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Respiratory #1
Airway Disorders
| Question | Answer |
|---|---|
| Pulmonary Blood Supply | To lungs for gas exchange |
| Bronchial Blood Supply | From thoracic aorta |
| Conducting Airway | Nasopharynx-Oropharynx-Larynx/Endolarynx-Trachea-Bronchi-Carina-Hili-Pulmonary & Lymphatic Vessels |
| What is Acinus | Cluster of cells, thin walled 16th-23rd divisions, alveolar ducts, the alveolar sacs contain 300 million alveoli |
| Respiratory Functions | Exchange CO2 & O2, maintain acid-base balance |
| Factors Affecting Respirations | *Neurochemical= Medulla @ base of brain-brain stem (pattern) & Pons (rate & debth) *Mechanical= Irritant, stretch & pressure receptors *Hering-Breuer= Keeps us from over stretching |
| Mechanisms Of Breathing-Ventilation | *Inspiration= Air flows into lungs 1-1.5 seconds *Expiration= Longer, gasses flow out of lungs 2-3 seconds *Normal= 12-20 times per minute |
| Examples Of Respiratory Passageway Resistance | Constriction, edema, mucus, tumors, infectious materials, spasms |
| This Happens In Non-Lung Compliance | Use of accessory muscle |
| This Improves Aveolar Surface Tension | Surfactant secretion (sigh)Surfactant lowers surface tension |
| Example Of Diffusion | O2 & CO2 exchange across alveolar capillary membrane, determined by pH, changes from area of high to low concentration, need good perfusion/cardic output |
| Accessory Muscles | *Sternocleidomastoid & Scalenus= Lift up thorax to expand volume * Intercostal and Scalene= Expand A&P (retractions) *Expiration= Abdominal and internal intercostal are compensatory |
| Pulmonary Blood Flow And Gravity | Air rises, blood drops to dependent area, "good lung down" More blood and less O2 lower, less blood and more O2 upper in lobe |
| Cues To Respiratory Illness | SOB, wheezing, pleuritic chest pain, cough, sputum production, hemoptysis , voice change, fatigue |
| Pt. History Assessment | Predominant complaints, family hx, health hx, smoking hx, occupational exposure |
| Patterns Of Breathing | *Kussmauls= Rapid breathing (compensatory) *Tachypnea= Fast >20 (intervine 30-40) *Tachy-Brady= OH SHIT *Brady= <12, start looking for reasons *Biots= Varies in rate, debth & rhythm w/ irregular periods of apnea (sign of brain stem problem) |
| Bronchospasms | Constriction (vagus nerve) Histamine release= >mucus/prostoglandin= more constriction |
| Causes Of Bronchospasms | NSAID, ASA, -olol, ACE, some inhalers |
| Symptoms Of Bronchospasm | SOB, chest tightness, fatigue, "silent chest" |
| Steps In Respiratory Assessment | #1 Inspection #2 Palpation #3 Percussion #4 Auscultation |
| Significance Of Positioning | *Lying=mild distress *Sitting=moderate *Upright=severe *Tripod=increases A&P diameter *Orthopnea="one,two,three pillow" |
| Finger Clubbing | Angle normally 20, occurs when body trying to compensate for hypoxia-develops collateral circulation |
| Significance Of Speech | Sentence= mild/moderate dyspnea *Phrase= moderate *Words= severe "1-2-3 word dyspnea" |
| Palpation | With pads of fingers, crepitus-crackles, nodes-if swollen should move, mediastinal shift- trachea shifts to opposite side of lung injury. |
| Tactile Fremitus | Vibration, ask pt. to say 99, decreased in atelectasis, emphysema, asthma, pleural effusion & pneumothorax, increased in pneumonia, tumor, secretions |
| Sounds Of Percussion | *Flat=solid (sternum) *Dull=no air/fluid (liver) *Tympanic=air (stomach) *Resonant=echo (lung) *Hyperresonant=low pitch, air free |
| How To Auscultation Pt. | Deep breath through mouth, not through gowns, listen laterally with an effusion, R= 3 lobes L= 2 lobes |
