CP 26 Nursing Assessment - Respiratory System.

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Lewis, Section 5 - Problems of Oxygenation: Ventilation - CP 26, Nursing Assessment - Respiratory System. Points to go over in Lewis: Table 26-2 Inadequate Oxygenation. Table 26-3 Critical Values for PaO2 and SpO2. Table 26-4 Gerontologic Differences. Table 26-5 for Respiratory System Assessment Health History what to ask. Pg 510 - Focused Assessment Table 26-7 Assessment Abnormalities. Table 26-8 Physical Assessment Normalities. Table 26-10 Diagnostic Studies. Table 26-11 TB Testing. Table 26-1…

What is the purpose of the Respiratory System?

Gas exchange. Involves the transfer of oxygen and carbon dioxide between the atmosphere and blood. Oxygen is provided to the tissues, Carbon Dioxide is removed.

What does the Respiratory System influence?

Acid-base balance, speech, smell, and thermoregulation.

What does the upper respiratory tract consist of?

Nose, pharynx, adenoids, tonsils, epiglottis, larynx, and trachea.

What does the lower respiratory tract consist of?

Bronchi, bronchioles, aveolar ducts, and alveoli.

How many lobes does the right lung have?

Three: upper, middle and lower.

How many lobes does the left lung have?

Two: upper, and lower.

What are the structures of the chest wall and what is the importance?

Ribs, pleura, muscles or respiration are important for respiration.

What are Alveoli?

Small sacs that are the primary site of gas exchange in the lungs. Interconnected to the pores of Kohn.

What are the Pores of Kohn?

Allow movement of air from alveolu to alveolus.

How many Alveoli are there in an adult lung?

300 million. Each 0.3 mm in diameter.

What is the tidal volume of an Alveoli?

2500 mL and a surface area for gas exchange about the size of a tennis court.

What condition can reduce gas exchange in Alveoli?

Pulmonary edema, excess fluid fills the interstitial space.

What is Surfactant?

A lipoprotein that lowers the surface tension in alveoli. Reduces the amount of pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse.

What is Atelectasis?

Collapsed, airless alveoli.

What is Ventilation?

Involves inspiration (movement of the air into the lungs) and expiration (movement of the air out of the lungs).

What is Compliance?

Distensibility - is a measure of the ease of expansion of the lungs. This is a product of the elasticity of the lungs and the elastic recoil of the chest wall.

What is Diffusion?

Oxygen and carbon dioxide move back and forth across the alveolar-capillary membrane by diffusion. The overall direction of movement is from the area of higher concentration to lower concentration. Oxygen moves from alveolar gas (atmospheric air) into arterial blood and carbon dioxide from the arterial blood into the alveolar gas. This continues till equilibrium is reached.

What is PaO2?

The amount of oxygen dissolved in the plasma and is expressed in millimeters of mercury (mm Hg).

What is SaO2?

The amount of oxygen bound to hemoglobin in comparison with the amount of oxygen the hemoglobin can carry. This is expressed as a percentage.

What is the Oxygen-Hemoglobin Dissociation Curve?

Describes the affinity of hemoglobin for oxygen.

What are ABG's?

Diagnostic measurement to determine oxygenation status and acid-base balance. Include measurement of PaO2, PACO2, acidity (pH), and bicarbonate (HCO3-).

How are ABG's obtained?

By an arterial puncture or from an arterial catheter, usually in the radial or femoral artery. Both are invasive and allow intermittent analysis. Continuous analysis is available via a fiberoptic sensor or an oxygen electrode inserted into an arterial catheter.

What are Mixed Venous Blood Gases?

Used for patients with impaired cadiac output or hemodynamic instability. Determines the amount of oxygen being delivered to the tissues or consumed.

How are Mixed Venous Blood Gases obtained?

A catheter is positioned in the pulmonary artery, termed a pulmonary artery catheter (PA).

What is Oximetry?

Non-invasive monitoring that can be continuous using a pulse ox probe on the finger, toe, ear, or bridge of nose. SpO2 is monitored.

Where is the respiratory center in the body?

The brainstem in the medulla. Responds to chemical and mechanical signals from the body. Impulses are sent from the medulla to the respiratory muscles through the spinal cord and phrenic nerve.

What are Chemoreceptors?

A receptor that responds to a change in the chemical composition (PaCo2 and pH) of the fluid around it.

Where are central chemoreceptors located?

