ncm 103 handout

PRELIMS OXYGENATION HANDOUT#2

Assessment

1. Health Historya. Cardinal signs and symptoms of respiratory dysfunction:

-Dyspnea, Orthopnea-Cough

Productive Non productive

-Increased sputum production -Wheezing, crackles-Clubbing of fingers-hemoptysis-cyanosis

b. Risk Factors associated with respiratory diseases-personal or family hx of lung disease-smoking-occupational exposure to allergens, environmental pollutants-age-related changes in lung capacity and respiratory function-hx of URTI-post-op changes resulting in diminished respiratory function

2. Physical Examinationa. Inspection

-general appearance-configuration and movement of the thorax during respiration-characteristics of respiration-presence of cough and characteristics of sputum (clear, purulent, bloody, tenacious)-note clubbing of fingers-softening of nailbeds

b. Palpation-chest for tender areas, mases on surface-evaluate chest excursion-presence of fremitus

c. Percussion-chest sounds

d. Auscultation-listen to air movement of lungs (normal vs. adventitious)-normal, clear lungs: __________________________________________ (low-pitched, rustling sound over most

of lung field more prominent on inspiration)-normal large airways: _________________________________________ (high-pitched, tubular sounds w/ slight

pause between inspiration and expiration)-bronchovesicular sounds _______________________________________: heard anteriorly to the right or left of

sternum, Posteriorly between scapulae, inspiration and expiration equal-adventitious breath sounds: _________________ (fine to coarse), ______________________ (sibilant or

sonorous),

3. Laboratory and Diagnostic Tests

a.Radiographic & Scanning PURPOSE: -_________________________________________________________________________

Chest RadiographyChest TomographyLung ScanComputed Tomography ScanPosition-emission Tomography ScanFluoroscopy (for bronchial tubes)

b.Endoscopic StudiesPURPOSE:-__________________________________________________________________________

BronchoscopyEsophagoscopyMediastinoscopy

c.ThoracentesisPURPOSE: -__________________________________________________________________________

d.Needle Biopsy

GreywolfRedSECTION F


PURPOSE:-__________________________________________________________________________

e.Pulse OximetryPURPOSE-___________________________________________________________________________

-93% to 100% : normal-93% : respiratory compromise

f.Sputum CulturePURPOSE-___________________________________________________________________________

g.SpirometryPURPOSE-___________________________________________________________________________(Pulmonary Function Test)

h.Skin TestsPURPOSE-determines causes of airway hypersensitivity in asthmatic clients (prevention)

-determines previous exposure to tuberculosis : __________________________________________________________________ (PPD) Test

i.ABG AnalysisPURPOSE-studies arterial blood gases

Respiratory Acidosis Respiratory Alkalosis Metabolic Acidosis Metabolic Alkalosis

pH

Carb

Causes

Respiratory failure / arrestPulmonary edema COPDPneumonia PneumothoraxAtelectasis OverdoseAspiration

HyperventilationPainAnxietyHypoxemiaVentilators

Diabetic ketoacidosisStarvation (ketoacidosis)Renal FailureDiarrheaAcetylsalicylic Acid Poisoning

VomitingNGTDiureticsAntacidsBicarb overdose (IV Tx)

S/S Sudden: CR LOCFeeling of fullnessDysrhythmiasChronic:WeaknessDull Headache

LightheadednessUnability to concentrateNumbnessTinglingTinnitus

Changes in LOC(confusion, drowsiness)h/n/vKussmaul’s respirations( rate depth)Dysrhythmias

TinglingDizzinessBradypnea Hypertonic musclesDysrhythmias

Tx

Health Promotion



1.Preventing Respiratory Infections / Health teaching limits exposure to and occurrence of ARI(flu, pneumonia)

-avoid exposure to known infected people, large crowds during peak flu season-good hygiene practices (handwashing, covering mouth & nose when sneezing/coughing, proper tissue

disposal)-high risk people should receive annual flu vaccinations

2. Encouraging Smoking Cessation-a positive step toward health regardless of the length of time a person has been a smoker-State-of-Change Theory provides a basis for understanding the process underlying changing an

addictive habit:a. Precontemplation - ___________________________________________b. Contemplation - ___________________________________________c. Preparation - ___________________________________________d. Action - ___________________________________________e. Maintenance - ___________________________________________

Relapse is common during smoking cessation attempts. Provide + encouragement, explain it takes more than one attempt to successfully stop smoking

3.Reducing Allergens / Advocate a pollution-free environment-reducing allergens that trigger bronchoconstriction and inflammation-aspirin sensitivity, cold air, exercise can induce an attack