| Normal Breath Sound Locations | *Bronchial= loud, high pitched, over large airways, expiratory * Bronchiovesicular= medium pitch, R&L bronchus, i=e *Vesicular= soft/low pitch, i>e *E-I-E-I-I |
| Crackles | Rales, not cleared by coughing, fluid scruntching down on aveoli, ex. pulmonary edema |
| Sonorous Wheezes | Rhonchi-gurgle, heard on expiration, occurs in conducting area, ex. COPD, asthma |
| Stridor | High pitched, harsh, inspiratory ex. laryngeal spasms due to tetany w/ low calcium, croup |
| Friction Rub | Loud, dry, creaking, loss of lubricant, most often heard laterally ex. pleurisy, pleuritis, effusion, poss pneumonia |
| Absent Or Diminished | Ex. atelectasis, pleural effusion, pneumonia, worsening bronchonconstriction |
| Pulse Ox | SaO2= saturation of oxygen on hemoglobin**Does not determine acid-base status |
| Inaccurate Pulse Ox Reading | Hypothermia, hypotension, vasoconstriction, IV dyes, HGB bound with other gas other then O2 eg. coal miner, <70% is + or - 4% |
| Pulse Ox Results | **<90-91% (12 hrs)= Report & corrective nursing action **<80% (4 hrs)= Hurry **<70% (1 hr)= You better run! |
| Normal VQ Scan (Ventilation/Perfusion) | 0.8-0.9, Perfect= 1mL O2 per 1mL of blood, Abnormal VQ= hypoxia, most often done for pulmonary embolism or baseline for someone with ARDS |
| Shunt | Low ventilation, "STUNT"= stump |
| Silent Unit | Poor VQ, compensatory-diverts blood to better ventilated areas, ex. PE, chronic alveolar collapse |
| Dead Space Unit | Poor perfusion=horrible blood flow to pick up O2, nothing wrong w/ lungs, ex. PE, decreased CO |
| PFT's | Based on age, height, wt, sex, monitor the course of pulmonary disease, evaluate meds, determine need for mechanical ventilation |
| Pre-Procedure For PFT | No..tobacco,bronchiodilators,heavy meal,sedatives,narcotics,distended abdomen. Instruct pt how to breathe for test= nose clip,tight seal |
| PFT Results | *FeV1= Low in COPD *VC= vital capacity *RV= Increased w/ COPD, the air left in the lungs after expiration *Tidal Volume= How much air w/ each breath the pt. draws in |
| Post PFT | Maintain airway, prevent injury-may be dizzy |
| Sputum Specimines | Gm stain= Identifies Gm + or - organisms, if + need C&S to identify best ATB therapy (lower the # the better) Acid-fast smear= TB identification. Cytology= looking @ cells and identifying maligancies |
| Pre Bronchoscopy procedure | Informed consent, clarify info, NPO, baseline VS, remove dentures/partials, sedative/conscious sedation, sterile set up |
| Post Bronchoscopy Procedure | NPO until gag reflex returns= cranial nerve #9, VS q hr, discourage coughing, smoking, talking for several hrs, expect hoarse voice, low fever common 1st 24 hrs, designated driver, notify dr. persistent cough, bloody, purulent sputum |
| Bronchoalveolar Lavage (BAL) | Diagnose pneumocystic pneumonia |
| Mediastinoscopy | Incisions for lymph node biopsy |
| Methemo-Globinemia | Benzocaine anesthestic spray- sx usually w/in 1st hr= central cyanosis, O2 ineffection, choclate brown blood, impairs Hgb to carry O2 (functional anemia)Allows CO2 binding, need co-oximeter, Antidote= Methyl Blue |
| Thoracentesis | Lg bore needle through chest wall, position client in supine or sitting postion, affected lung accessible |
| Low Flow O2 systems | NC: 24-45% Simple face mask: 40-60% Humidification needed at >4L |
| High Flow O2 systems | Venturi mask: 24-50% Partial/Non rebreather: Up to 100% New O2 cannulas: Up to 15L Heliox |
| Difference Between O2 Flow And O2 Concentration? | Flow= Force (# of liters) Concentration= Percent |
