Chapter 17 Assessment of Respiratory Function Flashcards
Functions of the Respiratory System
O2 transport, gas exchange, respiration, & ventilation
Ventilation
Movement of air in & out of the airways
Upper Respiratory Tract Function
Warms & filters air
Lower Respiratory Tract Function
Gas exchange (diffusion)
What occurs during gas exchange?
Delivering O2 to the tissues via bloodstream
Expel waste gases (CO2)
Upper Airway Structures
Nose, paranasal sinuses, pharynx, tonsils, adenoids, larynx, & trachea
Nose Function
Serves as a passageway for air to pass to & from the lungs
Filters impurities & humidifies & warms air as it is inhaled
Cilia
Short, fine hairs that provide a constant whipping motion that serves to propel mucus & foreign substances away from the lungs & toward the larynx
Paranasal Sinuses Function
Serves as a resonating chamber in speech
Tonsil & Adenoid Function
Guard the body from organisms invading the nose & throat
What is another name that the larynx is referred to?
“Voice box”
Epiglottis
A valve flap of cartilage that covers the opening to the larynx during swallowing
Glottis
Opening between the vocal folds in the larynx
Thyroid cartilage
Largest of cartilage structures that forms a part of the Adam’s apple
Cricoid cartilage
Only complete cartilaginous ring in the larynx
Arytenoid cartilage
Used in vocal movement w/the thyroid cartilage
Vocal Cords
Ligaments controlled by muscular movements that produce sound
Trachea
The “windpipe”
Composed of smooth muscle w/ C-shaped cartilaginous rings at regular intervals
Why are the cartilaginous rings in the trachea incomplete?
The cartilaginous rings in the trachea are incomplete on the posterior surface to give firmness to the wall of the trachea to prevent collapse
Which organs compose the lower respiratory tract?
The lungs w/alveolar & bronchial structures
How many lobes does the RT lung have versus the LT lung?
The RT lung has 3 lobes & the LT lung has 2
Pleura
Serous membrane that serves as the inner lining of the lungs
What area does the visceral pleura cover?
The lungs
What area does the parietal pleura cover?
Lines the thoracic cavity, lateral wall of the mediastinum, diaphragm, & inner aspects of the ribs
What is the purpose of lobar & segmental bronchi?
They facilitate effective postural drainage
Do bronchioles have cartilage in their walls?
No, their patency depends on the recoil of the surrounding smooth muscle & on alveolar pressure
Physiologic Dead Space
Portion of the tracheobronchial tree that does not participate in gas exchange
Respiration
Gas exchange between the atmospheric air & the blood & the cells of the body
Apnea
Temporary cessation of breathing
Obstructive Sleep Apnea
Temporary absence of breathing during sleep secondary to transient upper airway obstruction
Which areas need to move in order for ventilation to occur?
Ventilation req movement of the walls of the thoracic cage & of its floor, the diaphragm
Inspiration
When the capacity of the chest is increased, air enters through the trachea
Expiration
Chest wall & diaphragm move back into the original position
-Lungs recoil & force air out via trachea & bronchi
Compliance
Elasticity & expandability of the lungs & thoracic structures
Pulmonary diffusion
Process by which O2 & CO2 are exchanged from areas of high concentration to areas of low concentration
Pulmonary perfusion
Actual blood flow through the pulmonary vasculature
Tidal Volume
Volume of air inhaled & exhaled w/each breath
Inspiratory Reserve Volume
Maximum volume of air that can be inhaled after normal inhalation
Expiratory Reserve Volume
Max volume of air that can be exhaled forcibly after normal exhalation
Residual Volume
Volume of air that remains in the lungs after max exhalation
Dyspnea
Subjective feeling of discomfort while breathing
Tachypnea
Abnormally rapid respirations
Hypoxemia
Low blood O2 level
Orthopnea
Shortness of breath when lying flat, relieved by sitting or standing
Stridor
Continuous, high-pitched musical sound due to airway narrowing (usually heard on inspiration)
MEDICAL EMERGENCY!!
Where can stridor be auscultated?
It can be auscultated over the neck
Egophony
Abnormal change in tone of voice that is heard when auscultating the lungs
Cough
Reflex that protects the lungs from the accumulation of secretions/ inhalation of foreign bodies
Cough reflex may be impaired by…
Weakness/ paralysis of resp muscles
Prolonged inactivity
Presence of NG tube
Anesthesia
Brain disorders
Sputum Production
Reaction of the lungs to any constantly recurring irritant & often results from persistent coughing
Nursing Assessment: Sputum Production
Is there sputum production?
