Exam 2 (W5&6 Respiratory) Flashcards
Prolonged obstruction of nasal passage (NG tube or intubation is linked to what
sinusitis
Why is Endotracheal intubation also at risk for nosocomial sinus
because of pooling of nasopharyngeal secretions
Why are patients with artificial airway at high risk for infection
no cilia - cant catch cilia
What is the most common sign of meningitis
sinusitis
What are s/s meningitis
s/s photophobia, seizers, stiff neck (nucalrigidity), fever
neuroanatomy related to respiration is controlled by what
medulla and pons
What do Central chemoreceptors in the medulla do?
respond to change in PCo2 and ph levels in csf –> alter rate and depth of respirations
What do peripheral chemoreceptors do in relation to the respiratory system?
respond first to po2 (less than 60), then will respond to ph and pco2 by altering rate and depth
Describe what happens to the central chemoreceptors in patients with COPD
No longer respond to CO2 or pH in patients with COPD
elevated CO2 does not get a response; these people rely on peripheral chemoreceptors
Hering-breuer reflex
prevents overinflation of the lungs
Why do we not want to give patients with COPD too much o2?
their O2 will get too high ; if we give them too much they will stop breathing
What are the components of external respiration?
Ventilation (act of breathing)
Perfusion (blood flow to alveoli)
Diffusion (Movement of gases from high concentration to low concentration)
– between environment and lungs
Describe internal respiration
Oxygen is supplied to and co2 is removed from body cells by way of circulation
- between blood and cell
Describe the flow of air from the environment into the lungs
trachea, bronchi, bronchioles, alveoli
Airway resistance of determined by what?
The size of the airway through which the air is flowing
Bronchospasm
Airway resistance in which there is contraction of bronchial smooth muscle
Obstruction of airway
Airway resistance in which a foreign object is in airway preventing adequate CO2
What diseased is related to thickening of bronchial mucosa?
COPD, asthma
Compliance
ability of lungs to return to normal - expandability and elasticity
What contributes to compliance of the lungs?
a. Surfactant (surface tension)
b. CT
What happens to the lungs with increased compliance?
causes lungs to not return to normal elasticity (emphysema)
What happens to the lungs and with decreased compliance?
They are stiff ARDS, pneumothorax, pulmonary edema, pleural effusion
What is the tidal volume normal range?
500mL (5-10mL/kg)
What is vital capacity and what is its range?
the amount of air you can move out
4800mL (20-40mL/kg)
What needs to happen with vital capacity less than 20mL/kg?
patient needs ventilatory assistance
What is pulmonary perfusion?
Blood flow through the pulmonary circulation
– 2% of blood flow pumped by the rv does not perfuse the alveolar capillaries (doesn’t enter pulmonary circulation)
What is pulmonary artery pressure value?
20-30mmHg
Describe effects of gravity on pulmonary circulation?
Lower areas receive more blood flow than upper areas
Describe the functions of RV and LA
Right ventricle into pulmonary circulation, picks up o2, left atrium to be projected out into body by
Ventilation vs perfusion and their ratios
Ventilation is flow of gas in and out of lungs (normal 4 L/min)
Perfusion is filling of the pulmonary capillaries with blood (normal 5 L/min)
Perfusion ratio is 4:5 or 0.8
What is shunting?
Shunting (low v/q ratio)
Normal shunting is 2%
Secondary to airway obstruction
Blood is bypassing the alveoli without gas exchange
Severe hypoxia occurs when shunting is 20%
Dead space
(high v/q ratio)
Adequate ventilation but impaired perfusion
Pulmonary embolus
What is silent unit?
unit (absence of v/q)
Little to no ventilation and perfusion (ARDS)
Describe ventilation and perfusion with pulmonary embolism
clot siting in artery – ventilation is fine but the clot is blocking gas exchange (increase in shunts); RV not getting blood into pulmonary circulation
– hypoxic, cyanotic, dusky
Describe what happens when O2 saturation is below 70%.
vessels constrict
Start shunting O2 where it needs to be (heart, lungs, brain, kidneys)
Increased vascular resistance and pulmonary vasoconstriction
Increased pressure on right ventricle (Cor pulmonale)
Systemic vessels dilate
What is cor pulmonale
Right sided heart failure
Enlargement of the right ventricle due to high blood pressure in the lungs usually caused by chronic lung disease
What happens in the RV with COPD?