| Oral Airway | Holds tongue away from pharynx, insert with tip pointed upward then rotate |
| Advantages And Disadvantages To Oral Airway | Advantages=easy to insert, preserves airway. Disadvantages=easy to dislodge,unconscious pts,no use in facial/oral surgery |
| Endotracheak Tubes (ET) | Mechanical ventilation up to 100% O2, can be inserted oral or nasal |
| Oral vs. Nasal ET | Oral= Rapid, easier to insert-chip teeth, need bite block, excess salivation. Nasal= More comfortable, more secure-more resistence |
| Indications for ETT & Mechanical Ventilation | Respiratory failure- pH <7.25 CO2>50% O2<50% |
| Nursing Role For Insertion Of ET | Only nurses with training can perform, RN-sets up equpiment, verify placement, check cuff leaks, monitoring location, care vent. settings, teach conscious pt. about gagging/feelings of suffocation |
| Function Of Cuff On ET Tube | Keep secretions from going into lungs/keep O2 from escaping back upwards |
| Rapid Sequence Intubation (RSI) | *Fast acting narcotic ex. Fentyl *Sedative ex. Versed *Paralytic agent ex. curare derivative. **Do not use in narcotic overdose or code** |
| Procedure for RSI | Gather supplies. test cuff inflation, supine position/head extended "sniffing position" Nasal insertion=greater resp. effort |
| Correct ET location | 3-5cm above carina (bifurcation of mainstem bronchus) most likely to be accidently intubated in right mainstem |
| Verifying Placement Of ET | #1 CO2 indicator #2 Auscultate breath sounds bilaterally #3 Observe symmetric chest movement #4 Feels warm/exhaled air at end of tube #5 Confirm by chest x-ray |
| Quick Check Verification For ET | "Lip Line" Q-24 hrs, women 21cm, men 23cm, move side to side but not up and down, x-ray is absolute look! |
| O2 AND Ventilation | PaCO2=best indicator of hypo/hyper ventilation |
| Complications of ET | Aspiration and unplanned extubation **Assess, stay with pt. put on call light, airway assistance- bag or NC** |
| Maintaining Tube Patency | Suction PRN NOT routinely, hyper-oxygenate pre and post, hydration not NS spritzer, suction >120=mucosal damage |
| Closed Suction Technique | Useful for PEEP >7-8cmH20,secretions,freq. suctioning need,unstable |
| Nursing Dx | Impaired gas exchange & Decreased cardiac output |
| Negative Pressure Vent | Negative pressure on chect, pulls air into lung, Pneumowrap=Poncho fits over body & creates a vacuum which expands thoracic cage. |
| Positive Pressure Ventilator (PPV) | Inflates aveoli, must be intubated or trach, creates decreased cardiac output |
| Pressure Cycled Ventilators | Preset pressure, if increased airway resistance or decreased compliance=tidal volume may not be delivered |
| Volume Cycled Ventilators | Preset volume, tidal volume delivered regardless of resistance or compliance, more frequently used |
| Tidal Volume (TV or VT) | Amt. of air delivered w/ each ventilator breath, 7mL/kg of body weight |
| FiO2 | 21-100% ex. ARDS, Can have O2 toxicity (lost nitrogen) or absorbtion atelectasis (alveolar collapse) |
| Continuous Mandatory Ventilation (CMV) | Vent only delivers TV & breaths per min. that have been set, total control for pt. by decreasing work of breathing, but can cause muscle atrophy=harder to wean |
| Assist/Control Ventilation (ACV) | Senses & controls volume for each present breath, moderate control of pt. NOT for use in COPD |
| Synchronized Intermittent Mandatory Ventilation (SIMV) | Least control=used for weaning, pt. can take own additional breaths @ own TV, vent. rate gradually decreased, will not breathe as pt. breaths on their own |
