Respiratory
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128 terms
Terms | Definitions |
|---|---|
 Respiratory nursing diagnosis | Impaired airway clearance Ineffective breathing pattern Impaired gas exchange |
| Process of respiration | Ventilation-movement of air out of the lungs Diffusion-movement of gas across membranes Perfusion- passing of blood through the lung tissue |
| Paranasal sinuses | Frontal, Ethmoid, Maxillary and Sphenoid Air filled cavities within the bones surrounding the nasal passages |
| Serves as a passageway for both respiratory and digestive tracts | The Pharynx |
| The Pharynx | Located behind the oral and nasal cavities Divided into the nasopharynx, the oropharynx, and the laryngopharynx |
| Contains the adenoids (pharyngeal tonsils) and the distal opening of the Eustachian tube | Nasopharynx |
| Extends from the soft palate to the base of the tongue | Oropharynx |
| Located behind the larynx, extending from the base of the tongue to the esophagus | Laryngopharynx |
| Dividing point where solid food and fluids are separated from air | Laryngopharynx |
| Passageway divides into the larynx and the esophagus | Laryngopharynx |
| Composed of thyroid cartridge (Adams Apple) cricoid cartilage (containing the vocal cords) and the arytenoid cartilage (used in vocal cord movement) | Larynx |
| at the top of the larynx folds during swallowing to prevent aspiration | Epiglottis |
| Begins at the lower edge of the cricoid cartilage and extends to the fourth or fifth thoracic vertebrae | The Trachea |
| Branches into the left and right main stem bronchi at the carina | The Trachea |
| Begins at the carina | Mainstem Bronchi |
| Which Bronchus is wider, shorter and more vertical than the left | Right |
| site of foreign object aspiration and accidental intubation when endotracheal tube passed | Right bronchus |
| do not participate in gas exchange | Terminal bronchioles |
| basic unit of gas exchange within the capillaries | Alveoli |
| fatty protein secreted by the alveoli , reduces surface tension | Surfactant |
| (collapse of the alveoli) occurs without sufficient surfactant | Atelectasis |
| Location of the apex of the lungs | The apex in each lung is above the clavicles, the base just above the diaphragm |
| major of muscle of inspiration | The diaphragm |
| larger lung and divided into three lobes | Right |
| lung divided into two lobes | left |
| Chest wall innervated by the | phrenic and intercostal nerves |
| the bronchi innervated by the | vagus nerve |
| measure of elasticity, expansion and distension of the lungs; stiff lungs have decreased compliance | Compliance |
| Accessory Muscles of Respiration | -Scalene Muscles -Sternocleidomastoid muscles -Trapezius and pectoralis muscle -Abdominal muscles |
| Bupropion (Zyban, Wellbutrin SR) Chantix | Stimulates CNS dopamine pathways involved in reward and addiction Reduces withdrawal symptoms, nicotine craving Reduces weight gain in quitters as long as they are on the drug Start one week before quit date to achieve blood levels. |
| AP diameter of chest compared to the lateral diameter | 1:2 to 5:7 |
| Palpation of thorax: Increased fremitus | fluid filled or dense |
| Palpation of thorax: decreased fremitus | pleural space filled with air, fluid or obstruction |
| Palpation of thorax: Absent fremitus | no air, lung colapsed |
| vibration that you can feel with the palm of your hands when someone says "blue moon" or "99" | Tactile fremitus |
| Normal Breath Sounds harsh, hollow sounds heard over the trachea and mainstem bronchi | Bronchial or Tubular |
| Normal Breath Sounds moderate, mixed quality heard over the branching bronchi | Bronchovesicular |
| Normal Breath Sounds soft, rustling sound heard over peripheral lung fields. | Vesicular |
| popping, discontinuous sounds; air moving into previously deflated airways | Crackles |
| low-pitched, course, continuous snoring sounds; arise in large airways | low-pitched, course, continuous snoring sounds; arise in large airways |
| continuous squeaky, high pitched, musical sounds; narrowed airways | Wheezes |
| loud, grating scratching sounds; inflamed pleura rubbing together | Pleural Friction Rub |
| abnormal, loud, clear, transmission of voice sounds through an area of density; clearly transmitted spoken "99" (fluid or tumor) | Bronchopony |
| abnormally enhanced vocal resonance with high pitched nasal | Egophony |
| enhanced voice sounds; distinct whispered sounds. | Whispered pectoriloquy |
