Nursing Care Plan (NCP) for Bronchoscopy (Procedure)
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Outline
Lesson Objective for Bronchoscopy
- Understanding the Procedure:
- Provide detailed information to the patient about the bronchoscopy procedure, including its purpose, potential benefits, and what to expect during and after the examination.
- Preparation and Pre-procedural Care:
- Ensure the patient comprehends and follows the necessary pre-procedural instructions, including fasting, medication adjustments, and any required laboratory tests or imaging.
- Informed Consent:
- Facilitate the informed consent process, ensuring the patient fully understands the risks, benefits, and alternatives to bronchoscopy before consenting to the procedure.
- Managing Anxiety and Discomfort:
- Develop strategies to address patient anxiety and discomfort related to the procedure, incorporating relaxation techniques and providing reassurance throughout the pre-procedural and post-procedural phases.
- Post-procedural Care and Follow-up:
- Educate the patient on post-bronchoscopy care, potential side effects, and the importance of following up with the healthcare provider for results and further management.
Pathophysiology of Bronchoscopy
- Scope Insertion and Visualization:
- A bronchoscope, a flexible tube with a light and camera, is inserted through the patient’s nose or mouth and down the airways, allowing direct visualization of the bronchial passages and lungs.
- Diagnostic and Therapeutic Procedures:
- Bronchoscopy serves both diagnostic and therapeutic purposes. It enables the collection of samples (biopsy, cytology, culture) for further examination and allows for interventions such as removing foreign bodies or placing stents.
- Visualization of Abnormalities:
- The procedure helps identify and assess abnormalities in the respiratory system, such as tumors, inflammation, infections, or structural issues, aiding in the diagnosis and management of respiratory conditions.
- Pulmonary Function Assessment:
- Bronchoscopy provides an opportunity to assess pulmonary function by evaluating airway patency, detecting obstructions, and gauging the overall health of the respiratory system.
- Potential Complications:
- While generally safe, bronchoscopy carries potential risks, including bleeding, infection, or respiratory compromise. Understanding the pathophysiology involves recognizing these potential complications and taking appropriate precautions to minimize risk.
Etiology of Need for Bronchoscopy
- Diagnostic Investigation:
- The primary reason for bronchoscopy is to investigate and diagnose various respiratory conditions, including but not limited to lung cancer, infections, pulmonary fibrosis, or persistent cough of unknown origin.
- Evaluation of Abnormal Imaging Findings:
- Patients with abnormal chest X-rays or CT scans may undergo bronchoscopy to obtain more detailed information about the nature and extent of the identified abnormalities.
- Assessment of Respiratory Symptoms:
- Individuals presenting with symptoms such as hemoptysis (coughing up blood), unexplained shortness of breath, or persistent cough may undergo bronchoscopy to identify the underlying cause.
- Guidance for Treatment Decisions:
- Bronchoscopy is often performed to obtain samples for histological examination, aiding in the determination of treatment strategies, especially in cases of suspected lung cancer or other pulmonary diseases.
- Therapeutic Interventions:
- Besides its diagnostic role, bronchoscopy can be employed for therapeutic purposes, such as removing foreign bodies, clearing airway obstructions, or placing stents to alleviate bronchial strictures.
Desired Outcome after Bronchoscopy
- Accurate Diagnosis:
- Achieve a precise and timely diagnosis of the underlying respiratory condition or disease, providing essential information for subsequent management.
- Treatment Planning:
- Facilitate the development of an effective and personalized treatment plan based on the identified pathology, ensuring optimal care and improved patient outcomes.
- Resolution of Symptoms:
- Alleviate or resolve respiratory symptoms such as cough, shortness of breath, or hemoptysis, contributing to an enhanced quality of life for the patient.
- Prevention of complications:
- The patient does not experience complications during or after the procedure, such as aspiration, pneumothorax or bleeding.
- Early Intervention for Lung Cancer:
- Enable early detection of lung cancer, if present, leading to timely initiation of appropriate therapeutic measures and potentially improving long-term survival rates.
- Patient Education and Support:
- Provide comprehensive education to the patient regarding the diagnosis, treatment options, and potential lifestyle modifications, fostering active participation in their healthcare journey.
Bronchoscopy (Procedure) Nursing Care Plan
Subjective Data:
Indications
- Patient reports persistent cough
Complications
- Shortness of breath
- Dyspnea
- Chest tightness
- Restless/anxious
- Dysphagia/difficulty swallowing
Objective Data:
Indications
- Hemoptysis
- Abnormal findings on chest x-ray (mass/lesion)
- Known obstruction
- Excessive secretions, especially if thick
- Rhonchi or crackles
Complications
- Coughing when trying to swallow
- Decreased SpO2
- Increased RR
- Hemoptysis
- Wheezing
- Rhonchi/Crackles
Nursing Assessment after Bronchoscopy
- Respiratory Status:
- Monitor respiratory rate, depth, and pattern to identify any changes or abnormalities post-bronchoscopy.
- Vital Signs:
- Continuously assess vital signs, including heart rate, blood pressure, and oxygen saturation, to detect any signs of instability.
