Module 2-a Flashcards
Fetal circulation
Umbilical cord- 1 vein , 2 arteries. O2 bld –placenta–umbilical vein. Splits in 2 at the base of the liver.
Foramen Ovale
Opening between the right/left atria. Bypasses pulmonary circulation. Most oxygenated bld passes through here.
Infant Resp
30-60 per min. Abdominal breathing. Crackles sometimes present at the end of deep resp.
Early childhood resp (1-5 yrs)
20-40, irregular pattern. Expiration longer then inspiration.
Late childhood resp (6-12 yrs)
15-25 resp. Thoracic breathers. Inspiration longer then expiration.
Aged adult resp. (65 +)
12-20. Thoracic.
Factors that affect Respiratory Function
Age, gender, exercise, acid-base balance, brain lesions (hemorrhage/tumor), high altitude, resp disease (COPD), anemia, anxiety, meds (narcotics, amphetamines), acute pain.
Nursing assessment and Resp. function
patterns, recent changes, cough, sputum, CP, dyspnea, fever, fatigue.
Techniques for assessment (resp) Inspection
Inspection- always least invasive to most invasive. