Lewis - Ch 26 - Respiratory System: Nursing Assessment

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Signs & Symptoms of Inadequate Oxygenation: CENTRAL NERVOUS SYSTEM (CNS) (6)

1. Unexplained apprehension (early)
2. unexplained restlessness or irritability (early)
3. Unexplained confusion or lethargy (early)
4 Combativeness (late)
5. Coma (late)

Signs & Symptoms of Inadequate Oxygenation:
RESPIRATORY (6)

1. Tachypnea (early)
2. Dyspnea on exertion (early)
3. Dyspnea at rest (late)
4. Use of accessory muscles (late)
5. Retraction of inter-spaces in inspiration (late)
6. Pause for breath between sentences, words (late)

Signs & Symptoms of Inadequate Oxygenation:
CARDIOVASCULAR

1. tachycardia (early)
2. mild hypertension (early)
3. Dysrhythmias (early/late)
4. Hypotension (late
5. Cyanosis (late)
6. Cool, clammy skin (late)

Signs & Symptoms of Inadequate Oxygenation:
OTHER

1. Diaphoresis (early/late)
2. Decreased urinary output (early/late)
3. Unexplained fatigue (early/late)

Arterial Blood Gases (ABG) (SEA LEVEL)
PaO2 =
PaCO2 =
pH =
HCO3 =
SaO2 =

PaO2 = 80-100 mm Hg
PaCO2 = 32-48 mm Hg
pH = 7.35-7.45
HCO3 = 22-26 mEq/l
SaO2 = >95%

Venous Blood Gases (VBG)
PvO2
SvO2
PVCO2
HCO3-

PvO2 = 38 - 42 mm Hg
SvO2 = 60 % - 80 %
PVCO2 = 38-55 mm Hg
HCO3- = 22-26 mEq/L (mmol/L)

Lung Volume NORMAL VALUES
Tidal Volume (Tv)
Expiratory Reserve Volume (ERV)
Residual Volume (RV)
Inspiratory Reserve Volume (IRV)

0.5 L
1.0 L
1.5 L
3.0 L

Lung Capacities NORMAL CAPACITIES
Total Lung Capacity (TLC)
Functional Residual Capacity (FRC)
Vital Capacity (VC)
Inspiratory Capacity (IC)

6.0 L
2.5 L
4.5 L
3.5 L

A pt. is considered adequately oxygenated according to the oxy-hemoglobin disassociation curve at a Pa02 above what?

60 mmHg

T or F: A Pa02 above 60 mmHg will increase hemoglobin saturation.

False, that is why the curve shows a level at the top ... hemoglobin sat will NOT increase after Pa02 reaches 60 mmHg

When the curve shifts to the R. 02 is more readily picked up where?

at the tissue level

When the curve shifts to the L. 02 is more readily picked up where?

at the lungs

A shift to the left is caused by what 3 things? Give 2 examples.

1a. Increase in pH
1b. Decrease in Temperature
1c. Decrease on PC02
2a. Alkalosis
2b. hypothermia

A shift to the right is caused by what 4 things? Give 2 examples.

1a. Decrease in pH
1b. Increase in Temperature
1c. Increase in pC02
2a. Acidosis
2b. 2,3-DPG

What are the 2 primary methods used to assess the efficiency of gas transfer in the lung (if not critical)?

1. ABGs
2. Oximetry

ABGs measure ?

1. Oxygenation
2. acid-base balance

ABG analysis is usually obtained how?

Arterial puncture from an arterial cath, usually radial or femoral artery. This is intermittent analysis

How is mixed venous blood sample usually obtained?

pulmonary artery (PA) cath

Blood pulled from a PA cath s called a mixed venous blood sample because the blood is pulled from where?

blood that has returned to the heart from all tissue beds

Define chemoreceptor

a receptor that responds to a change in the chemical composition of the fluid around it. (i.e. the ones in the medulla effecting respiratory status)

An increase in H+ concentration (acidosis) will cause what via chemoreceptors?