| Changes Associated with Aging | Alveolar surface decreases Elastic recoil decreases Airway closes early Muscles atrophy Pulmonary capillary blood volume decreases Effectiveness of cilia decreases Body's response to hypoxia and hypercarbia decreases |
| Identifies individuals who have been exposed to Mycobacterium Tuberculosis | Tuberculin Skin Testing (Mantoux) |
| Tuberculin Skin Testing (Mantoux) | Inject 0.1 ml of purified protein derivative (PPD) into inner aspect of forearm with needle bevel up. Validate wheal formation. Read in 48-72 hours for induration, 0-4mm induration is negative |
| Throat Cultures | Performed to detect group A beta hemolytic streptococci Patient tilt neck, swab both tonsillar pillars and posterior pharynx using a tongue depressor to prevent contact with mouth flora Place swab in culture tube, name date initials and Pt label Routine culture gives results in 12-24 hours. Rapid strep takes 10-30 minutes |
| Sputum Studies | -Must come from lungs not the mouth -Done upon awakening after rinsing mouth -Take several deep breaths and then cough using diaphragm -Expectorate into sterile container |
| Pulse Oximetery | -Quick, convenient method of monitoring -Identifies what percent of hemoglobin saturation with oxygen -Normal values 95-100%(4% or 90) |
| Esophagram- | films taken after barium swallowed; NPO; watch for signs of constipation for 2-3 days |
| Angiogram | inject dye into pulmonary vasculature; NPO, consent, monitor VS Q15 and observe for bleeding |
| V/Q Scan | Ventilation/perfusion scan, films taken after radioactive due injected; substance clears the body in 8 hours. |
| RBC female | 4.2-5.4 |
| RBC male | 4.7-6.1 |
| Hemoglobin | Females 12-16 Males 14-18 |
| Hematocrit | Three times the hemoglobin Females 37%-47% Males 42%-52% |
| These tests evaluate lung volumes and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, and distribution of ventilation. | Pulmonary Function Testing |
| Pulmonary Function Testing values: considered abnormal | <Less than 80% |
| Pulmonary Function Testing values: Considered poor pulmonary performance | <50% |
| Pulmonary Function Tests | -Performed at the bedside, R/T lab by a RT -Pt breathe through the mouth only -Observe pt for increased dyspnea or bronchospasm |
| Flow rates | -Peak flow- forced expiratory volume in first second of expiration after full inspiration; valuable measurement of airway obstruction -Used in patients with asthma -Done during times of attack |
| Exercise testing | -Increase metabolism and gas transport -Assesses ADL's, differentiates reasons for exercise limitation, evaluates disease, determines if oxygen is needed -Done on a treadmill -Teach patient about close pt monitoring |
| assesses larynx, vocal cords, remove foreign bodies and take tissue samples | Laryngoscopy |
| performed in OR under general anesthesia, assesses for tumors, tissue samples. Tube is inserted thru the chest wall above the | Mediastinoscopy |
| Bronchoscopy | -Into the secondary bronchi -Purpose view structures, obtain tissue samples, diagnosis and manage pulmonary disease, most useful in staging cancer and removal of secretions -In ICU, or operating room |
| Bronchoscopy cont' | Explain procedure, obtain consent Allergies, time out, two identifiers Labs-CBC, PT, Electrolytes, chest x ray NPO for 4-8 Hours Premedicate with benzodiazepines & opioids Benzocaine spray can cause methemoglobinemia, lidocaine can be used as an alternate |
| can cause methemoglobinemia, | Benzocaine spray |
| Can be used as an alternative to Benzocaine spray: | Lidocaine |
| Treatment for Methemoglobinemia | IV administration of 1% of methylene blue and supplemental oxygen, NOTIFY RAPID RESPONSE TEAM! |
| Methemoglobinemia | -A conversion of normal hemoglobin to methemoglobin -An altered state of iron leading to tissue hypoxia -Normal level 1% -Monitor for cyanosis after topical anesthetic, blood is chocolate brown colored |
| Bronchoscopy Procedure | Performed in ICU, bedside Maintain IV access Assess vital signs, oxygen saturation, administer supplemental oxygen |
| Bronchoscopy post procedure nursing care | Monitor for return of gag reflex -Monitor vital signs, breath sounds, o2 saturation Q 15 minutes -Assess for complications including infection, bleeding, hypoxemia -Pink tinged sputum normal |
| aspiration of pleural fluid or air from the pleural space: | Thoracentesis |