RV has to work against the pulmonary pressure; the pulmonary pressure increases the workload and the patient goes into heart failure (cor pulmonale)
How much blood is deoxygenated before we see change in skin color?
1/3
What are the gas % at room air?
78% nitrogen
21% oxygen
traces of CO2, water vapor, helium, argon
Describe what blood does in the body
Transported dissolved in blood in two forms
- Dissolved in plasma
- Combines with the hemoglobin of RBC
- 100 ml of arterial blood carries 0.3 ml of oxygen dissolved and 20 ml combined with the hemoglobin
Hemaglobin
Hemoglobin rapidly releases oxygen into the tissues to satisfy metabolic needs
What happens when hemoglobin is present as methemoglobin
not carrying o2 –> hypoxic and cyanotic
drug reaction from local anesth.
What happens to hemoglobin when carbon monoxide is present
Causes hemoglobin to not combine with the oxygen
Resulting in tissue hypoxia and LACTIC ACIDOSIS
Gerontologic considerations for respiratory system: defense mechanisms
decreased cough reflex (increased infection risk); decreased pulmonary reserve, at risk for respiratory acidosis d/t hypoventilation
Gerontologic considerations for respiratory system: lung
Smaller alveolar space - impacts gas exhange
Gerontologic considerations for respiratory system: chest and wall muscle weakness
intercostal muscles are smaller which inhibits them from taking BIG deep breaths
Gerontologic considerations for respiratory system: skeletal changes
Kyphosis, scoliosis, lordosis –> Impact ability to take big deep breath
Respiratory assessment: dyspnea
difficult or labored breathing - SOB
Respiratory assessment: cough
Everyone w lung disease will have a cough –> ask if the cough is different than normal
Pneumonia or other rr conditions – don’t panic with little specks of blood – clots of blood = issue
Respiratory assessment: Sputum production
Color? Same or different color?
Yellow = indication of acute infection (on top of normal pathogens that they have in their sputum)
Respiratory assessment: hemoptysis
Blood in sputum
Respiratory assessment: chest pain
Accompanies cardiac events
Could be indicator of emboli
How do we know if chest pain is cardiac or pulmonary? Does this chest pain get worse when you breath (pulm. Issues gets worse with breathing)
Respiratory assessment: wheezing
Wheezing in someone with asthma = good
Stridor = never good (call provider)
Silent chest / no wheezing during acute asthma attack = not breathing
Respiratory physical assessment - color
Cyanosis = late indicator of hypoxia (not a reliable indicator of hypoxia)
polycythemia may always appear cyanotic
Where should you assess for physical assessment of skin for respiratory conditions of dark skinned individuals?
buccal mucosa and hard palate
What are early indicators of hypoxia?
tachycardia, agitation, confusion
What should you do if someones heart rate is greater than 100 (tachycardia)?
put oxygen on them
What can cause the trachea to NOT be midline?
Pressure in chest (air, blood) pushing trachea to be deviated = bad –> 3am phone call because patient cant breath long w this
Hard to put endotracheal tube w deviated trachea (almost impossible to intubate)
Neck surgery at risk for bleeding and can push trachea (thyroid, cervical fusion, carotid artery cleaning)
Physical assessment of lower respiratory structures and breathing - how do we asses?
