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AHI > Assessment of the Respiratory Sys > Flashcards

Assessment of the Respiratory Sys Flashcards

1
Q

Assess smoking habits
Promote smoking cessation
Determine exposure to other inhalation irritants
Protect the respiratory system

A

Health promotion and maintenance

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2
Q

Smoking at very high risk for resp diseases, comps, etc
Big thing assess on pats for smoking history
Current smoker or ever smoked? - prior smoker, when quit, how many years ago, how much did they smoke when they smokes
Record the smoking history in pack-years
Secondhand smoke and thirdhand smoke - indicated higher risk; common ask if exposed to smoke in home
Other:
Smoking history always really big

A

Assess smoking habits

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3
Q

Record the smoking history in pack-years

A

years smoked x packs smoked

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4
Q

Hookah or water pipes; E-cigarettes (more prevalent - help get off nicotine and tobacco but not lot evidence on what can do to lungs but need to assess this as well)

A

Other:

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5
Q

Joint commission requirement - smoking is with JCHO if current smoker talk about smoking cessation - offer resources for quitting
Nicotine replacement therapies - lot available but is very hard

A

Promote smoking cessation

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6
Q

Nicotine replacement therapies - lot available but is very hard

A

Ex. Zyban - med; Chantix - med; Nicotine patch, lozenges, gum

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7
Q

Current and past geographic living area
Occupation
Home conditions
Hobbies

A

Determine exposure to other inhalation irritants

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8
Q

Areas with high levels of air pollution
Exposure to inhalation irritants

A

Protect the respiratory system

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9
Q

Areas with high levels of air pollution

A

Teach patients to remain indoors with windows closed when air quality is poor and to not to engage in heavy physical activity

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10
Q

wear masks and ensure the area is well ventilated

A

Exposure to inhalation irritants

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11
Q

Everything worsens with age
Alveoli
Lungs
Pharynx and larynx
Pulmonary Vasculature
Exercise Tolerance
Muscle Strength
Susceptibility to Infection
Chest wall

A

Changes in the resp sys related to aging - things happen with aging

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12
Q

alveolar surface area decreases - because decrease SA for gas exchange can affect resp sys for exchange of O2 and CO2
Where gas exchange occurs
diffusion capacity decreases
elastic recoil decreases - less recoil: air can get trapped in lungs because not exhaled as efficiantly
bronchioles and alveolar ducts dilate - dilation in airways
ability to cough decreases - decreased cough reflexes
airways close early

A

Alveoli

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13
Q

residual volume increases - loss elasticity because of it; not as much exhale air out so get increase RV; not go thing because not want lot of it
vital capacity decreases - amount air can breathe in and out decreases
efficiency of oxygen and carbon dioxide exchange decreases
elasticity decreases

A

Lungs

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14
Q

Upper airway; swallowing affected because not have much strength; little bit of cartilage loss can make airways collapse
muscles atrophy - weaker
vocal cords become slack
laryngeal muscles lose elasticity
airways lose cartilage

A

Pharynx and larynx

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15
Q

Veins and arteries that supply blood to lungs and take blood away from lungs
vascular resistance to blood flow through pulmonary vascular system increases - when pumping blood out lungs more pressure in vessels and can damage lungs because harder on vessels because more resistance so get pulm HTN
pulmonary capillary blood volume decreases - less blood supply to pulm caps = less blood supply to alveoli (where gas exchange is)
risk for hypoxia increases and hypercapnia (High CO2 and low O2)

A

Pulmonary Vasculature

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16
Q

body’s response to hypoxia and hypercarbia decreases - because issues high CO2 and low O2 this decreases

A

Exercise Tolerance

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17
Q

respiratory muscle strength, especially the diaphragm and the intercostals, decreases
Decreases in whole body and resp muscles in intercostal spaces and diaphragm

A

Muscle Strength

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18
Q

effectiveness of the cilia decreases
immunoglobulin A decreases
alveolar macrophages are altered

A

Susceptibility to Infection

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19
Q

anteroposterior diameter increases
thorax becomes shorter
progressive kyphoscoliosis occurs
chest wall compliance (elasticity) decreases
mobility of chest wall may decrease
osteoporosis is possible, leading to chest wall deformities