Increased RR and tidal volume

A decrease in H+ conc. (alkalosis) will cause what via chemoreceptors?

Decreased RR and & TV

What occurs with an increased level of PaCO2

more CO2 is available to combine w/ H20 and form carbonic acid. This decreases cerbrospinal fluid pH and stimulates an increase in RR. A decrease in PaCO2 would cause the oppisite to occur.

What type of receptors are believed to cause tachypnea seen in pulmonary edema?

Juxtacapillary (j) receptors

Mechanical receptors are located where?

lungs, upper airways, chest wall and diaphram.

The Hering-Breur reflex prevents what?

overdistension of the lungs

Mucous is continually secreted at what rate?

100 mL/day by goblet cells and submucosal glands

Secretory _____________________ ____ (_____) in the mucous contributes to protection against bacteria and viruses.

Immunoglobin A (IgA)

Cilia beats 1000 per minute and is often destroyed by what?

Bacterial infections like that of COPD and cystic fibrosis pt.'s. Other factors are dehydration, smoking, inhalation of high 02 and ingestion of drugs and alcohol.

What is the primary defense system at the alveolar level?

Alveolar macrophages (nom, nom, nom)!

What are some of the significant effects of aging on the respiratory system?

stiffening chest wall
decrease in elastic recoil
costal cartlidges calcify
barrel shape
accessory muscles used to breathe
decrease in number of functional alveoli

It's important to inquire about ACE inhibitors during the assessment because of what?

a cough is a relatively common side effect of this drug

Define Hemoptysis

coughing up blood in which the pt. loses 100-600 mL/day. Medical Emergency

Define Hematemesis

vomiting blood

Define Wheezes

musical sounds that indicate airway obstruction (i.e. asthma, emphysema)

What is the most important risk factor for COPD pt.'s?

Smoking

Dyspnea can be a cause of what re: elimination patterns?

cause of limited mobility which may cause constipation

Define Orthopnea

respiratory problems brought on by laying flat

Hypoxemia interferes with what re: cognitive-perceptual patterns?

the ablity to learn and retain information. Teach another family member as a reinforcement prn

Breathing difficulties may alter sexual activity, if so teach what?

positions that decrease dyspnea during sexual activity and alt. methods for sexual fulfillment

Dyspnea causes anxiety and anxiety ________ __________. How does this play a role in coping-stress tolerance patterns?

1. exacerbates dyspnea.
2. the outcome is often physical and social isolation.

When inspecting the nose look for what?

Polyps, patency, color, symmetry or discharge

When inspecting the mouth/pharynx you should do what?

Note color, symmetry, or enlargement of tonsils. Stimulate the gag reflex indicating cranial nerves IX (glossopharyngeal) and X (vagus) are intact.

Inspect the neck by looking for?

Swollen lymph nodes; palpate

Performing the chest examination is best performed in a well-lit _______ room.

warm

It is best to begin your chest examination where?

Posterior chest wall (vs. anterior)

Chest expansion should be _______ on both sides, and the AP diameter should be less than the side to side or transverse diameter by a ratio of ______.

1. equal
2. 1:2

Define Pectus Carinatum

prominent protrusion of the sternum

Define Pectus Excavatum

indentation of the lower sternum above the xiphoid process

What is the ratio of inspiration:expiration?

1:2

Kussmaul (Define)

rapid, deep breathing

Define Cheyne Stokes

abnormal pattern of respiration characterized by alternating periods of apnea and deep, rapid breathing.

Long standing hypoxemia causes what?

Clubbing

Spinal curvatures that effect breathing include? (3)

1. kyphosis
2. scoliosis
3. kyphoscoliosis

Unequal chest expansion occurs when what is occurring?

air entry is limited by conditions involving the lung or chest wall; conditions may be from atelectasis or pneumothorax or incision

Define Fremitis . Which phrase helps determine fremitis upon touch?

