesthesia is used include:

i. Muscle pain ii. Change in blood pressure iii. Slower heart rate iv. Nausea and vomiting

Laryngoscopy

Laryngoscopy is a test healthcare providers perform to examine the larynx (voice box). They perform this test with a laryngoscope, a thin tube with lights, a lens and video cameras that help them to look closely at the larynx. Laryngoscopes may have tools the healthcare provider can use to remove tissue from the larynx.

How the test is performed

Laryngoscopy can be done in different ways:

i. Indirect laryngoscopy uses a small mirror held at the back of the throat. The health care provider shines a light on the mirror to view the throat area. This is a simple procedure.

v. Difficulty swallowing vi. Ear pain that does not go away vii. Feeling that something is stuck in your throat viii. Long-term upper respiratory problem in a smoker ix. Mass in the head or neck area with signs of cancer x. Throat pain that does not go away xi. Voice problems that last more than 3 weeks, including hoarseness, weak voice, raspy voice, or no voice A direct laryngoscopy may also be used to: i. Remove a sample of tissue in the throat for closer examination under a microscope (biopsy) ii. Remove an object that is blocking the airway (for example, a swallowed a marble or coin)

Results for the test

A normal result means the throat, voice box, and vocal cords appear normal. Abnormal results may be due to: i. Acid reflux (GERD), which can cause redness and swelling of the vocal cords ii. Cancer of the throat or voice box iii. Nodules on the vocal cords iv. Polyps (benign lumps) on the voice box v. Inflammation in the throat vi. Thinning of the muscle and tissue in the voice box (presbylaryngis)

Risks associted with the test

Laryngoscopy is a safe procedure. Risks depend on the specific procedure, but may include: i. Allergic reaction to anesthesia, including breathing and heart problems ii. Infection iii. Major bleeding iv. Nosebleed

v. Spasm of the vocal cords, which causes breathing problems vi. Ulcers in the lining of the mouth/throat vii. Injury to the tongue or lips

Considerations for the test

Indirect mirror laryngoscopy should NOT be done:

i. In infants or very young children ii. If you have acute epiglottitis, an infection or swelling of the flap of tissue in front of the voice box iii. If you cannot open your mouth very wide

Tracheostomy

A tracheostomy is a surgical procedure in which a surgeon creates a hole through the neck and into trachea (windpipe). The goal is to deliver oxygen to lungs easily and safely. A patient might need a tracheostomy if they have an obstructed upper airway or an underlying health condition. A tracheostomy may be temporary or permanent.

Procedure Details

What happens before a tracheostomy?

The healthcare provider will tell the patient how to prepare for the tracheostomy procedure. If patient will be under general anesthesia, they may need to fast for several hours before the appointment. Sometimes, a tracheostomy is done as emergency treatment. In these cases, there won’t be any preparation time.

What happens during a tracheostomy?

In most cases, tracheostomy will be done under general anesthesia. Once patient is comfortable, the surgeon will create an incision (cut) in the neck, just below the Adam’s apple. This incision will also go through the trachea (windpipe). Next, the surgeon will open the hole wide enough to fit a tracheostomy tube inside of it.

iv. Damage to trachea (windpipe). v. Tracheo-esophageal fistula (an abnormal opening between trachea and esophagus). vi. Injury to recurrent laryngeal nerve (the nerve that moves vocal cords). vii. Blocked tracheostomy. (Mucus or blood clots can block tracheostomy tube.) viii. Air that becomes trapped in lungs, chest or under the skin around tracheostomy.

Keeping tracheostomy tube clean and following all recommended guidelines can reduce risk of developing these complications.

Chest Intubation

Chest tube is a hollow, flexible tube placed into the chest. It acts as a drain.Chest tubes drain blood, fluid, or air from around lungs, heart, or esophagus. The tube around lung is placed between the ribs and into the space between the inner lining and the outer lining of chest cavity. This is called the pleural space. It allows lungs to fully expand.

Why the procedure is performed

Chest tubes are used to treat conditions that cause a lung to collapse. Some of these conditions are: i. Surgery or trauma in the chest ii. Air leaks from inside the lung into the chest (pneumothorax) iii. Fluid buildup in the chest (called a pleural effusion) due to bleeding into the chest, buildup of fatty fluid, abscess or pus buildup in the lung or the chest, or heart failure iv. A tear in the esophagus (the tube that allows food to go from the mouth to the stomach)

How the procedure is performed

A doctor may put a person under general anesthesia for a chest tube insertion. Alternatively, they will use a local anesthetic to numb the area before inserting the tube and will also provide the person with sedation and pain medications.

There are different incision approaches for inserting the chest tube, but the procedure will follow the same essential steps: i. Elevating the head of a person’s bed by 30–60 degrees. Someone will usually raise the arm on the affected side above the head. ii. Identifying the tube insertion site. This will typically be between the fourth and fifth ribs or between the fifth and sixth ribs, just behind the pectoralis (chest) muscle. iii. Cleaning the skin with a solution, such as povidone-iodine or chlorhexidine. Doctors will allow the skin to dry before placing a sterile drape over the patient. iv. Using local anesthetic to numb the insertion site. Once the area is completely numb, a doctor may insert a needle more deeply to see if they can pull back fluid or air. This will confirm that they are in the right area. v. Making an incision of about 2–3 centimeters (cm) through the skin. Using a surgical instrument called a Kelly clamp, the doctor will widen the incision and gain access to the pleural space. The clamp insertion should be slow to avoid puncturing the lung. vi. Inserting a gloved finger into the incision site. This is to confirm that the area is the pleural space. The doctor will also feel for unexpected findings, such as a mass or scar tissue. vii. Inserting the chest tube through the incision site. If fluid begins to drain through the tube, it is in the right place. It is also possible to attach the tube to a chamber containing water that moves when a person breathes. If this does not occur, the tube may need repositioning. viii. Suturing the tube in place so that the seal is as airtight as possible. ix. Covering the tube insertion site with gauze pads. x. A chest X-ray can also help to confirm the tube’s placement.