Thoracic inspection
Thoracic palpation
Thoracic percussion
(correct order)
Describe the inspection of the lower respiratory structures and breathing
symmetrical rise and fall of chest wall
side vs front –> ppl w normal pulmonary status will have double width to length of chest;
Course vs fine crackles
Depend on the amount of water in the lungs
What does pleural friction rub sound like and when would you hear it
Leather
- Hear it with pleural effusion and pleurisy
What might we hear when someone has pneumonia?
fine crackles because bacterial are liquidy, wet when they dry up you hear course
Describe basilar crackles
Edema in bases of the lungs - insignificant
What should we be concerned about crackles?
When we hear them taking up 1/3 - 2/3 of the lungs
What medications might we administer with edema, stridor and wheezes?
Edema - diuetics
Stridor - albuterol, IV corticosteroids
wheezes - albuterol
Common assessment findings we here for…
a. consolidation (pneumonia)
b. emphysema
c. asthma
d. pulmonary edema
e. pleural effusion
f. pneumothorax
g. atelectasis
a. Consolidation (pneumonia): crackles
b. Bronchitis: wheezes decreased
c. Emphysema: decreased with prolonged expirations
d. Asthma: wheezes
e. Pulmonary edema: crackles at bases, possible wheezes
f. Pleural effusion: decreased to absent breath sounds
g. Pneumothorax: absent or diminished
h. Atelectasis: decreased to absent, fine crackles (cough and deep breath)
Diagnostic evaluation: PFT
PFT: pulmonary function test
- never done in emergency
- lot of deep breathing, prolonged
- inhalation/exhalation and measuring that volume
- done if c/o SOB –> inhaler and then do PTF to see how it is working
can be done Q6 months or annually w ppl who have chronic lunch disease to monitor how well disease is being controlled
What are some considerations for PFT tests?
don’t have to be NPO in preparation, no consent needed, don’t eat too much before, need to know if provider wants the test done w or w/o inhaler,
Chest xray
radiation to take pic
CT
computerized tomography - can use contrast dye with consent from patient
MRI
can not have metal
with or without contrast
PET scan
d/x metastatic cancer disease; give potive glucose isotope that attacked to the fast growing cancer cells
Fluorscopic imaging
Watching lungs in motion
Pulmonary angiography
Using dye; put dye into very large vessel; assess bleeding w this procure; after hold pressure artery tight enough to decrease hematoma and loose enough feet get perfused (foot pulses)
What are considerations for contrast dye?
monitor BUN and Creatinine (can cause kidney failure –> fluids and diuretics); shellfish allergy, IV administration; stop metformin 24-48 h before contrast dye (lactic acidosis)
Pulse o2 considerations
not reliable –> only detects that the hemoglobin has something attached to it – but does not tell you WHAT
should be greater than 92%
if pt acting hypoxic and pulse o2 is high, something is going on
Describe end tidal co2
CO2 level
co2 we breath out tested thru nose
can have a monitor attack to nasal canula o2
35-45
how we pick up someone holding onto Co2 in
operating room for developing malignant CO2
What should you monitor when someone has a pulmonary angiography
s/s bleeding (tachycardia, hypotension)
What are examples of endoscopy diagnostic evaluations for respiratory system?
Bronchoscopy and tharacentesis
Describe thoracentesis
Sit in tripod position
Needle thru ribcage and sucking out fluid in pleural space
Yellowish fluid – plasma
must have consent
Describe bronchoscopy
stick tube down throat to look inside trachea and pulmonary branches
Could go in to do biopsy, flush/suck out occlusion, foreign body
requires throat numbing, usually with a–caine drug which takes away numbing
Risk of of methamaglobin
What are things to consider before and after bronchoscopy
After bronchoscopy patient could be hypoxic / cyanotic because of methamaglobin
Pt will not have gag reflex after, so no food until its back
NPO prior because we are getting rid of gag reflect with the anesthetic
What is something to consider when spinal and epidural anesthesia and thoracentesis
when we take out the needle, we put hole in cerebral spinal fluid and 90% of time it closes, but
Sometimes we get a leak (post spinal or epidural)
patient might complain of HA
Lay flat to put pressure where hole was to prevent leak and help close hole
What is Rhinitis?