1. Vibration of chest wall produced by vocalization
2. "ninety-nine" in a deeper, louder than normal voice

Increased fremitis occurs when?

the lungs become filled with fluid, this is found in pnuemonia, lung tumors, plueral effusion and thick bronchial secretions

Define Resonance

low-pitched sound heard over normal lungs

Define Hyperresonance

Loud lower pitched sound than normal resonance(COPD & Asthma)

Define Tympany

Drum-like, loud, empty quality (pnuemothorax)

Define Dull

Medium-intensity pitch

Define Flat

Soft, high-pitched sound

What are the 3 normal breath sounds and their definitions?

1. Vesicular sounds - relatively soft, low pitched, gentle, rustling sounds. Heard everywhere except major bronchi. 3:1 ratio
2. Bronchovesicular sounds - medium pitch and intensity heard over mainstream bronchi on either side of sternum and posterior between the scapulae. 1:1 ratio
3. Broncial Sounds - louder and higher pitched, resemble air blowing through a hollow pipe. 2:3 ratio

Define "Adventitious" sounds

Abnormal extra breath sounds. They include crackles, ronchi, wheezes, and plueral friction rub

Define Stridor

continuous musical or crowning sound of soft pitch; result of partial obstruction of larynx or trachea

Define Rhonchi

Continuous rumbling, snoring or rattling sounds; result of obstruction in large airways

Plueral Friction Rub

creaking or grating sound from roughened , inflamed pleura

Abdominal Paradox

Inward (rather than outward) movement of abdomen during inspiration

In trachial deviation found upon palpation, the potential collapsed lung (if that is the cause) will be on which side?

opposite side

Fine crackles

Short duration, high-pitched, heard just before the end of inspiration. (sounds like rolling hair just behind the ears)

Coarse crackles

Long duration, low-pitched, evident on inspiration. (sounds like blowing through a straw under water)

Cordectomy

partial removal of one vocal cord where there is a superficial tumor

Hemilaryngectomy

removal of part or one whole vocal cord, requires a temporary tracheostomy

Supraglottic laryngectomy

...removes structure above the "true cords"- false cords and epiglottis

Supraglottic swallow

A type of swallow that compensates for the removal of the epiglottis to minimize the risk of aspiration after neck surgery (treating cancer) box pg. 537

What is the benefit of a Blom-Singer and tracheostoma valve after a laryngectomy?

With this prosthesis and valve the patient will be able to speak "normally". (Without the valve the pt. would have to close the stoma with the finger in order to speak with the prosthesis in place alone)

Electrolarynx

hand-held battery operated device that creates speech with the use of sound waves (sound mechanical)

Artificial Larynx

Placed against the neck rather than in the mouth. Used after healing where no edema is present. (sound mechanical)

Of each 500 mL inhaled about ____ mL is anatomical dead space (Vd)?

150mL

Criteria for continous O2 Rx ? Indicate Sp02 & Pa02 levels

Sp02 of 88%, Pa02 55 mmHg

Why does an excess of C02 in the blood increase RR and Volume?

C02 binds with H20 to form carbonic acid; lowering the pH of cerebrospinal fluid

What are 2 causes of the age related change: decreased Pa02?

1. decreased functional alveoli
2. small airway closure, earlier in expiration

What are 2 causes of the age related change: Barrel chest appearence

1. Decreased elastic recoil
2. decreased chest wall compliance

What are 2 causes of the age related change: Decreased secretion clearance

1. decreased functional cilia
2. decreased force of cough

What are 2 causes of the age related change: Decreased resistance to infection

1. decreased alveolar macrophage activity
2. decreased IgA

What is the BEST liquid to give a when initiating a supraglottic swallow after a radial neck dissection?

Cola! Beverages with carbonation provide an "effervescence" which clues about the liquid's position

What is the importance of testing clear nasal drainage after facial trauma including a nasal fracture?

To monitor if it Cerebrospinal fluid (CSF). You test for the presence of glucose

What does contraction of neck muscles indicate upon inspiration?

The use of accessory muscles upon inspiration; the pt. is in serious respiratory distress

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.

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