A

Chest wall

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20
Q

Doing assessment ask questions and phys assessment
Family and personal data
Smoking
Drug use (prescribed and recreational that could affect lungs) - meds
Allergies esp for resp assessment for asthmatic pat (hypersensitivity rxn - have lot triggers related to allergies); emphysema/chronic lung pat exposed to something that causes upper resp distress exacerbate lung probs
Travel, geographic area of residence - travel to area with increased pollutants or live in area like that
Nutritional status - imp
Current health problems

A

History

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21
Q

Is the current health problem acute or chronic? - chronic lung probs or is this an acute sit
Question the patient about cough: - big thing about is sputum - know amount, thick/thin, sticky, color
chest pain
Dyspnea - SOB
Related to resp assessment

A

Current health problems

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22
Q

Productive or Non productive
What does the sputum look like? How much?

A

Question the patient about cough: - big thing about is sputum - know amount, thick/thin, sticky, color

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23
Q

Complete physical assessment via inspection and auscultation of lungs (auscultate lung sounds) - if find have pulm issues may do percussion/palpation - higher level practitioner level assessment because another way to assess lungs to assess for dullness and see changes in lung field area
Auscultation
Skin and mucous membrane changes (pallor, cyanosis)
General appearance
Endurance

A

Assessment

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24
Q

Lungs clear - great
Diminished - means something going on; not as much air movement going on; pneumonia/consolidation
Wheezes - asthmatic or constriction
Crackles - fine/coarse
Rhonchi - coarse crackles: secretions
Rales - fine crackles: more fluid type situation
Sound lungs good idea what going on with pat

A

Auscultation

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25
Q

Assess the nail beds and mucous membranes of the oral cavity
Skin give good indication
Cyanosis - hypoxemia going on and not getting blood supply to the tissues; check nail beds, mucous membranes/skin
Examine fingers for clubbing (indicate long-term hypoxia); angle nail not as sharp and may indicate long-term chronic lung probs

A

Skin and mucous membrane changes (pallor, cyanosis)

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26
Q

Long-term respiratory problems lead to weight loss and a loss of general muscle mass
Arms and legs may appear thin or poorly muscled
Neck and chest muscles may be hypertrophied - will use accessory muscles to breathe - upper muscles used more often
Chronic lung prob: certain disease processes: bloated/fluid retention; typ emaciated, thin, working harder to breathe - higher caloric needs; breathing so hard that not eating as well; had choice eating and breathe and pacing self will breathe; issues with weight loss and muscle mass decreases

A

General appearance

27
Q

Decreases whenever gas exchange is inadequate
Observe how easily the patient moves and whether the shortness of breath is at rest or upon exertion; good assessment is SOB: worse if SOB at rest than with activity - make distinction, SOB when laying flat
Note how often the patient pauses for breath between words when talking; if pat has to stop when talking to take a breath are SOB; if notice breathing are SOB - pay attention to it means SOB

A

Endurance

28
Q

Sputum imp assessment to look at: how much coughing up, when coughing it up; blood - keep track actual volume - thick, thin, watery
Sometimes hear secretions
Cough: productive/nonproductive
Productive: what looks like
Having secretions but is their cough production strong enough to get it out

A

Secretions

29
Q

Imp for resp pats
Shortness of air often induces anxiety (supposed to be breathe and not notice it so when breathe and notice it makes very anxious) and anxiety can exacerbate shortness of air - vicious cycle so want keep pats relaxed and be cognisant that are anxious; pat pop where controlling anxiety imp; sometimes need take antianxiety - benzodiazepene - conscious of giving those meds because can be sedating which can affect breathing; if chronic lung prob need cognisant of anxiety levels and keeping them as low as possible can
Stress may worsen some respiratory problems
Discuss coping mechanisms esp if chronic thing - so disabled from SOB that cannot care for self anymore; find resources for them to be able to get the help they need
Chronic respiratory disease
Assist the patient to identify available support systems

A

Psychosocial assessment

30
Q

Chronic respiratory disease

A

changes in family roles or relationships
social isolation
financial problems/unemployment
Disability

31
Q

Red blood cell count (RBC)
Hemoglobin
White Blood Cell count (WBC) with Diff
Arterial blood gases (ABG)
Sputum
Chest x-rays
CT Chest (computerized tomography)

A

Laboratory and imaging assessment

32
Q

Data about the transport of oxygen - imp assessment

A

Red blood cell count (RBC)

33
Q

Transports oxygen to the tissues - imp assessment
Low hemo - anemia can affect O2 because not as much hemo carrying O2 around
Deficiency could cause hypoxemia