Inflammation and irritation of the mucous membranes of the nose; contagious
can be acute, chronic or d/t allergies
do not have s/s and treatment
rhinosinusitis
Inflammatory process involves sinuses
and nasal cavity
Acute bacterial
Acute viral
Symptoms?
Management?
complications?
Pharyngitis
Sudden inflammation of the pharynx
Acute post streptococcal glomerulonephritis
Patho?
Manifestations?
Complications?
Pharyngitis treatment
Keep airway patent
Fluids if they can drink
What is the most common cause of pharyngitis?
Steptococcous
considerations for streptococcal bug
potential for strep bug to land in other organs (kidneys common, hip, knee joints)
Kidney failure common w this bug
Laryngitis
inflammation of larynx
Patho?
Manifestations?
management?
Obstructive sleep apnea
Recurrent upper airway obstruction while sleeping
Reduction in ventilation — frequent arousals— periodic desaturation
What does obstructive sleep apnea have a higher prevalence in?
hypertension
what is someone at increased risk of if they have obstructive sleep apnea
MI, stroke, death, insulin resistance which can increase risk of vascular disease
obstructive sleep apnea: diagnosis
sleep study
obstructive sleep apnea: management
CPAP/BiPAP mask while sleeping, positive pressure that hold airway open (do not breath for patient or give patient o2) – apply pressure (positive pressure) to keep airway open (but you can get supplemental O2 for these if pt needs)
cpap and bipap - teaching
clean to prevent infections
What might cause obstructive sleep apnea?
Soft tissue collapsing (overweight or lot of neck tissue)
Epistaxis
Nose bleed - rupture of tiny distended vessels
Epistaxis managemange
Do not lay down; lean forward so we don’t swallow blood (n/v can make nose bleed again d/t pressure)
Pressure on lower 1/3 of nose (not tip of nose)
Cauterize vessels
Nasal obstruction: what, cause, management
Passage of air obstructed
Cause: foreign body or deviated septum
Management
- Surgery to remove foreign body
- Rhinoplasty to fix deviated septum
Nasal fractures cause
direct assault
Nasal fracture complications
hematoma, infection, abscess, vascular/ septic necrosis
Nasal fracture management
rebreak nose to get septum straight
surgery
Laryngeal obstruction cause
Caused from allergic reaction
Laryngeal obstruction complication
edema ??
management of upper airway obstruction (foreign body, allergic reaction)
Foreign body - heimlich, tracheostomy
allergic reaction - SQ epinephrine, corticosteroid
continous pulse ox
ensure patent airway
Asphyxia
a condition arising when the body is deprived of oxygen, causing unconsciousness or death; suffocation.
Cancer of larynx: s/s
Hoarseness > 2 weeks harsh raspy and lower pitch Dysphagia dyspnea unilateral nasal obstruction discharge
Persistent hoarseness
persistent ulceration
foul breath
Cancer of larynx management
Removal of larynx
What is a tracheostomy
opening into the tracheostomy
What are the types of tracheostomy
cuffed, uncuffed, fenestrated
When might someone get a fenestrated trach
holes on tube; when we start to allow patient to talk and ween off ventilator
Pulsating tracheostomy
BAD
Why do people with long term ventilation do well with a trach
easier to ween off than ventilator
what should nurse do if trach comes out in first 72 hours of administration
call provider - they must reinsert reinserts because fragile scar tissue. After 72 nurse can reinsert
tracheostomy considerations
always make sure there is a replacement tube in room in case is comes out
might be bloody immediately after insertion. Patient might even be coughing clots up from it because the new tube is irritating the airway
What is atelectasis
collapse of alveoli, loss of lung volume
Atelectasis causes what? (external respiration)
Causes a mismatch of ventilation and perfusion causing deoxygenated blood reaching circulation
