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Med Surg Exam 4
3/4 Respiratory, GI System, and GI system / esophageal disorders
Terms in this set (54)
What does coarse crackles sound like?
What does fine crackles sound like?
Velcoro being torn apart
high pitched violins
loud crowing sound
pleural friction rub?
leather rubbing together
faint lung sounds
air hunger resulting in labored or difficult breathing is?
A patient with low oxygen saturation may develop.....
A crackling or rattling sound made by a part of the body either spontaneously or during physical examination is.....
What may develop if air leaks into tissues from a chest tube site?
What may be neccessary for severe pleual effusion?
thoracentesis (removal of fluid by needle through the chest wall and into the pleural space)
what normally causes a barrel chest and what is the end result?
most often caused by COPD due to increased functional residual capacity, which in turn results from airway narrowing and a loss of lung elasticity.
The client with air trapping may develop a ....
How can a nurse check chest expansion?
respiratory excursion can be measured
an adventitious lung sound is a/an
abnormal lung sound
what is the absence of respirations?
what are the 5 goals of respiratory function?
1) maintenance or promotion of lung expansion
2) Mobilization of pulmonary secretions
3) maintenance of patent airway
4) maintenance and promotion of oxygenation
5) restoration of cardiopulmonary function by CPR
what are the 5 things to do to maintain or promote lung expansion?
1) positioning procedures (sit up)
2) breathing exercises
3) incentive spirometry
4) IPPB intermittent positive pressure breathing
5) Chest tubes
What breathing exercises are there, and an explanation of each
- Pursed lip breathing - helps to keep alveoli open
- Abdominal diaphragmatic breathing - place both hands on diaphragm and on deep breath bottom hand should go out
the more we open alveoli the more what can happen......?
what does intermitten positive pressure breathing do?
expands alveoli by pressure
what do chest tubes do?
they are utilized to help expand the lungs, they are inserted to remove air and fluids from pleural space and to prevent them from reentering and to reestablish pressure gradient
what happens if lung collapses?
patient can't get a breath, respirations go up, pulse goes up and BP
what causes a lung to collapse?
a decrease in pressure gradient will cause the lung to collapse, to reestablish pressure we insert a chest tube
why do we encourage deep breathing to immobile patients?
because shallow breathing doesn't move fluids then they are in danger of pneumonia
What are the 4 things used to help mobilize pulmonary secretions?
1. hydration 2. Humidification 3. nebulization 4. chest physiotherapy (CPT)
How much fluid a day are we trying to get in the patient and why?
1500 to 2000 ml a day, this is to help liquefy pulmonary secretions so that they can get them out
why do we use humidification?
because straight oxygen is very drying to nasal mucosa. the humidification is used with oxygen therapy.
what is nebulization and when do we see it alot?
It's the process of adding moisture or medications to the inspired air - we see this alot with respiratory treatments
what does chest physiotherapy (CPT) include?
postural drainage and chest percussion and vibration
when is the airway patent?
Airway is patent when the trachea, bronchi, and large airways are free from obstructions
what are the 4 ways of maintaining a patent airway accomplished?
1. cough techniques 2. suctioning techniques 3. artificial airways
what are the two cough techniques and describe
1. huff cough - hold something and cough
2. cascade cough - cough that starts light and then goes deeper and deeper
what are the two types of suctioning techniques?
1. oropharyngeal and nasopharyngeal - either thru nose or thru mouth but only to nasopharynx
2. orotracheal and nasotracheal - nasotracheal most likely
what are the types of artificial airways?
oral airways, tracheal airways (endotracheal tubes, nasotracheal tubes, tracheostomy tubes)
which artificial airway can stay longer than a week because it won't damage vocal chords?
what is the percent of oxygen that room air is?
what are the four methods of delivering oxygen above room air? and what is the percentage of oxygen of each?
1. nasal cannula (most comfortable) 2-6 L / min, 24-44%
2. Simple face mask 5-8 L / min, 40-60%
3. Partial rebreather mask 6 - 11L / min, 60-70%
4. Non-rebreather mask 10-15L / min 80-95%
what 3 things deliver high flow oxygen with high humidity that we use for critically ill patients when we need precise amounts of oxygen?
1. Venturi mask - regulates ration of oxygen to room air so precise % of oxygen delivered 4-10 L / min 24-55%
2. aerosol mask, face tent, tracheostomy collar - at least 10 L / min, 24-100%
3. T-piece - at least 10 L / min 24-100%
was is pneumonia?
inflammation of the lung tissue - the respiratory bronchioles and alveoli) - inflamed by either infectious (bacteria, viruses, fungi, protozoa) or noninfectious sources ( aspiration of gastric contents and inhalation of toxic irritating gases or chemicals, smoke)
what is opportunistic pneumonia?
infections found in immunocompromised people
How does pneumonia by infectious agent begin?
organism gets past respiratory defenses and enters respiratory tract or may spread to the lungs via the blood from an infection somewhere else in the body
what are the next steps in developing pneumonia?
WBC's migrate to area of infection - from this two things happen 1) capillaries leak and cause alveolar edema and 2) exudate formation (waste product formation). Then alveoli and respiratory bronchioles fill with serous exudate, blood cells, fibrin, and bacteria. Finally there is a consolidation of lung tissue
From pneumonia how can it pass to other areas of the body?
capillary leakage can spread the infection to other areas of the lung, organsisms can move into the bloodstream which means that sepsis can result.
what is empyema and what causes it?
pus within the pleural cavity, caused by infection moving into the pleural cavity
what happens when fibrin and edema stiffen the lungs?
vital capacity goes down and tidal volume then alveolar collapse which means atelectasis. oxygenation is down with resulting hypoxemia and then there are airless spaces in the lungs
what is pneumonia with consolidation?
lack of air spaces as a result of solidification
where can pneumonia with consolidation occur?
in a segment, in scattered patches (bronchopneumonia), in an entire lobe
If absceses form what can result?
the abscess can possibly perforate bronchial wall
what are the 5 things that make the elderly more susceptible to pneumonia and the resulting complication?
1. the number of cilia decreases with age
2. the cough weakens
3. gag and cough reflexes diminish
4. older client at greater risk for dehydration
5. immune function declines with age
what are respiratory signs and symptoms of pneumonia?
pleuritic chest pain, SOB, crackles and wheezes, cough, sputum production, rapid, shallow respirations, dull percussion over affected areas because of the solid area, bronchial breath sounds
what are the clinical manifestions seen with pneumonia on diagnostic tests (6)?
1. respiratory acidosis as seen on ABG
2. pulse oximetry less than 95%
3. elevated wbc's
4. chest x-ray may show consolidation
5. culture and sensitivity positive for microorganisms (in 50% of cases not identified)
6. hypernatremia (high K)
what is one way to state a nursing diagnosis for pneumonia?
Impaired gas exchange related to effects of alveolar-capillary membrane changes.
what are some goals for client with pneumonia?
1. adequate gas exchange (SaO2 of at least 95%)
2. Maintain a patent airway
3. Be free of invading organism
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