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Lewis - Ch 26 - Respiratory System: Nursing Assessment
Terms in this set (88)
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:
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:
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:
1. Diaphoresis (early/late)
2. Decreased urinary output (early/late)
3. Unexplained fatigue (early/late)
Arterial Blood Gases (ABG) (SEA LEVEL)
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 = 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)
Lung Capacities NORMAL CAPACITIES
Total Lung Capacity (TLC)
Functional Residual Capacity (FRC)
Vital Capacity (VC)
Inspiratory Capacity (IC)
A pt. is considered adequately oxygenated according to the oxy-hemoglobin disassociation curve at a Pa02 above what?
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
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
What are the 2 primary methods used to assess the efficiency of gas transfer in the lung (if not critical)?
ABGs measure ?
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
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
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
coughing up blood in which the pt. loses 100-600 mL/day. Medical Emergency
musical sounds that indicate airway obstruction (i.e. asthma, emphysema)
What is the most important risk factor for COPD pt.'s?
Dyspnea can be a cause of what re: elimination patterns?
cause of limited mobility which may cause constipation
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.
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 ______.
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?
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?
Spinal curvatures that effect breathing include? (3)
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
low-pitched sound heard over normal lungs
Loud lower pitched sound than normal resonance(COPD & Asthma)
Drum-like, loud, empty quality (pnuemothorax)
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
continuous musical or crowning sound of soft pitch; result of partial obstruction of larynx or trachea
Continuous rumbling, snoring or rattling sounds; result of obstruction in large airways
Plueral Friction Rub
creaking or grating sound from roughened , inflamed pleura
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?
Short duration, high-pitched, heard just before the end of inspiration. (sounds like rolling hair just behind the ears)
Long duration, low-pitched, evident on inspiration. (sounds like blowing through a straw under water)
partial removal of one vocal cord where there is a superficial tumor
removal of part or one whole vocal cord, requires a temporary tracheostomy
...removes structure above the "true cords"- false cords and epiglottis
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)
hand-held battery operated device that creates speech with the use of sound waves (sound mechanical)
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)?
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
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