Atelectasis risk factors
Hypoventilation: post op, pain, narcotics, chronic lung, obesity
Atelectasis: clinical manifestations and assessment
Dyspnea, cough, leukocytosis, diminished breath sounds, sputum production
atelectasis: medical management and nursing management
Incentive spirometer
Chest physiotherapy
Nebulizers
prevention
Atelectasis: chest physiotherapy
cuffing hands and beating back of chest off the way up
Atelectasis: postural drainage
affected lung up (laying on side) and beating on affected lung to loosen it up
Pneumonia pathophysiology
Microorganisms reach the lower airways activate an inflammatory response
Pneumonia clinical manifestations and assessment
fever and cough (productive or non productive), dyspnea, leukocytosis
Pneumonia - medical and nursing management
Pharmacologic therapy (dependent on culture) Oxygen inhalation therapy
Pneumonia prevention
oral care, hand washing, immunizations
pneumonia gerontological considerations
encourage vaccine, teach to cough and deep breath on the own, incentive spirometer
Pulmonary TB patho
airborne transmission
Pulmonary TB clinical manifestations and assessment
Night sweats, low grade fever, cough, fatigue, weight loss
dyspnea, chest pain, hemoptysis as disease progresses
Pulmonary TB: Sputum AFB test reading
confirmative is sputum afb smear indicating mycobacterium (acid fast bacilli will come back + when active)
pulmonary TB: Skin test and quantiferon TB Gold reading
indicate the person has been infected and further testing is required to determine active or latent disease
TB skin test reading procedure and reading
TB skin test read 48-72 hours (induration 5 mm significant for those at risk, 10 mm for those with normal immunity)
TB meds
Isoniazid (INH) & rifampin
all hepatotoxic
What is taken with Isoniazid to prevent peripheral neuropathy
Vitamin b (pyridoxine)
What is recommended treatment for those whose sputum remains positive after the 1st two months of treatment for TB
30 week treatment recommended
Side effects of TB meds: isoniazid
Avoid tyramine
HA, flushing, hypotension
Compliance is an issue r/t sfx of medications
Side effects TB Rifampin
Orange urine
increased metabolism of many common medications
Compliance is an issue r/t side effects of medication
What can we do to increase and assure compliance of TB meds
use direct observation treatment (DOB)
Pulmonary Edema: Patho
Capillary fluid leaks into the alveolar spaces
The edematous alveoli are unable to participate in gas exchange
Clinical Manifestations and assessment of pulmonary edema
Pink tinged frothy sputum
crackles
Medical management and nursing management of pulmonary edema
O2, respiratory support, IV fluids, cardiac treatment aimed at improving LV function
Pleurisy patho
inflammation of pleurae
Pleurisy risk factors
Pneumonia, PE, cancer
Pleurisy: clinical manifestations and assessment
Sharp knife-life pain
Taking deep breath makes pain worse
Pleurisy: medical and nursing management
time and pain meds (intercostal pain blocks, opioids)
Pleural effusion and empyema: patho
Collection of fluid in the pleural space
Pleural effusion and empyema is often a complication of what?
pneumonia, chf, tb, pe, tumors, nephrotic syndrome, pancreatitis, cirrhosis
Clinical manifestations and assessment of pleural effusion and emphysema
Severity depends on size of effusion
Decreased or absent breath sounds in area of effusion
Pleural effusion and empyema: medical and nursing management
Thoracentesis (drain) TPA (breaks up fibrin surrounding empyema so we can treat it) Pleurodesis Decortication (scrape out "orange peel) Pleuroperitoneal shunt
Acute respiratory failure: patho
Sudden life threatening deterioration of gas exchange
Decreased respiratory drive
Dysfunction of the chest wall
Acute respiratory failure cause?