Risks of the procedure

Some risks from the insertion procedure are: i. Bleeding or infection where the tube is inserted ii. Improper placement of the tube (into the tissues, abdomen, or too far in the chest) iii. Injury to the lung iv. Injury to organs near the tube, such as the spleen, liver, stomach, or diaphragm

Spirometry Measurements:

Forced Vital Capacity (FVC): The total volume of air that can be forcibly exhaled after taking a deep breath.

Forced Expiratory Volume in one second (FEV1):The volume of air exhaled in the first second of the FVC maneuver.

FEV1/FVC Ratio: Used to distinguish between obstructive and restrictive lung diseases.

Spirometry is essential for identifying respiratory issues early and for guiding treatment and management of chronic lung conditions.

How spirometry is performed

Preparation:

The patient is usually seated and a clip is placed on their nose to keep the nostrils closed.

The patient is then asked to take a deep breath and exhale into a mouthpiece connected to a spirometer.

The Procedure :

The patient inhales deeply to fill their lungs with as much air as possible.

They then exhale as forcefully and quickly as possible into the mouthpiece.

This process may be repeated several times to ensure consistency and accuracy of the results.

The spirometer records the volume and flow of air, producing a graph called a spirogram.

Measurements Taken:

Forced Vital Capacity (FVC): The total amount of air exhaled during the test.

Forced Expiratory Volume in one second (FEV1): The amount of air exhaled in the first second.

FEV1/FVC ratio: A calculated ratio used to diagnose obstructive and restrictive airway diseases.

Clinical Presentation:

Patients who undergo spirometry typically present with symptoms indicative of lung function impairment, including:

• Shortness of breath (dyspnea)
• Chronic cough
• Wheezing
• Increased mucus production
• Chest tightness or discomfort
• Fatigue, especially with exertion

Reasons for Conducting Spirometry

a.) Diagnosis : To help diagnose conditions such as asthma, chronic obstructive pulmonary disease (COPD), and other disorders that affect breathing.

Diagnostic Procedures

Spirometry is performed to assess the following. It is done by:

1. Preparation:
   • Taking patient history and physical examination.
   • Instruction on proper technique and purpose of the test.
2. Procedure:
   • Patient sits comfortably and wears a nose clip.
   • Takes a deep breath in and then exhales forcefully into the spirometer.
   • Multiple attempts (usually three) to ensure consistent and accurate results.
3. Measurements:
   • Forced Vital Capacity (FVC): Total volume of air exhaled.

1. Pneumothorax (Collapsed Lung):
   • Although extremely rare, there is a small risk of pneumothorax in patients with certain lung conditions, such as severe emphysema or lung fibrosis.
2. Increased Intrathoracic Pressure: - The forceful exhalation can temporarily increase pressure in the chest, which may be problematic for individuals with cardiovascular issues, recent surgery, or eye surgery.
3. Exacerbation of Symptoms:
   • In patients with severe obstructive or restrictive lung diseases, the test could potentially exacerbate their symptoms..

Incentive Spirometry

An incentive spirometer is a medical device that helps measure lung capacity and exercise the lungs. The device can often help people who have undergone surgery, but it may help people with other conditions as well.

Incentive spirometers are common tools in respiratory, speech, and physical therapy. They are usually easy to use and inexpensive, serving as visual aids for people who need to assess how well their lungs function.

How to use an incentive spirometer

The person using the incentive spirometer should:

i. Sit on a chair or the edge of their bed. ii. Hold the incentive spirometer upright. iii. Breathe out, then close their lips tightly around the mouthpiece. iv. Breathing only through their mouth they should take a slow, deep breath in. The ball or piston will move toward the top of the chamber. If the device has a marked area to aim for when inhaling, they should use this as a guide. v. They should hold breath for as long as the doctor tells them to. This may be a period of a few seconds or for as long as they can.

vi. Take the mouthpiece out of their mouth and release breath. The ball or piston will settle at the bottom of the chamber. vii. Take a short break, then repeat the steps.

The doctor will help the patient to determine how often to use an incentive spirometer. If the patient experiences any complications while using the incentive spirometer — such as shortness of breath, lightheadedness, or coughing — talk with the doctor before continuing.

How to measure the results from an incentive

spirometer

An incentive spirometer can measure lung capacity and improve overall lung function.

The main chamber of an incentive spirometer has lines with numbers that can help to measure the volume of breath. These numbers are usually milliliters (ml).

When a person inhales through the mouthpiece, the piston or ball in the main chamber will rise and allow them to see how many milliliters of air they can hold in their lungs. This can then let the doctor set a higher goal.

For example, if you have undergone lung surgery or have a lung condition, you may only be able to reach 1000 ml. Your doctor may then set a goal of 1500 ml and have you work with the incentive spirometer until you can reach that goal.

Typical range for someone using an incentive spirometer

The typical range for spirometry varies based on factors such as age, height, sex assigned at birth, and general health. The doctor can take these factors into account when setting goals for an incentive spirometer.

Who needs an incentive spirometer

An incentive spirometer can help people with breathing difficulties or weakened lungs measure their lung capacity and strengthen their respiratory muscles. There are many conditions that can impair breathing and lung function, increasing the need for an incentive spirometer.