BN Ch.86 Respiratory Disorders (Nursing Process) Flashcards
State the rationale for the use of each of the following: sputum, lavage, throat culture, ABG, CXR, lung scan, lung perfusion scan, pulmonary angiography, PFT, and skin testing.
- Sputum testing: Help determine the presence of organisms or blood is a person’s sputum. Specimens are best in the morning, when they are most likely to contain sputum, rather than just saliva.
- Lavage: If a client is unable to cough up sputum, bronchoalveolar lavage is to be obtained using sterile saline is instilled in the bronchus, the cells and fluid from the bronchioles and alveoli are removed endoscopy along with the saline. The cells are analyzed in the lab, most often diagnosing pulmonary tuberculosis.
- Throat culture: To test the presence of an infection, a sample of both mucus and secretions from the back of the clients throat is obtained. A complete culture will determine all organisms present in the specimen.
- ABG: Best indicator of oxygen deficiency is the level of arterial blood gasses.
- CXR: A chest x-ray is ordered to determine lung or heart abnormalities. Ex. lung tumors, lung abscess, pulmonary tb, pneumonia, enlarged heart, & used to observe foreign objects in the lungs.
- Lung scan: This test yields a two-dimensional map of various organs and tissues by introducing a medication administered through inhalation.
- Lung perfusion scan: Illustrates different views through which lesions, pneumonia, and other disorders can be located.
- Pulmonary angiography: Involves an injection of radiopaque dye into the pulmonary blood vessels to determine pathology of dye related problems.
- PFT (pulmonary function test): Measures how much air a client inhales and exhales in one breath and assess the client’s general respiratory status. The PFT measures total lung capacity, vital capacity, and residual volume. It also measures tidal volume, inspiratory volume, and expiratory volume. The machine used for these tests is the spirometer.
- Skin testing: Indicates whether a person has ever been exposed to the tubercle bacillus or other disorders. The procedure is the same as that for administering tests to determine allergies to medications or other allergens.
Demonstrate the positions of postural drainage.
- The person adopts a head downward position, which allows secretions to run far enough into the trachea from the bronchi so that they can be coughed out.
- The client’s exact position depends on the portion of the lung to be drained.
Differentiate the following: thoracentesis, paracentesis, and thoracotomy.
- Thoracentesis:
- Involves puncturing the chest wall to remove excess fluid or air from the pleural cavity.
- Paracentesis:
- Puncturing of a body cavity for aspiration of fluid; however this process most commonly refers to puncture of the abdominal cavity.
- Throactomy:
- Lung surgery; an incision into the thorax or chest cavity.
Identify four nursing considerations related to closed water-seal chest drainage.
Monitor the client closely for signs of shock, dyspnea, pain in the chest, or a rapid increase in chest tube drainage, and report symptoms immediately.
Identify five alterations in normal respiratory status.
- Dyspnea: Labored or difficult breathing, painful breathing.
- Orthopnea: Difficulty breathing lying down, relieved by sitting upright.
- Tachypnea: Very rapid breathing.
- Hyperpnea: Increase in depth of breaths; may be increase in rate.
- Bradypnea: Respiration slower than normal; regular rhythm.
- Hypoventilation: Respirations that have reduced in rate and depth (shallow) or irregular.
- Hyperventilation: Increased rate and depth of respiration often leading to decreased carbon dioxide levels.
- Apnea: Cessation of breathing for brief periods of time.
- Central apnea: No brain drive to breathe.
- Mixed apnea: Central apnea immediately followed by obstruction.
- Obstructive apnea: No airflow owing to upper airway obstruction.
- Adult sleep apnea: Prolonged and frequent episodes of apnea during sleep.
Identify 10 interventions that can assist the client who is in respiratory distress.
- Orthopneic position:
- Utilize position to lessen the physical weight of gravity of the body during breathing.
- Turning, Coughing, & Deep breathing reduces the client to be immobile and develop respiratory problems more quickly.
- Suctioning to remove oral nasal secretion
- Administering nasal treatments
- Oxygen
- Breathing treatments
- Postural drainage
- Breathing exercises
- Incentive spirometer
Identify three nursing considerations for a client with ARDS.
- Acute rhinitis: The common cold, a viral illness of the upper respiratory tract, that is the nose and throat. Rhinitis means inflammation of the nasal mucous membranes causing a runny nose.