- Bleeding and Hemodynamic Stability:
- Evaluate for signs of bleeding such as hemoptysis and assess hemodynamic stability to detect potential complications.
- Pulmonary Function:
- Monitor pulmonary function, including lung sounds and chest movement, to ensure adequate ventilation and oxygenation.
- Pain Assessment:
- Assess the patient’s pain level at the site of bronchoscopy or any discomfort, providing appropriate pain management interventions.
- Level of Consciousness:
- Evaluate the patient’s level of consciousness and orientation to detect any neurological changes or adverse reactions to medications.
- Fluid Balance:
- Monitor fluid intake and output to assess for imbalances or signs of dehydration, especially if the patient has received sedation.
- Patient Education and Psychosocial Assessment:
- Engage in patient education regarding post-procedural care, potential complications, and recovery expectations. Assess psychosocial aspects, addressing any concerns or anxiety related to the procedure.
Implementation after Bronchoscopy
- Post-Procedure Monitoring:
- Continuously monitor the patient for the initial post-procedure period, paying close attention to respiratory and hemodynamic parameters.
- Verify the patient’s gag reflex is present before initiating oral intake, as local numbing agents may be utilized during scope insertion.
- Airway Management:
- Provide appropriate airway management, ensuring the patient maintains a patent airway and administering supplemental oxygen as needed.
- Auscultate breath sounds to detect potential pneumothorax post-procedure.
- Monitor the patient’s secretions. Pink or blood-tinged sputum may be expectorated after the procedure. Bright red or copious amounts of sputum would be concerning.
- Pain Management:
- Administer prescribed pain medications as needed and assess the patient’s pain level regularly. Employ non-pharmacological interventions, such as positioning for comfort.
- Fluid Management:
- Maintain adequate hydration, monitoring intravenous fluids, and encouraging oral intake as tolerated to prevent dehydration.
- Patient Education:
- Offer detailed post-procedure instructions, including signs of complications, activity restrictions, and follow-up appointments. Ensure the patient understands and follows the recommended care plan.
Nursing Interventions and Rationales
- Ensure informed consent is obtained and the patient is educated about the procedure
Informed consent should be obtained by the provider, including indications, risks, and possible complications of the procedure. You, the nurse, should simply ensure it is done and witness the patient’s signature.
- Keep patient NPO for 6-8 hours prior to the procedure
The patient is at high risk for aspiration, which is increased if they have had anything to eat or drink in the last 6-8 hours. Emesis could be aspirated into their lungs.
- Ensure emergency equipment available at bedside
As with any procedure involving the airway, emergency equipment should be kept ready at the bedside, including suction, ambu bag, and artificial/advanced airways in case of respiratory distress.
- Insert IV. Administer and manage conscious sedation
Sedation should be given to make the patient drowsy and comfortable, but still able to follow commands. Follow facility policy and medication orders from the provider for conscious sedation administration/monitoring.
- Monitor Vital Signs, LOC, Respiratory status before, during, and after procedure per facility policy.
- Obtaining a baseline assessment and set of vital signs helps to know if anything has changed during or after the procedure.
- Monitor VS during procedure per facility guidelines for conscious sedation – being alert for possible respiratory distress.
- Monitor vitals and LOC after procedure to ensure patient wakes up safely from conscious sedation and recovers well.
- Place in High-Fowler’s position and administer supplemental O2 as needed
Patient is at risk for aspiration and respiratory distress post-procedure. Placing the patient in high-fowler’s position can improve oxygenation and prevent aspiration. As patients may still be drowsy or could experience some bleeding in the lungs after the procedure, supplemental O2 can help improve oxygen levels.
- NPO after procedure until gag reflex returns
Patients’ throats will be numb because of the numbing spray, this means they may not have a good gag reflex until 1-2 hours post-procedure. Keep NPO until gag reflex returns and patient can safely swallow – prevents aspiration.
- Monitor for possible complications:
- Bleeding
- Bronchospasm
- Respiratory Distress
- Aspiration
- A slight cough with specks of blood or clots is expected, bright red hemoptysis would be an emergency. Bronchospasm presents as severe dyspnea and anxiety with possible wheezing or stridor.
- Assess for signs of aspiration or respiratory distress and intervene as needed (artificial airway, suction, O2)
- Educate patient on post-procedure instructions:
- No driving x 24 hours
- May have cough
- Swallow may be impaired x 1-2 hours
- Sedation may impair response times or ability to safely operate a vehicle or heavy machinery.
- A slight cough is normal but ensure gag reflex has fully returned before eating or drinking, to prevent choking or aspiration.
Evaluation after Bronchoscopy
- Respiratory Status:
- Assess the patient’s respiratory status, monitoring for signs of complications such as increased respiratory rate, decreased oxygen saturation, or difficulty breathing.
- Pain Assessment:
- Evaluate the patient’s pain level using a pain scale and assess the effectiveness of prescribed pain medications. Ensure the patient’s comfort and address any unresolved pain.