In the medulla and respond to changes in the hydrogen ion (H+) concentration.

What does an increase in H+ concentrations indicate?

Acidosis and causes the medulla to increase the respiratory rate and tidal volume (VT).

What does a decrease in H+ concentrations indicate?

Alkalosis and has the opposite effect of acidosis. Decrease respiratory rate and tidal volume from the medulla.

Where are peripheral chemoreceptors located?

In the carotid bodies at the birfurcation of the common carotid arteries and in the aortic bodies above and below the aortic arch. Respond to decreases in PaO2 and pH and to increases in PaCO2. Also cause stimulation of the respiratory center.

What are the different Respiratory Defense mechanisms?

Filtration of air, mucociliary clearance system, cough reflex, reflex bronchoconstriction, alveolar macrophages. - Help protect from inhaled particles, MO, and toxic gases.

What happens during Filtration of Air?

Nasal hair filters inspired air. Abrupt changes in direction of airflow cause particles and bacteria to contact the mucosa lining these structures. Most large particles are removed this way. As airflow slows, the larynx facilitates deposition of smaller particles. Smaller particles settle in alveoli.

What is the Mucociliary Clearance System?

The movement of mucus through the respiratory system by aid of cilia. i.e., mucuciliary escalator.

What secretes mucus in the Respiratory System?

100 mL/day by goblet cells and submucosal glands.

What is Reflex Bronchoconstriction?

In response to inhalation of large amounts of irritating substances (e.g., dusts, aerosols), the bronchi constrict in an effort to prevent entry of irritants.

What is an Alveolar Macrophages?

Macrophages the rapidly phagocytize inhaled foreign particles such as bacteria located in the level below the respiratory bronchioles.

What are Gerontologic Structure Alterations for the Respiratory System?

Chest wall stiffening, costal cartilage calcification, decreased elastic recoil, decreased chest wall compliance, increased anterior-posterior diameter, decreased functioning alveoli, decreased muscle strength.

What are the Gerontologic Defense Mechanism Alterations for the Respiratory System?

Decrease cell-mediated immunity, decrease specific antibodies, decrease cilia function, decrease cough force, decrease alveolar macrophage function, decrease sensation in pharynx.

What are the Gerontologic Respiratory Control Alterations for the Respiratory System?

Decrease response to hypoxemia, decrease response to hypercapnia.

What are the Gerontologic differences in assessment findings in relation to Structural Changes with the Respiratory System?

Barrel chest appearance; kyphotic posture; decrease chest wall movement; decrease deep breathing; mucus thickened; decreased vital capacity; increase residual volume; increased functional residual capacity. Decreased breath sounds, particularly at lung bases; decrease PaO2 and SaO2; normal pH and PaCO2.

What are the Gerontologic difference in assessment findings in relation to Defense Mechanisms with the Respiratory System?

Decrease cough effectiveness; decrease secretion clearance, increase risk of upper respiratory aspiration, infection, influenza, pneumonia, respiratory infections may be more severe and last longer.

What are the Gerontologic differences in assessment findings in relation to Respiratory Control with the Respiratory System?

Greater decrease in PaO2 and increase in PaCo2 before RR changes, decrease ability to maintain acid-base balance, significant hypoxemia or hypercapnia may develop from relatively small incidents, retained secretions, excessive sedation, or positioning that impairs chest expansion may substantially alter PaO2 or SpO2 values.

What Subjective Health Information do you need to Assess in a Respiratory Assessment?

Past Health History, Medications, Surgery or Other treatments.

What in a Past Health History is important for a Respiratory Assessment?

Frequency of upper respiratory problems, and if season effects it. Allergies with medications, pollen, smoke, mold or pet exposure. Characteristics and severity of allergic reactions. Frequency of asthma exacerbations and triggers. Hx of lower respiratory problems such as asthma, COPD, pneumonia and TB. History of additional health problems.

What about Medications is important for a Respiratory Assesment?

Through med history. Assess and document prescription, OTC, and herbal meds. Assess for overuse of short-term bronchodilators. Inquire about angiotensin-converting enzyme inhibitors (ACE) as cough can effect. Oxygen documentation.

What about Surgery and other Treatments is important for a Respiratory Assessment?

Determine previous hospitalization for respiratory problems. Note dates, therapies including surgery, and current status of problem. Has the patient ever been Intubated. Do they use nebulizer, humidifier, or airway clearance modalities, high frequency chest oscillation, postural drainage, and percrussion.