| Thoracentesis | -Microscopic examination of pleural fluid assists in making a diagnosis -Pleural fluid drained to relieve pulmonary compression and respiratory distress caused by cancer, empyema, pleurisy, or tuberculosis. |
| Patient Preparation for Thoracentesis | -Need a consent -Allergies to anesthetics -Done at the bedside -Need a chest x-ray prior and after -Monitor VS during procedure -Cont Pulse Ox sat -Patient preparation for stinging sensation and -feeling of pressure -Correct position -Motionless patient |
| Thoracentesis Procedure | -NP or Physician -Guided with CT or US -Drape and clean site -No more than 1000 mL removed -Biopsy -Apply pressure to site |
| Thoracentesis follow up | -Chest x ray -Monitor VS, auscultate breath sounds -Monitor site -Assess for complications-sq emphysema, infection, pneumothorax, reaccumulation of fluid |
| Thoracentesis Nursing interventions | -Encourage deep breathing -Document procedure -Volume and character of fluid -Send specimen to lab -Location of site -Respiratory assessment before, during and after -Teach pt of manifestations of pneumothorax, and to seek emergency help if manifestations occur |
| Manifestations of Pneumothorax | -Pain on affected side, worse at the end of inhalation & at the end of exhalation -Tachycardic -Tachypnea -Shallow respirations -Feeling of air hunger -Prominence of affected side that does not move in and out with respiratory effort -Trachea deviation to the unaffected side |
| Lung Biopsy | -Performed to obtain tissue for histologic analysis, culture, or cytologic examination. -Patient preparation. -May be performed in patient's room. |
| Lung Biopsy Follow-up care: | Assess vital signs and breath sounds at least every 4 hr for 24 hr. Assess for respiratory distress. Report reduced or absent breath sounds immediately (pneumothorax) Monitor for hemoptysis. |
| low levels of oxygen in the blood | Hypoxemia |
| decreased tissue oxygenation | Hypoxia |
| Goal of oxygen therapy | -to use the lowest fraction of inspired oxygen for an acceptable blood oxygen level without causing harmful side effects |
| PaO2 level | 80-100mm Hg partial pressure of arterial oxygen |
| SaO2 level | 95%-100% arterial oxygen saturation |
| Hazards and Complications of Oxygen Therapy | -Combustion -Oxygen-induced hypoventilation -Oxygen toxicity -Absorption atelectasis -Drying of mucous membranes -Infection |
| Oxygen induced hypoventilation | -COPD patient -Hypoxic drive -Oxygen therapy 1-3L/min, venturi mask preferred -Monitor respiratory rate and depth -Manifestations seen first 30 minutes -Ashen to pink then apnea or respiratory arrest -Monitor LOC, respiratory rate and pattern and pulse oximetry |
| Oxygen toxicity | -Oxygen greater than 50% for more than 24-48 hours -Monitor ABG notify HCP Paco2 90mm Hg Identify patients at high risk -CPAPA,BIPAP,PEEP,mechanical Ventilation |
| Early clinical manifestationsof oxygen toxcity | nonproductive cough, substernal chest pain, GI upset, dyspnea. |
| Late symptoms of oxygen toxicity | -decrease vital capacity, decrease lung compliance, crackles and hypoxemia, atelectasis, pulmonary edema, hemorrhage |
| Absorption atelectasis | -Increase O2, decrease nitrogen causes collapse of the alveoli- crackles and decreased breath sounds -Drying mucous Membranes -Infection |
| Low Flow Oxygen Delivery Systems Nasal Cannula | 24% 1L/min 28% 2L/min 32% 3L/min 36% 4L/min 40% 5L/min 44% 6L/min |
| Low-Flow Oxygen Delivery Systems | -Nasal cannula -Simple facemask -Partial rebreather mask -Non-rebreather mask |
| Low Flow Oxygen Delivery System: Simple Face Mask | -40%-60% 5-8L/min (5L needed to prevent rebreathing of exhaled air) |
| Low Flow Oxygen Delivery System: Partial Rebreather Mask | 60%-75% 6-11L/min- Reservoir Bag must stay inflated |
| Low Flow Oxygen Delivery Systems: Non- Rebreather Mask | 80%-95%- maintain reservoir bag two thirds full Monitor patient closely, keep valves and flaps patient. Delivers 100% |
| High-Flow Oxygen Delivery Systems: Venturi mask | -Can deliver precise high flow rates of O2 despite breathing pattern; can be used to deliver humidity; interferes with eating and talking; do not cover entrainment ports with sheets |
| High-Flow Oxygen Delivery Systems: Face tent | 24%-100% with flow rates of at least 10L/min |
| High-Flow Oxygen Delivery Systems: Aerosol mask | 24%-100% with flow rates of at least 10L/min |
| High-Flow Oxygen Delivery Systems: Tracheostomy collar | 24%-100% with flow rates of at least 10L/min |