A

Hemoglobin

34
Q

Good Indication of infection

A

White Blood Cell count (WBC) with Diff

35
Q

Data on oxygenation as well as acid base balance - blood drawn from arterial blood stream and gives indic of oxygenation and acid base balance: PO2, PCO2, bicarbonate, pH; indices adequate gas exchange, getting rid CO2 and getting O2 in

A

Arterial blood gases (ABG)

36
Q

Culture and sensitivity - pneumonia, sputum
Cytology - concerned about pathology (like lung cancer); run on sputum
Productive cough - target antibiotics

A

Sputum

37
Q

Pneumonia - first thing do if think this
Very common diagnostic tool - chest pain, resp, SOB get this
Preliminary tool; go to
Typically one of the first tools

A

Chest x-rays

38
Q

Typ With contrast (concerned for allergies and kidney func) or sometimes without
Better pics for masses

A

CT Chest (computerized tomography)

39
Q

Assess for oxygenation
Identifies measurement hemoglobin saturated with oxygen
Readings recorded as SpO2, SaO2 or O2 sat(uration)
Normal: 95% - 100%: no issues 98-100
Below 91%
Below 85%
Pats with chronic COPD, emphysema - keep oxygenation and SpO2 lower level - sometimes chronic lung pats goal between 88-92; deals with hypoxic vasoconstriction; sometimes consideration where retain CO2 and issues with alveolar damage keep SpO2 at lower level
Able to detect desaturation before other manifestations occur (dusky skin, pale mucosa, pale or blue nail beds)

A

Pulse oximetry

40
Q

require immediate assessment and do interventions/treatment

A

Below 91%

41
Q

body tissues have a difficult time becoming oxygenated - very concerning

A

Below 85%

42
Q

Capnometry and Capnography - measuring exhaled CO2; good indic of ventilation; see if too sedated and hypoventilating
Some Oxygen cannulas - measure exhaled CO2
Pulmonary function tests (PFTs)
Exercise testing
Skin tests

A

Other noninvasive diagnostic assessments

43
Q

Often in outpat setting if eval someone for obstructive/restrictive lung disease: COPD/asthma/pulm fibrosis: things restrict/obstruct airway
Lot measurements of volume
RTs run these
These 3 need look at as nurse
Forced vital capacity (FVC)
Forced expiratory volume (FEV1)
Peak expiratory flow (PEF)
Good measurements for obstructions/restrictions in airway

A

Pulmonary function tests (PFTs)

44
Q

Volume of air exhaled from full inhalation to full exhalation
Air fully inhale and fully exhale - indication if airway restricted/obstructed because numbers decreased

A

Forced vital capacity (FVC)

45
Q

Volume of air blown out as hard and fast as possible during the first second of the most forceful exhalation after the greatest inhalation
Look across board from chronic COPD pats; take deepest breath can and blow out as hard and as fast as possibly can and measure volume air comes out in first sec
COPD pats have issue with getting rid RV because alveolar damage - trapping air not able fully exhale so exhalation good measurement for obstructive diseases because obstruction and not able to fully exhale

A

Forced expiratory volume (FEV1)

46
Q

Fastest airflow rate reached at any time during exhalation
How fast exhale

A

Peak expiratory flow (PEF)

47
Q

More outpat

A

Exercise testing

48
Q

Very common
Allergy testing - ID tests and see what react to
Tuberculin skin testing - screening

A

Skin tests

49
Q

Invasive procedure - informed consent
Receive at min moderate sedation/gen anesthesia
Laryngoscopy
Mediastinoscopy
Bronchoscopy

A

Endoscopic examinations

50
Q

Scope inserted into larynx to assess the function of the vocal cords
Go look into larynx
Concerned about swallowing and speech
Uses:
Patients receive sedation

A

Laryngoscopy

51
Q

remove foreign bodies caught in the larynx
obtain tissue samples for biopsy or culture

A

Uses: - Laryngoscopy

52
Q

Insertion of a flexible tube through the chest wall just above the sternum into the area between the lungs
Full gen anesthesia
Uses:
Performed under general anesthesia