What functional health patterns are involved with Respiratory Assessment?

Health perception health management, nutritional-metabolic, elimination, activity-exercise, sleep-rest, cognitive-perceptual, self perception-self concept, role-relationship, sexuality-reproductive, coping-stress tolerance, value-belief.

What important data do you need to collect before examination of the respiratory system?

Vital signs, including temperature, pulse, and respirations, blood pressure, SpO2.

What Physical Objective Data are you going to assess in regards to the Nose of the Respiratory Assessment?

Inspect for patency, inflammation, deformation, symmetry, and discharge. Check each aris for air patency when one is occluded. Inspect interior of nose, mucus membrane, nasal deviation, polyps, discharge.

What Physical Objective Data are you going to assess in regards to the Mouth and Pharynx of the Resporatory Assessment?

Inspect the interior mouth for color, lesions, masses, gum retration, bleeding and poor dentition. Tongue for symmetry and presence of lesions. Pharynx. Tonsils. Gag reflex.

What Physical Objective Data are you going to asses in regards to the Neck of the Respiratory Assessment?

Symmetry, presence of tender or swollen areas. Palpate the lymph nodes.

What Physical Objective Data are you going to assess in regards to the Thorax and Lungs in regards to the Neck of the Respiratory Assessment?

Inspect, palpate, percussion, and auscultate. Observe for respiratory distress, note apperance accessory musles. Chest movements, A-P diameter, RR- depth, rate and rhythm, skin color, tracheal position, chest movements, fremitus.

What is Fremitus?

Vibration of the chest wall produced by vocalization.

What are the normal percussion sounds?

Resonance, hyperresonance, tympany, dull, and flat.

What is Resonance?

Low-pitched sound heard over normal lungs.

What is Hyperresonance?

Loud, lower-pitched sound than normal resonance heard over hyperinflated lungs, such as in COPD and acute asthma.

What is Tympany?

Sound with drumlike, loud, empty quality heard over gas-filled stomach or intestine, or pneumothorax.

What is Dull?

Sound with medium-intensity pitch and duration heard over areas of "mixed" solid and lung tissue, such as over top area of liver, partially consolidated lung tissue (pneumonia) or fluid filled pleural space.

What is Flat?

Soft, high pitched sound of short duration heard over very dense tissue where air is not present, such as posterior chest below level of diaphragm.

What are Adventitious Sounds?

Extra breath sounds that are abnormal. Crackles, rhonchi, wheezes, and pleural friction rub.

What are Crackles?

Short low pitched sounds consisting of discontinuous bubbling caused by air passing through air passing through airway intermittently occluded by mucus, unstable bronchial wall, or fold of mucosa.

What are Rhonchi?

Continuous rubbing, snoring or rattling sounds from obstruction of large airways with secretions.

What are Wheezes?

A form of rhonchus characterized by a continuous high-pitched squeaking sound caused by rapid vibration of bronchial walls.

What is Pleural Friction Rub?

Creking or grating sound from roughened, inflamed surfaces of the pleura rubbing together, evident during inspiration, expiration, or both and no change with coughing.

What can fine crackles indicate?

Idiopathic pulmonary fibrosis, interstitial edema (early pulmonary edema), alveolar filing (pneumonia), loss of lung volume (atelectasis), early phase of heart failure.

What can coarse crackles indicate?

Heart failure, pulmonary edema, pneumonia with severe congestion, COPD.

What can Rhonchi indicate?

COPD, cystic fibrosis, pneumonia, bronchiectasis.

What can Wheezes indicate?

Bronchospasm (Caused by Asthma), airway obstruction (foreign body, or tumor), COPD.

What can Stridor indicate?

Croup, epiglottitis, vocal cord edema extubation, foreign body.

What blood tests are done for the Respiratory System?

Hemoglobin, hematocrit, ABGs, and oximetry.

What Sputum Studies are done for the Respiratory System?

Culture and sensitivity, gram stain, acid fast-smear and culture, cytology.

What radiologic studies are done for the respiratory system?

Chest x-ray, CT, MRI, Ventilation-perfusion (V/Q), pulmonary angiogram, PET.

What Endoscopic studies are done for the respiratory system?

Bronchoscopy, mediastinoscopy.

What type of Biopsy is done for the Respiratory System?

