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43 terms

Med-Surg. 2

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Pursed lip breathing
Orthopneic position; pt.'s w/obstructive lung disease or (dyspnea), to promote better exhalation & decrease air trapping 293
What determines rate & depth of respirations?
Blood ph
Difference between restrictive & obstrucitve respiratory disorders
Restrictive-decreased lung capacity:
kyphosis, arthritis, pneumothorax, neuromuscular, pneumonia, atelectasis, fibrosis
Obstructive-problems moving air into & out of lungs;
tumor, asthma, emphysema & chronic bronchitis (CAL)
chronic airflow limitation.
Major cause of throat cancer
Smoking and alcohol
Flu Vaccines
People who are allergic to eggs ; chicken protein; feathers b/c vaccine is prepared from embryos
Vesicular
Over lung tissue to level of 6th intercostal space; low to medium pitch w/a soft whooshing quality; inspiration 2-3 times length of expiration.
Bronchovesicular breath sounds
Over mainstem bronchi, below level of clavicles, beside sternum; posteriorly; between scapulae;
Moderate to high pitch w/hollow muffled quality; equal time of inspiration & expiration
Bronchial breath sounds
Over trachea above sternal notch (these sounds are abnormal elsewhere & often indicate atelectasis)
High pitch w/loud, harsh, tubular quality; inspiration half as long as expiration.
Wheezes
whistling, musical, high-pitched sound produced by air being forced through a narrowed airway.
Asthma
Crackles
Fine or coarse. Sound familiar to sound like rubbing hairs between fingers.
Fine-fibrosis, pneumonia, early congestive heart failure.
Coarse-louder, and low in pitch
Bronchitis, pulmonary edema, and resolving pneumonia.
Stridor
croaking/partial obstruction of upper air passages.
Croup
Adventitious
Pleural friction rub; grating or scratchy sound; occurs when irritated visceral and parietal pleura rub against each other.
Suction how long?
10 seconds; suctioning for longer length depletes oxygen
Kussmal's
Diabetic acidosis; coma
distressing difficulty in breathing that occurs as increasing depth and rate of respiration w/no expiratory pause. Abnormal breathing pattern.
Fast, deep respirations
Biot's
Increased intracranial pressure; irregular period of apnea alternating w/periods in which 4-5 breaths if identical depth are taken
Fast, deep respirations w/abrupt pauses
Apneustic
apnea; damage to respiratory center in brain; prolonged gasping inhalation followed by short, ineffective exhalation.
(apnea-absence of breathing)
Cheyne-Stokes
Patients in coma ; for a disorder affecting CNS; rhythmic waxing and waning depth of respiration
w/regularly recurring periods of apnea.
Respirations become faster and deeper, then slower and shollower w/a period of anea
Tachypnea
Rapid breathing
Bradypnea
Slow breathing
Eupnea
Normal rate and rhythm
Turn, coughing, & deep breathing
...
Hypoxia
Oxygen deficit in tissues; produces loss of energy.
Hypoxemia
Deficient oxygenation of the blood.
Cor pulmonale
Is the development of right ventricular failure as a result of chronic lung disease, leading to fluid retention manifested by weight gain. Distended neck veins, right upper quadrant tenderness from engorged liver, peripheral edema, weight gain, GI distress and ascites may occur.
hemoptysis
blood in sputum
PPD or TST -tuberculin skin test
Test is positive when swelling at site of injection is more than 5mm in diameter 48 to 72 hrs. after injection.
Positive TB test indicates person has been infected w/TB at some time. It does not indicate that disease is active or inactive, only that body tissues are sensitive to. Once skin test positive, person will always test positive. A diagnosis of active TB is established when tubercle bacilus has been found in the sputum or gastric washings. Sputum exams are required every 2-4 weeks; when 3 consecutive sputum cultures are negative, patient is considered no longer infectious
Treat with isoniazid (INH) 85% effective.
Pneumonia
Patient experiencing high fever and chills, a productive cough, chest pain, general malaise, and aching muscles.
Diagnosis is confirmed by chest x-ray, which reveals densities in affected lung. Chest radiography reveals diffuse, patchy areas of density. Sometimes breath sounds normal; occasional crackles and wheezes; no pleural involvement; no pain; dry cough or feeling of extreme fatigue.
