NUR 303--Fundamentals of Nursing
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| physiology of repiration | pulmonary ventilation / pulmonary exchange of gases / transport of oxygen and carbon dioxide / tissue excahne of gases
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| pulmonary ventilation (breathing) | movement of air between the atmosphere and alveoli of the lungs / includes phases of inspiration and expiration
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| pulmonary exchange of gases | diffusion of oxygen and carbon dioxide between the alveoli and pulmonary capillaries
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| transport of oxygen and carbon dioxide | via bloodstream to and from the tissues
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| tissue exchange of gases | diffusion of oxygen and carbon dioxide between the capillaries and the body cells
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| structure of the upper repiratory system | mouth / pharynx / nose / larynx
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| what happens to air as it passes throught the nose | it is warmed, humidified, and filtered
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| after the nose, what other structures does air ass through? | nasopharynx and oropharynx where lymphoid tissue (tonsils and adenoids) traps and destroys pathogens
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| structure of the lower respiratory system | trahea / bronchi / broncioles / alveoli / pulmonary capillary network / pleural membranes
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| function the mucosal epithelium in the respiratory system? | traps pathogens and other particulate matter
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| function of the cilia | sweep debris upward toward the pharynx
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| what is the cough reflex? | is stimulated by vagal nerve impulse to the medulla which initiates the cough and the expectoration of these secretions
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| where does gas exchange occur? | at the junction f the alveolar and capillary walls
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| what is the respiratory membrane? | consists of the thin-walled alveoli covered by a thick mesh of pulmonary capillaries
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| what is the outer surface of the covered with? | parital and visceral pleura
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| what is the purpose of the potential space between the pleural layers? | lubricated by serous fluid / prevents friction / promotes adherence
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| adequate pulmonary ventilation depends on: | clear airways / intact CNS including the respiratory center in the medulla and pons / intact thoracic cavity capable of expanding and contacting / adequate pulmonary compliance and recoil
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| the act of breathing | diaphragm and intercostal muscles contract / the diaphragm descends / thoracic cavity and lung volume increase / intrapulmonary pressure decreases causing air to rush in / as the diaphragm and itercostal muscles relax, intrapulmonary pressure increa
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| accessory muscles of respiration | anterior neck muscles / intercostal muscles / abdominal muscles / retractions may be seen / indicates increaseed work of breathing / seen in COPD patients
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| work of breathing (WOB) | is the effort required to expand and contract the lungs
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| the amount of energy expended on breathing depends on: | the rate and depth of breathing / the ease in which the lungs can be expanded (compliance) / airway resistance
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| inspiration | is an active process, stimulated by chemical receptors in the aorta
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| expiration | is a passive process that depends on the elastic recoil properties of the lungs, requring little ot no nuscle work
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| surfactant | is a chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing // decrease in surfactant production can lead to atelectasis
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| atelectasis | is a collapse of the alveoli that prevents normal exchange of the oxygen and carbon dioxide
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| compliance | is the ability of the lungs to expand or inflate // necessary for inspiration
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| what may cause the collapse of a lung? | pneumothorax
hemothorax
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| how would an MD treat a collapsed lung | insert a chest tube
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| nursing responsibilities for compliance: | assisting with insertion and removal of chest tube // monitoring the insertion site for air leaks // monitoring patency of the tubes // monitoring functioning of the grainage system
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| airway resistance | is the increase in pressure that occurs as the diameter of the airway decreases from the mouth/nose to the alveoli
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| increased airway resistance leads to | decreased amoutn of oxygen delivered to the alveoli
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| increased work of brathing leads to... | decrease in lung compliance // increases in airway resitance // increase in use of accessory muscles
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| increased WOB leads to... | increased energy expenditure
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| increased energy expenditure leads to... | increased metabolic rate // increased need for more oxygen // increased need for elimination of carbon dioxide