- Streptococcal throat infection: Sore throat
- Influenza: Commonly called the flu. It is an active contagious respiratory disease caused by one of several strains of filterable viruses.
- Laryngitis: Inflammation of the larynx. It may accompany a respiratory infection or result from overuse of the voice or excessive smoking.
- Bronchitis: Inflammation of the bronchial tubes. Acute bronchitis often follows a respiratory infection especially during winter months.
- Lung abscess: A localized area of infection in the lung that breaks down and forms pus. It can be caused by a foreign body or aspiration of oral fluids or respiratory secretions.
- Pneumonia: An inflammation of the lung with consolidation or solidification. The lung becomes firm as the air sacs are filled with exudates.
- Pleurisy: An inflammation of the pleura can be a complication due to pneumonia.
- Histoplasmosis: Mimics “super flu”, is caused by inhaling spores of fungus.
- Tuberculosis: An infectious disease caused by the acid fast bacillus. This organism encases itself in a waxy coating that makes destruction difficult. When found in the lungs the bacilli are encased in a lump called a tubercule.
- Empyema: Sometimes called pyothorax, is a collection of purulent (pus-containing) exudates in the pleural cavity. It can be acute or chronic.
Compare and contrast the following pulmonary diseases: asthma, bronchiectasis, chronic bronchitis, and emphysema.
- Asthma: Is a chronic airway condition characterized by inflammation of the lining of the bronchial airways.
- Bronchiectasis: A chronic dilation of the bronchi in which the walls become permanently widened, distended, flabby, and scarred. The main causes are infections or conditions that injure the bronchial airways or prevent the airways from clearing mucus.
- Chronic bronchitis: A more serious bronchitis. It often develops so gradually that the person disregards its most significant symptom, a chronic cough.
- Emphysema: Abnormal permanent enlargement of the alveoli and alveolar ducts, with destruction of the alveolar walls, which result in lack of elasticity.
Identify three nursing considerations for a client with ARDS.
- ARDS: A state of progressive oxygen deprivation following a serious illness or injury.
- Nursing considerations: Open airway, effective breathing pattern, & improved gas exchange.
State three common sources of trauma to the lungs, along with three nursing considerations for each.
- Absence of air exchange
- Chest trauma
- Drowning /Near drowning
- Drug poisoning
- Pneumothorax
Differentiate between the two types of malignant lung tumors and state the names of three forms of NSCLC.
- Pulmonary carcinoma: A malignant tumor characterized by uncontrolled cell growth of lung tissues.
- NSCLC: small cell lung cancers non small cell lung cancers.
Identify three common inflammatory disorders and four structural disorders of the nose.
- Inflammatory disorders: Sinusitis, acute sinusitis, chronic sinusitis
- Structural disorders: Deviated septum, nasal polyps, plastic surgery, care of the client undergoing nasal surgery.
Collapse of a lung due to obstruction by mucus or a foreign object is called __________.
atelectasis
The incentive __________ helps the client to perform respiratory exercises and to maintain lung function.
spirometer
An inflammation of the double membrane
covering of the lungs is called
pleurisy
Identify the equipment in the figure.
The figure shows an example of a metered-dose
inhaler with a spacer.
Which health condition is this equipment used for?
It is used to treat moderate to severe asthma. The
inhalation of steroids helps to improve lung
function and to decrease inflammation, asthma
symptoms, and flare-ups.
Identify the equipment shown in the figure.
The equipment shown in the figure is a Pleur-Evac
operating system, which is one kind of chest
drainage system.
What is the purpose of this equipment?
The equipment is used for carrying out closed
water-seal drainage. In this procedure, one or more
catheters are inserted into the chest to reestablish
negative pressure in the lungs.
What are the different components of this system?
The Pleur-Evac is a single unit with three chambers:
a collection chamber, a water-seal chamber, and a
suction control chamber.
What are the nursing implications during this procedure?
The nurse should monitor the client closely for
signs of shock, dyspnea, pain in the chest, or a
rapid increase in chest tube drainage and report
these symptoms immediately. The most serious
complications are hemorrhage into the lung cavity
or collection of air in the pleural cavity, causing
collapse of all or part of a lung.