Nursing interventions to help prevent pneumonia
Ensure frequent turning, coughing, and deep breathing for postoperative patients or those who are otherwise unable to ventilate their lungs adequately.
Pneumovax
The pneumococcal pneumonia vaccine. People over age 65, and those w/chronic respiratory disease, should receive the vaccine. A second dose is needed 6 years after the first dose.
NI to help prevent pneumonia
If in decreased state of consciousness, carefully watch and properly position vomiting patients; such as patients recovering from anesthesia, on their sides.
Treatment of pneumonia
IV or oral antibiotic agents; erythromycin; Biaxin, cephalosporins, aninoglycoside, fluoroquinilones; (Cipro).
Viral-Bactrim; Barberry root bark (alternative treatment); supplemental O2; mechanical ventiliation. Patient should deep breath and cough 5-10 times each hour while awake. Fluid increased 2500 to 3000 mL/day. Confusion and delirium. Rest.
TB-Mycobacterium tuberculosis
Pulmonary TB is an infectious disease of the lung characterized by lesions within the lung tissue. Not highly contagious. Infection occurs after prolonged exposure to tubercle bacillus; not everyone contracts disease.
2 major causes - immunodeficient people w/AIDS and influx of immigrants who are infected w/TB. Poor living conditions, malnutrition; increase in population of malnourished urban poor.
Pleurisy
Inflammation of the pleura; from TB, pneumonia, neoplasm, and pulmonary infarction. Pain is sharp and abrupt ; evident in onset and inspiraiton. Causes shallow breathing. Lying on affected side may help. Affected side splinted during coughing.
Pleural effusion
Collection of fluid in pleural space. Transudate-Congestive heart failure, chronic liver failure, renal disease.
Exudate - thicker; lung cancer, pulmonary embolism, pancreatic disease, pulmonary infections.
Thoracentesis
Removal of fluid from pleural cavity; 500mL can be removed.
Atelectasis
Incomplete expansion or collapse of alveoli. Occurs from compression of lungs from outside; decrease in surfactant, bronchial obstruction that prevents air from reaching alveoli.
Sao2 - oxygen saturation -will decrease. Is reversible. Treatment-ridding bronchial tre of excess secretions by coughing; and by providing air to depth of lung by deep breathing ; use of incentive spirometer.
COPD
Chronic obstructive pulmonary disease includes emphysema and chronic bronchitis.
Emphysema
Disease or destruction of alveolar and alveolar-capillary walls; small airways. Air that is inhaled becomes trapped; causing victim to work harder to exhale air. Emphysema progresses to loss of lung elasticity. Dyspnea is early sign. Produces barrel chest.
Bronchitis
Excess secretion of mucus that interfers w/airflow and inflammatory damage to brochial mucosa , causes productive cough. Extreme-increased resistance to airflow, hypoxia, and hypercapnia (excess O2) and cor pulmonale. Cor polmonale is a heart condition characterized by pulmonary hypertension and enlarged R-ventricle, secondary to lung disease. Risk for R-sided heart failure. Patient suffers from hypoventilation and hypoxemia. Patient has increase in partial pressure of arterial CO2 ( Paco2) The retention of CO2 and deficiency of O2 give skin a reddish blue color. Rhonchi
Asthma
Chronic lung disease ; reversible airway obstruction, airway inflammation from edema; increased airway sensitivity to allergens, viruses, exercise, perfumes, and emotional stress; genetic correlation. Inflammation of airways. Wheezing
Acute asthma attack can cause death from hypoxia.
Treatment for asthma
Bronchodilators in for of beta-adrenergic agonists, theophyllines, anticholinergic agents - Atrovent; corticosteroids, mucolytics, antibiotics and O2; raise Sao2 to 90 mm Hg
Pneumothorax
Presence of air of gas withing pleural cavity.
If knife stuck in chest cavity, do not remove it; instead stabilize so it does not move aroung. Object may be wedged against severed vessels, preventing them from bleeding; removing may cause hemorrhage.
Turn coughing and deep breathing
Pg. 292 The nurse should explain that deep-breathing and coughing maneuvers are the most effective ways to remove sputum so that it can be coughed up and wxpectorated or to suppress the cough.