| High-Flow Oxygen Delivery Systems: T-Piece | 24%-100% with flow rates of at least 10L/min |
| mechanical delivery of set positive inspiratory pressure each time the patient begins to inspire; as the patient begins to exhale, the machine delivers a lower set end-expiratory pressure, together improving tidal volume. | BiPAP |
| continuous positive airway pressure throughout each cycle of inhalation and exhalation | CPAP |
| Continuous Nasal Positive Airway Pressure | -Technique delivers a set positive airway pressure throughout each cycle of inhalation and exhalation. -Effect is to open collapsed alveoli. -Patients who may benefit include those with atelectasis after surgery or cardiac-induced pulmonary edema; it may be used for sleep apnea. |
| Transtracheal Oxygen Delivery | -Used for long-term delivery of oxygen directly into the lungs -Avoids the irritation that nasal prongs cause and is more comfortable -Flow rate prescribed for rest and for activity |
| Nursing Interventions for the patient on o2 therapy | -Right dose, right administration -Monitor patency -Monitor Sao2 and ABG values -Monitor Vital signs -Monitor for signs of hypoxia Teach patient about therapy -Monitor for skin breakdown -Monitor breath sounds -Monitor for complications |
| s the surgical incision into the trachea for the purpose of establishing an airway. | Tracheotomy |
| is the stoma, or opening, that results from the procedure of a tracheotomy. | Tracheostomy |
| Tracheostomy Postoperative care | -ensure patent airway, breath sounds, and respiratory assessment Q2 hours |
| Tracheostomy Possible complications assessment: | -Tube obstruction -Tube dislodgment—accidental decannulation -Pneumothorax -Subcutaneous emphysema -Bleeding -infection |
| Tracheostomy : Tube Obstruction | -Dyspnea, noisy respirations, unable to suction, thick secretions -Interventions: assess hourly, TCDB, provide inner cannula care, humidify o2, & suction |
| Cuff displacement | Notify HCP or NP |
| Tube dislodgement & accidental decannulation | -Prevent-secure tube -First 72 hours is emergency -At bedside trach insertion tray, trach tube same size or smaller -Nursing intervention for dislodgement -First ventilate -Call for help |
| First 72 hours after Tracheostomy must have at bedside: | trach insertion tray, trach tube same size or smaller |
| Decannulation | After 72 hours extend neck, replace tube |
| Other complications r/t Tracheostomy | -Pneumothorax -Subcutaneous emphysema: Puffy skin, notify md immediately -Bleeding: Small amount normal, oozing abnormal -wrap with gauze -Infection:: Sterile technique No cutting if gauze Change as soiled or order by HCP or protocol |
| Care Issues for the Tracheostomy Patient: Prevention of tissue damage: | Cuff pressure can cause mucosal ischemia. Use minimal leak technique and occlusive technique. Check cuff pressure often. Prevent tube friction and movement. Prevent and treat malnutrition, hemodynamic instability, or hypoxia. |
| Air Warming and Humidification | -The tracheostomy tube bypasses the nose and mouth, which normally humidify, warm, and filter the air. -Air must be humidified. -Maintain proper temperature. -Ensure adequate hydration. |
| Suctioning | -Suctioning maintains a patent airway and promotes gas exchange. -Assess need for suctioning from the patient who cannot cough adequately. -Suctioning is done through the nose or the mouth. |
| Suctioning can cause: | -Hypoxia (see causes to follow) -Tissue (mucosal) trauma -Infection -Vagal stimulation and bronchospasm -Cardiac dysrhythmias from hypoxia caused by suctioning |
| Causes of Hypoxia in the Tracheostomy | -Ineffective oxygenation before, during, and after suctioning -Use of a catheter that is too large for the artificial airway -Prolonged suctioning time -Excessive suction pressure -Too frequent suctioning |
| Possible Complications of Suctioning | -Tissue trauma -Infection of lungs by bacteria from the mouth -Vagal stimulation—stop suctioning immediately and oxygenate patient manually with 100% oxygen -Bronchospasm—may require a bronchodilator |
| Possible Complications of Suctioning: Vagal stimulation | stop suctioning immediately and oxygenate patient manually with 100% oxygen |
| Possible Complications of Suctioning: Bronchospasm | may require a bronchodilator |
| Tracheostomy Care | -Assessment of the patient. -Secure tracheostomy tubes in place. -Prevent accidental decannulation. |
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