4. Promoting Proper Breathinga. Deep Breathing

-helps expand alveoli and promote effective cough-shallow breathing leads to mucous plugging, atelectasis, hypoxemia, pneumonia

b. Incentive Spirometry-motivates deep breathing (usually visually), and take increasingly deeper breaths-____________________________________________________________________

c. Monitoring Peak Flow-uses a peak flow meter (hand-held device that measures highest flow during maximal expiration)-____________________________________________________________________-changes in peak flow measurements reflects changes in airway diameter

5. Promoting Comforta. Positioning and Ambulation

-prevents pooling of mucus, decreases risk of bacterial colonization and infection-help shift respiratory mucus into portions of the airways where it may generate a cough,

expectoration easier-encourage progressive ambulation for clients with dyspnea with exertion

b. Maintaining Adequate Hydration-to maintain mobility of respiratory mucus-6 to 8 glasses a day, preferably water [caffeinated bev & alcohol (diuretic f/x), milk products

c. Providing humidified aird. Performing chest physicotherapye. Maintaining good nutrition to promote optimal immune function

6. Managing Chest Tubes-assist with insertion and removal of chest tube-monitor the patient’s respiratory status and vital signs-check the dressing-maintain the patency and integrity of the drainage system

7. Meeting Respiratory Needs with Medicationsa. Cough suppressants, Expectorants, Lozengesb. Inhaled Medications

Bronchodilators — ______________________________________________________________Mucolytic agents — ______________________________________________________________Corticosteroids — ______________________________________________________________

Types of Inhalers______________________________— disperse fine particles of medication into deeper passages of

respiratory tract where absorption occurs______________________________ — delivers controlled dose of medication with each compression of the

canister



_______________________________ — activated by the patient’s inspiration

Nursing Diagnoses

1. Ineffective Breathing Pattern-state in which a person’s inspiration/expiration pattern does not provide adequate ventilation

2. Ineffective Airway Clearance-the state in which a person is unable to clear secretions or obstructions from the respiratory tract to maintain

a clear airway3. Impaired Gas Exchange

-state in which a person experiences an excess/deficit in oxygenation/carbon dioxide elimination at an alveolar-capillary level

Overview on Respiratory Alterations

Respiratory Dysfunctions1. Hypoxia-____________________________________________________

- increased, rapid pulse, rapid, shallow respirations and dyspnea, increased restlessness or lightheadedness, flaring of the nares, substernal and/or intercostal retractions, cyanosis

2. hypoxemia _________________________________________________- PaO2 less than 80 mm Hg

3. hypercapnia _______________________________________________ - PaCO2 greater than 45 mm Hg

4. hypocapnia ________________________________________________ - PaCO2 less than 35 mm Hg

Respiratory Disorders1. Pneumonia

-inflammatory process of bronchioles, alveolar space/walls/lobes-caused by chemical irritants, bacteria, virus, fungi, parasites

2. COPD (_______________________________________________)-group of disorders associated with persistent/recurrent obstruction of airflow (chronic bronchitis,

emphysema, asthma)3. Occupational Lung Disease (__________________________________)

-nonneoplastic alterations of the lung-caused by exposure to organic/inorganic dusts, gases in the workplace (silicosis, asbestosis, CWP –

black lung)4. Acute Respiratory Failure

-results when exchange of O2 for CO2 in the lungs cannot match the rate of O2 consumption and CO2 production in body cells 5. Pulmonary Embolism

-obstruction of one or more pulmonary arteries by thrombus originating from the venous system 6. Pleural Effusion

-collection of fluid in the pleural space7. Chest Trauma

-injury to the chest wall or lungsa._____________________________ (blood in pleural space) – penetrating or blunt chest injury b._____________________________ (air in pleural space) – disease or injury (lacerations of the lung,

tracheobronchial tree, esophagus)c. _____________________________ (sucking chest wound) – penetrating chest injury

8. Acute Respiratory Distress Syndrome (ARDS)-clinical syndrome characterized by pulmonary edema, progressive in arterial O2 content-occurs after serious illness or injury, accumulation of lung fluids (____________________________________)-caused by aspirations, drug overdose, prolonged inhalation of high concentrations of O2, smoke,

corrosives, shock, Systemic infection, trauma (pulmonary contusions, multiple fractures, head injury)

9. Airway Obstruction-any mechanical impediment of O2 delivery or absorption in the lungs-obstruction by aspirated food, foreign objects, laryngospasm/edema due to inflammation, injury,

anaphylaxis10. Near-drowning

-pathologic status of a person surviving events that lead to drowning-asphyxia and aspiration are primary problems-alcohol ingestions is an important factor in adult drowning deaths

11. Mechanical Ventilation-maintains ventilation and O2 delivery for a prolonged period-indicated during continuous decease in oxygenation, increase in arterial CO2, persistent acidosis


ncm 103 handout

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