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| incrased WOB in a patient with impaired ventilation can lead to... | further deterioration of respiratory status and the ability to oxygenate adequately
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| recoil | tendency of the lungs to move away from the chest wall after expansion // necessary for expiration and inflation of alveoli // surfactant reduces surface tension of the fluid lining the alveoli which aids their inflation and promotes lung recoil
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| partial pressure of oxygen (PO2) in the alveoli is... | 100mgHG
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| partial pressure of oxygen (PO2) of venous blood in the pulmonary artery is... | 60mmHG
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| partial pressure of carbon dioxide (PCO2) of venous blood entering the pulmonary capillaries is... | 45mmHG
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| partial pressure of carbon dioxide (PCO2) in the alveoli is... | 40mmHG
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| alveolar gas exchange | gases move by diffusion from an area of greater pressure to an area of lower pressure
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| transport of oygen | O2 combines with hemoglobin of RBCs and is carried to tissues as oxyhemoglobin
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| the rate of oxygen transport depends on: | cardiac output (pumping ability of the heart) // the number of RBCs
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| decrease in H&H | anemia
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| increase in H&H | increase in H&H
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| transport of carbon dioxide | inside of RBC as bicarbonate (HCO3) // combined with hemoglobin as carbaminohemoglobin // dissolved in plasma as carboinc acid
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| stimulant to breath | increase in CO2 concentration
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| stimulant to breath in COPD patients | decrease in O2 concentration = hypoxic drive // only low concentration of supplemental O2 (2L/min) shoud be administered to COPD patients
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| hypoxemia | reduced O2 in the blood // low PAO2 // measured by drawing arterial blood gasses
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| hypoxia | insufficient O2 anywhere in the body from the inspired gas to the tissues // can result from pulmonary edema, anemia, heart failure, embolism, COPD
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| O2 saturation | the amount of oxygenated hemoglobin in arterial blood (SAO2)
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| normal SAO2 level | 95-100% // below 70% is life threatening
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| hypoventilation | inadequate pulmonary ventilation (excess CO2) // may be caused by disease of the respiratory muscles, drugs, and anesthesia // will lead to hypoxia
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| signs of hypoxia | rapid pulse // rapid, shallow respirations // dyspnea // restlessness // lightheadedness // flaring of nostrils // substernal or intercostal retractions // cyanosis (late sign)
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| nursing interventions to promote oxygenation | promote breathing // teach deep breathing techniques // teach effective coughing //provide hydration // administer medications // encourage use of incentive spirometer // provide chest physiotherapy // adminsiter oxygen therapy // insert ar
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| promote breathing | position patient to allow maximum chest exansion (fowler's) // encourage frequent changes in position // encourage ambulation // implement comfort measure such as giing meds
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| deep breathing techniques | abdominal / diaphragmatic breathing // purased lip breathing
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| abdominal / diaphragmatic breathing | purse lips as if about the whistle and breathe out slowly and gently without puffing cheeks (keeps alveoli inflated // concentrate on feeling the abdomen fall // contract abdominal muscles while exhaling // count to 7
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| frquency of breathing exercises | 5-10 minutes 4xday
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| effective coughing | controlled coughing // huff coughing
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| controlled coughing | inhale deeply and hold breathe for a few seconds // cough twice (the first loosen the second exspells)
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| huff coughing | lean forward and exhale forcefully with a "huff" (helps keep airways open while mobilizing secretions) // inhale by taking rapid short breahts "sniffs" to prevent mucus from moving back into smaller airways // rest
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| provide hydration to help promote oxygenation | fluid intake thins pulmonary secretions allowing them to be mobilized by cilia and expectorated // the environment should be humidified to keep secretions thin and prevent drying of mucous membranes // cool mist humidifiers, nebulizers, and humidified
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| administer medications | bronchodilators // expectorants // cough suppressants
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| bronchodilators (albuterol) | promote direct dilation of the bronchioles
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| teach patient proper use of metered dose inhalers | place mouthpiece far enough into mouth to extend beyond teeth // inhale slowly and deeply through mouth while pressing down once on canister // continue to inhale for 2-3 seconds // hold breath for 5-10 seconds while removing inhaler from mouth //