Lung Biopsy.

What other tests can be done with the Respiratory System?

Thoracentesis, and Pulmonary Function tests.

What are skin tests used for with the Respiratory System?

To test for allergic reactions, or exposure to tuberculosis (TB) bacilli or fungi.

What does a positive TB test indicate?

Patient has been exposed to a antigen. It does not indicate that TB is currently present.

What does a negative TB test indicate?

There has been no such exposure or there is a depression of cell-mediated immunity such as occurs in HIV infections.

What are nursing considerations for a TB test?

To prevent false-negative tests, be certain intradermal is done, not sub-q. Circle injection site and instruct pt not to remove marks. Draw a diagram and forearm on chart. Use a good light to read.

What is a Bronchoscopy?

Procedure in which the bronchi are visualized through a fiberoptic tube. Maybe used for diagnostic purposes to obtain biopsy specimens and assess changes resulting from treatments.

What is the bronchoscope coated with?

A local anesthetic lidocaine (Xylocaine).

What is the purpose of a Lung Biopsy?

To obtain tissues, cells, or secretions for evaluation.

What is Thoracentesis?

Insertion of a large bore needle through the chest wall into the pleural space to obtain specimen for diagnostic evaluation, remove pleural fluid, or instill medications into the pleural space.

What is the purpose of Pulmonary Function Testing?

PFT's measure lung volumes and airflow. Diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators.

What is the purpose of Exercise Testing?

Used in diagnosis to determine exercise capacity, and for disability evaluation.

What does a complete Exercise testing involve?

Walking on a treadmill while expired oxygen and carbon dioxide, respiratory rate, heart rate, and heart rhythm are monitored.

What is the purpose of a Ventilation Perfusion (V/Q) test?

Used to assess ventilation and perfusion of the lungs. Radioactive gas is inhaled (xenon or krypton) which outlines alveoli. Normal scans show homogenous radioactivity. Diminished or absent radioactivity suggests lack of perfusion or airflow. Ventilation without perfusion suggest a PE.

What is the purpose of a Pulmonary Angiogram?

Used to visualize pulmonary vasculature and locate obstruction or pathologic condition. Contrast media is injected through a PA cath or right side of the heart. X rays are taken.

What is the purpose of a PET scan?

Used to distinguish between benign and malignant pulmonary nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan, which uses IV radioactive glucose prep, can demonstrate increased uptake of glucose in malignant lung cells.

What is the nursing responsibility for Radiology studies?

Instruct the patient to undress, put on gown, and remove any metal between neck and waste. Assess BUN and creatinine, and allergy to shellfish (iodine) if contrast used. Contrast may cause warming or flush. Relaxation or other modes to cope. Encourage fluids after.

What is Tidal Volume and the normal value?

Volume of air inhaled and exhaled with each breath; only a small proportion of total capacity of lungs. - 0.5 L.

What is Expiratory Reserve Volume (ERV) and normal volume?

Additional air that can be forcefully exhaled after normal exhalation is complete. - 1.0 L.

What is Residual Volume (RV) and normal values?

Amount of air remaining in lungs after forced expiration; air available in lungs for gas exchange between breathes. - 1.5 L.

What is Inspiratory Reserve Volume and normal values?

Maximum volume of air that can be inhaled forcefully after normal inhalation. - 3.0 L.

What is Total Lung Capacity (TLC)?

Maxiumum volume of air that lungs can contain. (TLC = IRV + Vt + ERV + RV) - 6.0 L.

What is Functional Residual Capacity (FRC)?

Volume of air remaining in lungs at end of normal exhalation (FRC = ERV + RV); increase or decrease possible with lung disease. - 2.5 L.

What is Vital Capacity (VC)?

Maximum volume of air that can be exhaled after maximum inspiration (VC = IRV + Vt + ERV) higher VC for men generally. - 4.5 L.

What is Inspiratory Capacity (IC)?

Maximum volume of air that can be inhaled after normal expiration (IC = Vt + IRV). - 3.5 L.

What are the systems you evaluate for signs and symptoms of inadequate oxygenation?

CNS - apprehension, restlesness, irritability, combativeness, coma, respiratory - tachypnea, dyspnea, accessory muscles, retraction, pausing, cardiovascular - tachycardia, hypertension, dysrhythmias, hypotension, cyanosis, clamyness. Also diaphoresis, urinary output decrease and fatique.

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