Dysfunction of the lung parenchyma (pneumo, hemo, effusion, obstruction)
Cervical spine injury
Drowny, DIC
Acute respiratory failure: medical and nursing management
Turning, mouth care, skin care, prevent contractures
be sure to do these when patient on ventilator
Acute respiratory distress syndrome
Severe lung injury
Sudden and progressive pulmonary edema
Hypoxemia refractory to supplemental oxygen
Lung compliance and functional reserve capacity decrease
Acute respiratory distress syndrome: risk factors
Direct injury to lungs (smoke, near drowning)
Transfusion related (TRALI), transfusion circulatory overload (TACO)
DIC
Shock
Fat or air embolism
Acute respiratory distress syndrome: assessment
Pao2 to fio2 ratio (normal ratio is over 300)
– 200-300mild, 100-199 moderate and less than 100 severed
Pao2 (abgs) and fio2 being administered
Acute respiratory distress syndrome: medical and nursing management
Positive end expiratory pressure
Keep alveoli open 30 mmhg or less
Low tidal volume
May cause hypotension r/t leakage of fluid into interstitial spaces
Acute respiratory distress syndrome: pharm therapy
Neuromuscular blockers
Pain and anti anxiety
***patient receiving aminoglycosides and/or steroids increased the chance of the client who is chemically paralyzed developing polyneuropathy (muscular atrophy and deconditioning: requires intensive physical therapy to correct)
ARDs nutritional therapy
20-25 kcal/kg/day
Enteral is preferred
ARDS - general measures (nursing management)
positioning - prone
rest is important
ARDS: vent considerations
Pneumothorax can occur
Corneal abrasions
Skin breakdown
rom
What is the mean PA systolic pressure?
12-15mmhG
What is pulmonary artery hypertesion
mean PA pressure greating than 25mmHg
Pulmonary artery hypertension cause
Idiopathic (no known cause) or secondary r/t to a known cause
— CHD, portal hypertension, pulmonary disease
Pulmonary artery hypertension clinical manifestations and assessment
increased pressure leads to RV failure
pulmonary artery hypertension medical and nursing management
Goal is to treat underlying cause Oxygen therapy Anticoagulant therapy Calcium channel Lung transplant Prostacyclin
What is prostacyclin?
Used for pulmonary artery hypertension
potent vasodilator direct into the pulmonary circulation: very short half life
Decrease pressure
Pulmonary embolism
Blood clot or thrombus, air, fat, amniotic fluid, tumor cells, iv injected particulates and sepsis
Alveolar dead space: ventilation no perfusion
PE clinical manifestations and assessment
S4 and split s2 heart sound Sudden onset of chest pain SOB Tachycardia Extra heart sound Saddle emboli refers to location of clot Death commonly occurs within hours D dimer positive Spiral ct
PE medical and nursing management
Anticoagulant (PTT therapeutic 2-2.5 times normal, 70-90)
Thrombolytic Surgical intervention Minimize the risk of pe Monitoring thrombolytic therapy Bed rest Close vital sign monitoring
Lung cancer patho
Benign, malignant, metastatic
Leading cancer killer among women and men
Most caused by cigarette smoking
Staging T (extent of tumor) N (node involvement) M (Metastasis)
Lung cancer Risk factors
Genetic, tb, copd, cigarette, environmental
lung cancer: clinical manifestations and assessment
Dyspnea, hemoptysis, fever
lung cancer: medical and nursing management
Surgical management
Radiation
Chemotherapy
Palliative therapy
Tumors of mediastinum patho
Neurogenic tumor, thymus, lymphomas
tumors of mediastinum: clinical manifestations and assessment
Symptoms result from pressure against intrathoracic organs
Cough, wheezing, dyspnea
Tumors of mediastinum: medical and nursing management
Most are benign and operable
Blunt and penetrating trauma: patho
MVA, falls, bicycle crashes
Gunshot, stab
Blunt and penetrating trauma: clinical manifestations and assessment
Airway obstruction Tension pneumo: trachea not midline Flail chest Cardiac tamponade Pulmonary contusion
What is the MOST important thing to make sure of with blunt and penetrating trauma
CIRCULATION (only time circulation will be more important) then…
- airway, breathing
Blunt and penetrating trauma: medical and nursing management
Blood transfusion
Crystalloids
Chest tube
surgery