A

Mediastinoscopy

53
Q

Examine for tumors
Obtain tissue samples for biopsy or culture from mediastinum

A

Uses: - Mediastinoscopy

54
Q

Most common endoscopic exams for resp pats
Insertion of a tube/scope in the airways, usually as far as the secondary bronchi; looking as far down as bronchi
Uses:
Very common tool because used for lots diff things such as diagnostic/intervention
Rigid bronchoscopy requires general anesthesia in the OR
Flexible bronchoscopy can be performed at the bedside/pulm lab/GI lab/lab outside full OR
Short procedure
Nursing Interventions Post Procedure: - caring for pats

A

Bronchoscopy

55
Q

View/look in airway structures
Obtain tissue samples for biopsy or culture - looking for mass can biopsy
Remove excessive secretions or foreign bodies - full secretions can suck out all secretions - remove foreign bodies from airways
Also flush airways with saline suck saline back out and send bronchial washing down to be tested if concerned about lung cancer because lung cells in bronchial wash
Assist with placing or changing endotracheal tube

A

Uses: - Bronchoscopy

56
Q

Monitor for hemoptysis - not unusual for little bit but if excessive report that
Min moderate sedation so must be closely monitored during procedure and immediately post
Monitor VS, O2 saturation, and assess breath sounds every 15 min for 2 hours - could puncture airway and cause bleeding in airway and cause comps so need monitor for bleeding, infection (not seen right away), issues with breathing postop give sedation checking for oxygenation as well
Monitor for return of gag reflex - numb airway: larynx and pharynx not safe to eat/drink once come back from procedure so cannot eat/drink until check gag reflex
Assess for possible complications of bleeding, infection or hypoxemia
Can damage lung so do CXR postop to make sure no puncture of of lung

A

Nursing Interventions Post Procedure: - caring for pats - Bronchoscopy

57
Q

Where place needle into pleural space (between lung wall and pleural lining) - typ not much space between there but are times where fluid, blood, air collects in space and when that happens the lung collapses/pushes the lung down
Needle aspiration of pleural fluid or air from the pleural space for diagnostic or management purposes; needle in there to remove fluid; fix prob as management purposes but also for diagnostic - even if not huge amount of fluid draw little amount of fluid and test it if concerned about cancers/infection; diagnostic/treatment
Nursing Interventions Post Procedure

A

Thoracentesis

58
Q

Often performed at the bedside
Local anesthetic agent to numb area - wide awake so not much prep besides consent
Help to position patient - lung be as expanded as much as possible; put over bedside table and hunched over in tripod position; cannot do that on side and in fetal
Stress the importance not to move, cough, or deep breath during the procedure

A

Needle aspiration of pleural fluid or air from the pleural space for diagnostic or management purposes; needle in there to remove fluid; fix prob as management purposes but also for diagnostic - even if not huge amount of fluid draw little amount of fluid and test it if concerned about cancers/infection; diagnostic/treatment - Thoracentesis

59
Q

CXR to rule out possible pneumothorax (can occur within 24 hours) - Needle could go into lung to cause pneumothorax - draining fluid - hole in lung and air leaking from pleural space into lung; very common so always get CXR to make sure not occurred; if have pneumothorax - no air movement heard so lung sounds extremely diminished or absent because lung collapsed when air collected in there
Monitor VS, lung sounds, bleeding at puncture site - check puncture site - typ not many comps with puncture site but need monitor it

A

Nursing Interventions Post Procedure - Thoracentesis

60
Q

Invasive
Often for cancers/masses
Performed to obtain tissue for histologic analysis, culture, cytologic examination - some or all
May be performed:
Nursing Interventions Post Procedure:

A

Lung biopsy

61
Q

In the radiology department with the help of fluoroscopy or CT guided biopsies and more common because less invasive for pat and have CT and know where exactly where going and get sample need
In the OR if an open biopsy is required under general anesthesia
Through a bronchoscopy
Depending on how done depends on type monitoring needed

A

May be performed: - Lung biopsy

62
Q

radiology/bronchoscopy - moderate sedation - follow-up care and CXR
CT or CXR to rule out pneumothorax - taking chunk for biopsy from lung could put hole in lung
Follow-up care:

A

Nursing Interventions Post Procedure: - Lung biopsy

63
Q

Assess vital signs, breath sounds at least every 4 hours for 24 hours
Assess for respiratory distress/issues
Assess airway
Report reduced/absent breath sounds immediately
Monitor for hemoptysis - blood - not unusual for little bit but if excessive report that

A

Follow-up care: - Lung biopsy

AHI (77 decks)

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