- Complications and Adverse Events:
- Evaluate for any procedural complications or adverse events, such as bleeding, infection, or pneumothorax. Promptly address and document any complications that may arise.
- Patient Understanding:
- Assess the patient’s understanding of post-procedure care instructions, ensuring they can articulate signs of complications and know when to seek medical attention. Provide additional education if needed.
References
- http://wps.prenhall.com/wps/media/objects/737/755395/bronchoscopy.pdf
- https://www.medicinenet.com/bronchoscopy/article.htm#bronchoscopy_facts
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Transcript
This is the nursing care plan for the bronchoscopy procedure. So the purpose for a bronchoscopy is to visualize the airways in order to diagnose issues or remove obstructions. Indications for a bronchoscopy indicate persistent cough of unknown origin, excessive thick secretions, that the patient is unable to clear on their own, abnormal findings on a chest x-ray, coughing up blood or hemoptysis, or a lesion or mass that requires biopsy or sampling. Some nursing considerations are that we want to manage sedation. We want to monitor vital signs, draw labs and frequent respiratory assessment. The desired outcome for a patient undergoing a bronch is that we want to be able to identify the cause of symptoms and abnormal findings. We want to obtain samples as needed. And if needed, we want to clear any airway obstruction like foreign bodies, thick sputum. We want to minimize the occurrence of any possible complications.
So the bronchoscopy procedure, this is a unique procedure, because this is really speaking on care, why a patient would come in for a bronch, and so we’re going to focus on that. Some of the subjective things that a patient will report, is they may report a persistent cough. So, let’s write that persistent cough. So, some things that we are going to, uh, maybe as a complication is there may be shortness of breath or dyspnea, which is difficulty breathing. There may be some chest tightness. They may be restless or anxious, dysphasia, which is just difficulty swallowing. There may be some hemoptysis, so bloody sputum. There may also be abnormal findings on a chest x-ray that may indicate a need for a bronchoscopy. There may be a known obstruction that could be a thick sputum. We may hear breath sounds. So breath sounds we may auscultate are ronchi, or crackles. Some other complications may be coughing when trying to swallow. So coughing when swallowing. We may see a decreased SATs. We may see increased respirations or hemoptysis. So, this patient presents with a persistent cough. We may see hemoptysis, we may see different complications, maybe a known obstruction, excessive secretions. So, what are some things that we want to do for a patient who is anticipated with all of these things that’s going on? This patient needs a bronch. So, what are we going to do? Well, first thing is we want to keep that patient NPO, nothing by mouth for at least six to eight hours prior. And the reason why is because this patient is at a high risk for aspiration. If you think about it, we are literally taking a scope to go down into the lungs, into the airway that is going to induce a choking, coughing, possible vomiting, so we want to keep them NPO, so there’s nothing to vomit. Emesis could be aspirated into their lungs. The next thing we want to do is to ensure emergency equipment is at the bedside. The reason why is because with any procedure involving the airway, we need to keep that emergency equipment at the bedside. And these things are going to include suction, ambu bag, maybe we want to do an artificial airway, such as an intubation kit or a tracheotomy kit. We want to monitor this patient for signs of respiratory distress. The next thing we want to do is we want to make sure that this patient has an IV. We want to administer and manage conscious sedation. Remember, this is not a procedure where the patient is going to be wide awake. Looking at you, talking to you. This is the procedure, what we want this patient sedated. So, because we want that sedation, we want to ensure that they are drowsy, comfortable, but if necessary, be able to follow commands.
We want to monitor their vital signs. That includes their level of consciousness, their respiratory status before, during, and after the procedure. We are doing this so that we can get a baseline for the patient. And we get a baseline of vitals. We know if anything has changed, for example, we’re going to get those vitals. Remember, that the level of consciousness after the procedure, we want to ensure the patient wakes up safely from the sedation and recovers well. We want to make sure that they are alert as possible for any possible respiratory distress, especially as a high risk for respiratory distress. Finally, we want to make sure that we put this, you know, this is my favorite position, high Fowler’s, high Fowler’s. We want to set that patient up because this patient is at risk for aspiration of respiratory distress, post-procedure. We want to give them enough room for the chest to properly expand. Remember, patients are coming up from sedation, so they may be drowsy or could experience a bleeding of the lungs after the procedure. We want to make sure to administer any supplemental o2 as necessary to improve their oxygen levels.
So the key points, what are some path physiology behind this? Remember the goal of the Bronch, is to visualize the airways in order to help diagnose issues or remove any obstructions. The subjective data, the patient is going to report a persistent cough. That could be one of the indicators for a Bronch. Something that we may see that may be an indicator for a Bronch is hemoptysis or bleeding, any known obstruction, thick secretions. Some things we want to do are to keep this patient in NPO. We want to keep them NPO for a procedure. This patient is at a high risk for aspiration. They should be NPO for a minimum of six to eight hours prior to the procedure. We want to do a good respiratory assessment. Remember, pre-op during the operation, and post-op complications include atelectasis, bleeding, respiratory distress, and aspiration. We love you guys here and go out and be your best self today. And as always, happy nursing.
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