lungs and respiratory Flashcards
oxygenation
the process that facilitates and impair oxygen: breathing, blood flow (hemoglobin)
why is adequate perfusion necessary
deliver oxygenated blood to tissues
remove metabolic waste
what is needed to support brain
adequate oxygenation
what does the respiratory system do
supply oxygen to cells
removes carbon dioxide using ventilation
ventilation
process of moving gases in and out of the lungs by inspiration and expiration
lower airway consists of
trachea
right and left main stem bronchi
pleural cavities
contain lungs
lined with two types of serous membranes:
- parietal pleura
- visceral pleura
what are chest wall and diaphragm protected by
parietal, pleura lines the inside of the rib cage and the diaphragm while the inner, visceral or pulmonary, layer covers the lungs.
what does the nurse describe when assessing respiratory system?
- lung sounds
- effort of pt. to breathe
- appearance of the chest wall
- status of the airways
what vital signs will nurse assess
- oxygen saturation
- respiratory rate
- rate, depth, rhythm
where is cyanosis noted?
lips
gums
nailbeds
range of normal oxygen stat
95% to 100%
range of oxygen stat in chronic lung disease
might tolerate a level as low as 85%
expected range of respiratory rate
12 to 20
rate
number of full inspirations and expirations in 1 min
depth
amount of chest wall expansions that occur with each breath
- abnormal are deep and shallow
rhythm
observation of breathing intervals
bradypnea
regular breathing pattern with a rate less than 12/min
tachypnea
regular breathing pattern with a rate greater than 20/min
hyperventilation
deep breathing pattern with an increased rate
hypoventilation
shallow breathing pattern with an abnormally low rate
apena
periods where there is no breathing
primary muscles for inspiration
diaphragm and intercostal muscles
what do accessory muscles contribute to
respiratory effort
midsternal line
through the center of the sternum
midclavicular line
through the midpoint of the clavicle
midaxillary line
through the apex of the axilliae (shoulder blades)
vertebral line
along the center of the spine
anterior axillary
imaginary vertical lines on right and left side of chest, parallel to midsternal line
posterior axillary
imaginary vertical lines on right and left sides of chest from axillary folds
how many lobes does right lung have
3
how many lobes does left lung have
2
maximize sounds by:
- take deep breaths with an open mouth each time you move the stethoscope
- place diaphragm stethoscope directly on the skin to prevent muffling or distortion of sounds
- medicating pain
- give clear directions
- sitting position
high fowlers
sitting up 45 degree angle
when does a pt. have a harder time breathing
laying down
vesicular lung sounds
- normal breathing sounds
- heard over most lung fields
- soft, low pitched, breezy sounds like air going through trees
- inspiration 3 times longer than expiration over most of the peripheral areas of lungs
inspiration 3 times longer than expiration over most of the peripheral areas of lungs
vesicular lung sounds
bronchial
- loud high pitch lung sounds
- hallow quality
- exhaling is longer than inhaling and heard over the trachea
exhaling is longer than inhaling and heard over the trachea
bronchial
bronchovesicular
- medium pitch
- blowing sounds and intensity with equal inspiration and expiration times over the larger airways
blowing sounds and intensity with equal inspiration and expiration times over the larger airways
bronchovesicular
crackles or rales
fine to coarse bubbly sounds caused by fluid
wheezes
high pitch whistling, musical sounds as air passes through narrowed or obstructed airways, usually louder on the expiration
rhonchi
coarse, loud, low-pitched rumbling sounds, during either inspiration or expiration from fluid or mucous, can clear with coughing
stridor
high pitched sound in the upper airway
pleural friction rub
dry, grating, or rubbing sound as the inflamed visceral and parietal pleural rub against each other during inspiration or expiration
absence of breath sounds
collapsed or surgically remove lobes
atelectasis
collapsed alveoli
- diminished or absent breath sounds
- oxygen saturation may decrease to less than 90%
incentive spirometer
used to re-expand the lungs and improve atelectasis
general problem of lung
asthma bronchitis emphysema lung cancer tuberculosis pneumonia copd
