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PRELIMS OXYGENATION HANDOUT#2

Assessment

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

-Dyspnea, Orthopnea-Cough (hacking, brassy, wheezing, productive, nonproductive)-Increased sputum production (purulent, rusty, bloody, mucoid)-Angina pectoris-Wheezing, crackles-Clubbing of fingers-hemoptysis-cyanosis (buccal, peripheral)

b. Risk Factors associated with respiratory diseases-personal or family hx of lung disease-smoking (most significant contributing factor in lung disease)-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 (body size, age, skin quality and color, posture)-configuration and movement of the thorax during respiration-characteristics of respiration (rate, rhythm, depth, used muscles)-presence of cough and characteristics of sputum (clear, purulent, bloody, tenacious)-note clubbing of fingers (angle of nailbed >160 degrees, distal phalangeal depth > interphalengeal

depth)-softening of nailbeds

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

c. Percussion-chest sounds (resonant is air-filled lung, dull or flat suggests presence of firm mass)

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

prominent on inspiration)-normal large airways: bronchial sounds (high-pitched, tubular sounds w/ slight pause between

inspiration and expiration)-bronchovesicular sounds (combination of vesicular and bronchial): heard anteriorly to the right or left

of sternum, Posteriorly between scapulae, inspiration and expiration equal-adventitious breath sounds: crackles (fine to coarse), wheezes (sibilant or sonorous), pleural friction

rub

3. Laboratory and Diagnostic Tests

a.Radiographic & Scanning PURPOSE: -to visualize structures

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

b.Endoscopic StudiesPURPOSE:-invasive, visualize structures, obtain specimen

BronchoscopyEsophagoscopyMediastinoscopy

c.ThoracentesisPURPOSE: -needle aspiration of pleural fluid (dx & tx), not for the lungs

d.Needle Biopsy

GreywolfRedSECTION 1 level 3


PURPOSE:-invasive, tissue analysis of the lung and pleura

e.Pulse OximetryPURPOSE-monitoring of oxygen saturation of hemoglobin

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

f.Sputum CulturePURPOSE-to diagnose pathogens

g.SpirometryPURPOSE-determine lung volumes, ventilator function, airway resistance, distribution of gases(Pulmonary Function Test)

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

-determines previous exposure to tuberculosis : Purified Protein Derivative (PPD) Test

i.ABG AnalysisPURPOSE-studies arterial blood gases

Respiratory Acidosis Respiratory Alkalosis Metabolic Acidosis Metabolic Alkalosis

pH Ph < 7.35 Ph > 7.35 Ph < 7.35 Ph > 7.35

Carb PaCO2 > 45 mmHg PaCO2 < 45 mmHg HCO3 < 22 mEq/L HCO3 > 26 mEq/L

CO2 = acid CO2 = acid HCO3 = base HCO3 = base

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 DBEPositioningSuctioningO2Monitor: VS, ABG, PONeuro Assess

Treat causeEncourage slow breaths

Administer NaCO3Monitor: VS, I&O, ABG, DysrSeizure Precautions

Restore F&EMonitor: VS, I&O, ABG, DysrNeuro Assess

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 - not thinking about quittingb. Contemplation - thinking about quitting in the next 6 monthsc. Preparation - thinking about quitting in the next 30 daysd. Action - in the process of quittinge. Maintenance - abstaining from tobacco use for 6 months or more

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-200 occupational asthma triggers, most common: chemical vapors in paper & textile mills,

chemical/printing plants, hair salons-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-indicates how deep a breath the client has taken

c. Monitoring Peak Flow-uses a peak flow meter (hand-held device that measures highest flow during maximal expiration)-indicates how rapidly a client can breathe out air-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 (tend to

thicken secretionsc. 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 — open narrowed airwaysMucolytic agents — liquefy or loosen thick secretionsCorticosteroids — reduce inflammation in airways

Types of InhalersNebulizers — disperse fine particles of medication into deeper passages of respiratory tract where

absorption occursMetered dose inhalers — delivers controlled dose of medication with each compression of the canisterDry powder inhaler — activated by the patient’s inspiration

8. Administering Cardiopulmonary Resuscitation

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 or deficit in oxygenation/carbon dioxide elimination at an alveolar-capillary level

Overview on Respiratory Alterations

Respiratory Dysfunctions1. Hypoxia-inadequate cellular oxygen

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

2. hypoxemia reduced oxygen tension in arterial blood- PaO2 less than 80 mm Hg

3. hypercapnia increased carbon dioxide tension in arterial blood - PaCO2 greater than 45 mm Hg

4. hypocapnia decreased carbon dioxide tension in arterial blood - 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 (chronic airflow limitation)-group of disorders associated with persistent/recurrent obstruction of airflow (chronic bronchitis,

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

-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 (right side of heart)6. Pleural Effusion

-collection of fluid in the pleural space7. Chest Trauma

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

tracheobronchial tree, esophagus)c. open pneumothorax (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 (noncardiogenic pulmonary edema)-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 inflam, injury (blood, teeth, tongue), anaphylaxis

10. 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


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