Nature:
-Color: Thick & yellow, green, rust-color, or change in color is indicative of bacterial infection
-Consistency
-Odor
For respiratory disorders, where is the chest pain usually located?
Pain is present usually on the side where the pathological process is located
True or False (T or F):Patients w/chest pain from a pulmonary cause may get relief from laying on the affected side
True
Wheezing
Continuous, high-pitched musical sound (can be heard in either inspiration or expiration)
Wheezing on Inspiration
Bronchitis
Wheezing on Expiration
Asthma
Hemoptysis
Expectoration of blood from the respiratory tract
Hemoptysis from the Lungs
Frothy, bright-red & mixed w/sputum
Hemoptysis from the Stomach
Blood is a darker red color, not frothy
Smoking is the single most important contributor to respiratory illnesses (T or F)
True
Pack Years
The number of cigarettes smoked per day X the number of years the patient has smoked
Risk Factors for Developing Respiratory Disease
Abnormal immune response (asthma)
Exposure to indoor & outdoor pollutants
Genetic makeup
Infection
Obesity
Personal/family history of lung disease
Smoking
Nail Clubbing
Nail bed appears to be spongy and nail angle is distorted
Cyanosis
Bluish coloring of the skin (late indicator of hypoxia)
True or False (T or F): Central cyanosis is an early sign of hypoxia
False; Confusion, decreasing O2 sats, labored breathing, & nasal flaring are early signs
-Cyanosis is a late indicator
Which accessory muscles are used during inspiration?
Sternocleidomastoid, scalene, and trapezius muscles
Which accessory muscles are used during expiration?
Abdominal and internal intercostal muscles
Crackles
Non-musical discontinuous popping sounds during inspiration caused by delayed reopening of the airways heard on chest auscultation
What respiratory conditions are crackles associated with?
Associated w/ HF, pulmonary fibrosis, obstructive pulmonary disease
Friction Rubs
Discontinuous, low-pitched, rubbing sound (can be heard during both inspiration & expiration)
What respiratory conditions are friction rubs associated with?
Inflammation & loss of lubricating fluid
Diagnostic Test: Pulmonary Function Tests (PFTs)
Used for diagnosis w/chronic respiratory disorders via spirometry measurements, lung volumes, arterial blood gas (ABG)
What do PFTs evaluate?
Lung mechanics, gas exchange, and acid-base disturbance
Nursing Interventions for PFTs
Determine whether analgesics are needed
Consult w/physician regarding holding bronchodilators
Instruct client to void prior to exam
-Once test starts, it cannot stop
Remove dentures
Reframe from smoking or eating a heavy meal 4-6 hours before the test
Diagnostic Test: Arterial Blood Gases (ABG)
Provides info on O2 status & and acid-base balance
What does an ABG (arterial blood gas) assess?
The lung’s ability to provide adeq tissue perfusion, removal of CO2, ability to maintain normal pH
Normal pH Ranges
7.35-7.45
Normal CO2 Range
35- 45 mmHg
Normal PO2 Range
> 80 mmHg
Normal HCO3 Range
22-26 mEq/L
Metabolic Acidosis
pH is low & Bicarb is low
Metabolic Alkalosis
pH is high & Bicarb is high
Respiratory Acidosis
pH is low & CO2 is high
Respiratory Alkalosis
pH is high & CO2 is low
ROME Acronym
Respiratory
Opposite
Metabolic
Equal
Diagnostic Tests: Pulse Oximetry (SpO2)
Normal values 95% - 100%
* Values < 90% need evaluation
Unreliable when there is low
perfusion
* Shock, cardiac arrest, sepsis,
hypothermia
* Nail polish can affect SpO2
When should cultures be obtained?