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| expectorants (robitussin) | thin secretions
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| cough suppressants (dextromephorphan, codeine) | suppress cough reflex
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| why should you monitor respiratory status when giving narcotic analgesics (morphine, demerol) | they depress the respiratory center in the medulla
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| encourage use of the incentive spirometer | offers the patient an incentive to improve inhalation // measures the flow of inhaled air // loosens pulmonary secretions // expands alveoli // improves pulmonary ventilation and gas exchange
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| instruct patient how to use the incentive spirometer | seal lips around mouthpiece // take in a slow, deep breath and hold for 2-6 seconds // remove mouthpiece and breathe normally // repeat 4-5 times an hour // try to increase depth of inhalation each time
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| chest physiotherapy | percussion // vibration // postural drainage
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| percussion | forcefull striking with cupped hands over congested lung fields (mechanically dislodges secretions) // cover area with towel // ask patient to breath slowly and deeply to romote relaxation // percuss each affected lung segment for 1-2 minutes
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| vibration | used after percussion to increase turbulence of exhaled air and loosen secretions // place hands one on top of the other, palms down // ask patient to inhale deeply and exhale slowly through pursed lips // during exhalation, tense hand and arm muscl
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| postural drainage | each position is assumed for 15 minutes // bronchodilator or nebulizer treatment may be given first // entire tratment is usually 30 minutes // nurse must auscultate lung sounds before and after treatment // nurse notes amount, color, characterist
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| secquence of postural drainage | positioning // percussion // vibration // removal of secretions by coughing or suctioning
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| administeration of oxygen therapy | the amount of O2 delivered is determined by regulating the flow rate using a flow meter // O2 must be humidified to prevent drying of mucous membranes if flow rate is over 2L/min
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| oxygen delivery systems | nasal cannula // simple face mask // partial rebreather mask // non-rebreather mask // venturi mask // transtracheal cannula
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| nasal cannula | 24-45% concentration // 2-6L/min
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| simple face mask | 40-60% concentration // 5-8L/min
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| partial rebreather mask | 60-90% concentration // 6-10L/min
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| non-rebreather mack | 95-100% concentration // 10-15L/min
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| venturi mask | 24-50% concnetration // 4-10L/min // most percise
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| transtracheal cannula | small, narrow cannula surgically inserted through the trachea (0.5-2L/min) // must be flushed with NS and cleaned with rod
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| the rule of four | for each liter of supplemental oxygen, the concentration is increased by 4% // room air is 20% oxygen
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| to calculate percentage of oxygen | # liters x 4 + 20 = % oxygen
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| to calculate liters per minute | % oxygen - 20 / 4 = liters per minute
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| artificial airways | used to keep upper airways open when secretions or the tongue may obstruct them // oropharyngeal // nasopharyngeal // endotracheal tubes // tracheostomy
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| oropharyngeal | used for patients with altered LOC due to general anesthesia, overdose, head injury // lubricate prior to insertion // insert with distal end pointed up, along to of tongue // rotate 180 degreess when soft palate is reached // slip just past uvula
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| nasopharyngeal | inserted through nares // nurse should provide frequent oro-nasal care // reposition q8h to opposite nares
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| endotracheal tubes | inserted by MD // used to administer general anesthesia // also used in ER when mechanical ventialtion is needed
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| tracheostomy | surgical incision is made into the trachea just below to larynx // used for long term airway management // O2 is delivered va trach collar // patient may also be on mechanical ventilation
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| nursing responsibilities for a tracheostomy | suctioning // providing trach care by cleaning the inner cannula // cleaning the peristomal skin // changing the dressing and ties
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| suctioning of secretions | aspirate secretions using a catheter connected to a suction machine // use sterile technique // oro-naso pharyngeal suctioning clears the upper airways // endotracheal suctioning removes secretions from the trachea and bronchi
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| the nurse should assess the need for suctioning | patient is SOB // has rattling or bubling breath sounds // has decreased SAO2 // is cyanotic // lungs should alsways be auscultated before and after suctioning
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