| Continuous Positive Airway Pressure (CPAP) | + pressure applied via facemaskor ET helps maintain open airways and aveoli >5cm Used mostly for weaning and sleep apnea |
| Positive End Expiratory Pressure (PEEP) | 3-5cm, increases amt. of air remaining in the lungs during expiratory phase, allows for reduction of FiO2 |
| Peak Inspiratory Pressure | Amt. of pressure required to deliver TV, Plateau pressure: 30cm H20 or less, if increased=bad, decreased=good |
| Low Pressure Alarm | Little/No pressure generated duringdelivery of machine breaths**Check for disconnection, placement, cuff leak/tear |
| High Pressure Alarm | Pre-set peak inspiratory pressure limit is reached b4 venthas delivered set TV, Fix the problem! Check for obstruction, placement.. |
| If In Distress With An Alarming Vent.. | Take care of client first!! Manually vent pt. and have someone else fix vent |
| Pressure Support | 5-10cm, pt. receives increased TV |
| Sighs | Prevents microatelectasis, pulses of air delivered at 100-300x per min. or 1-5mL/kg, high frequency but low pressure |
| Hypoventilation | Acidosis |
| Hyperventilation | Alkalosis, check for arrythmias/calcium imbalances, may be caused by overventilation/overinflation |
| V/Q Mismatch | Uneven blood flow in lungs |
| Decreased CO | + pressure in thorax instead of - pressure, decreased CO=decreased BP, increased HR, vasoconstriction. May require Dopamine to increase BP |
| Volu or Barotrauma | Assess crepitus |
| O2 Toxicity | Exposed to >50% FiO2, exposure time and concentration |
| Pressure Necrosis R/T Tubings | Reposition side to sidein mouth, release cuff pressures via protocol |
| Pneumothorax | May be caused by high vent pressure |
| When to draw ABGs | Anytime a vent setting is changed**Wait 15-30 minutes after vent setting change |
| Nursing Assessments | Breath sounds, VS, chest movement, need for suctioning, hypoxia/hypercapnea, vent settings, pule ox, PEEP (decreased CO) skin, stress ulcers, joint mobility, nutrition, bowels, emotions |
| Nursing Implementations | Humidified/warmed air, HOB 30 degrees, position change, suction, ABGs, keep vent alarms on, correst bucking, decrease anxiety, respect sleep/wake cycles, high calorie need |
| Weaning Phase #1 Pre-Weaning | Assess resp. and non-resp. factors, spontaneous breathing trial |
| Weaning Phase #2 Weaning Process | *Short term pt-linear *Long term pt. peaks & valleys *Psych support for pt. and family |
| Weaning Phase #3 Outcome | Continue O2 therapy, oral care, monitor VS & resp. distress, ABGs within 1 hr |
| Ready To Wean? | Stabilized condition, stable chest wall, resp rate 12-20, PEEP <5cms, good nutrition, improved vital copacity, stong cough, no accessory muscle use, lungs clear, ABG WNL, adequate CO, afebrile |
| Weaning Guidelines | Trust=essential, initiate in the AM not PM, watch for compromise (HR >20bpm from baseline, BP changes, RR changes, ABG deterioration) put back on vent on original settings |
| Spontaneous Breathing Trial | 30 min-2 hrs, increasing time, stop before fatigue |
| T-Piece | Remove pt. from vent, place on t-piece which delivers specified FiO2 back on vent then gradually increase time (10 min or so) off until pt. breaths spontaneously for prolonged period |
| SIMV | Gradually decrease # of breaths that machine delivers until pt. breathing totally on own. Vent is there for support, do not need to return to original vent settings |
| CPAP | Vent in CPAP mode, used commonly and provides monitoring that t-piece doesn't |
Created by:
tjcox50
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