They should be obtained prior to starting antibiotic therapy
Imaging Studies: Chest X-Ray
Patient is not required to be NPO
Patient need to be able to take a
deep breath and hold it without
discomfort
Imaging Studies: CT scan
NPO for 4 hours beforehand if contrast dye used
* Allergy to iodine or shellfish
* Contrast contraindication
MRI Nursing Interventions
All metal must be removed (includes nicotine patches that have foil comp)
Assess for implanted devices: Aneurysm clips, pacemaker/defibrillator
Assess px’s ability to lie flat 30-90mins
Px will hear loud/thumping noise
Px will be able to comm w/staff via microphone
If px is claustrophobic may need anti-anxiety meds
If confused, may need to be sedated
MRI Contraindications
Severe obesity
Confusion & agitation
Claustrophobia
Implanted metal
Bronchoscopy
Scope inserted via throat to inspect inner respiratory structures
Complications of Bronchoscopy
Infection
Aspiration
Hypoxemia
Pneumothorax
Bleeding
Perforation
Nursing Interventions for Bronchoscopy
Informed consent
NPO for 4-8hrs (prev aspiration)
Dentures must be removed
Pt is sedated
Topical anesthetic used to suppress cough reflex
Small amount of blood-tinged sputum & fever may be expected w/in the first 24hrs
Post-Procedure Monitoring for Biopsies
NPO until gag reflex returns
Vital signs per orders
Dyspnea
Bleeding
Pneumothorax
Uneven/absent breath sounds Right vs. Left
Uneven chest movement
Infection at the site
Thoracentesis
Aspiration of fluid and air from the pleural space
Pre-Procedure Nursing Interventions for Thoracentesis
Informed consent
Monitor vital signs
Check labs (coagulation)
Help to position the client over the bedside table
Instruct client to breathe deeply & not cough
Post-Procedure Nursing Interventions for Thoracentesis
Monitor vital signs
Apply pressure dressing (monitor for bleeding & crepitus)
Monitor for pneumothorax, air embolism, & pulmonary edema
Crepitus
Crackling/grating sound caused by subcutaneous air
Atelectasis
Collapse of alveoli & often is described in relation to chest x-ray findings & clinical signs & symptoms
Signs & Symptoms of Atelectasis
Dyspnea
Cough
Sputum prod
Common Causes of Acute Atelectasis
People who are immobilized and have a shallow, monotonous breathing pattern due to thoracic/abdominal surgery
Signs & Symptoms of Acute Atelectasis
Lobar atelectasis (large amount of lung tissue)
Dyspnea
Cough
Sputum prod
Tachycardia
Tachypnea
Pleural
Central cyanosis
How does non-obstructive atelectasis occur?
Occurs as a result of reduced ventilation
How does obstructive atelectasis occur?
Occurs due to a reabsorption of gas (trapped alveolar air is absorbed into the bloodstream)-> no additional air can come in-> collapse
Nursing Measures to Prevent Atelectasis
Frequent turning
Early mobilization
Strategies to expand the lungs and to manage secretions
Pleural Effusion
Fluid accumulating in the pleural space
Pneumothorax
Air in the pleural cavity caused by a puncture of the lung/chest wall
Hemothorax
Blood in the pleural space
A nurse is caring for a client following a thoracentesis. Which manifestations are recognized as a risk for complication?
A) Dyspnea
B) Fever
C) Localized bloody drainage on the dressing
D) Hypotension
A) Dyspnea
A client’s partner states the client woke up this morning, did not recognize her, & report chills. Which action should the nurse take FIRST? (Priority)
A) Obtain vital signs
B) Obtain a complete history from the client
C) Obtain sputum culture
D) Provide a pneumococcal vaccine
A) Obtain vital signs
Which client diagnosed w/pneumonia, is MOST likely to have community-acquired pneumonia?
A) A client newly admitted to a long-term care facility
B) A client who recently traveled on a cruise ship
C) A client who has had multiple family visitors
D) A client whose spouse recently died
A) A client newly admitted to a long-term care facility
A nurse is assessing a client following a bronchoscopy. What findings should the nurse report to the provider?
A) Blood-tinged sputum
B) Sore throat
C) Dry, nonproductive cough
D) Bronchospasm
D) Bronchospasm
The nurse is interviewing a client who reports a dry, nonproductive cough. Which medication does the nurse question?
A) Aspirin
B) Angiotensin-converting enzyme (ACE) inhibitors
C) Cardiac glycosides
D) Bronchodilators
B) Angiotensin-converting enzyme (ACE) Inhibitors
Which assessment finding indicates that the client has chronic hypoxia?
A) Crackles
B) Peripheral edema
C) Clubbing of the fingers
D) Cyanosis
C) Clubbing of the fingers
The nurse is caring for a client w/ a pulmonary disorder. Which finding is indicative of a LATE symptom of hypoxia?
A) Cyanosis
B) Dyspnea
C) Restlessness
D) Confusion
A) Cyanosis
