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Respiratory #1

Airway Disorders

QuestionAnswer
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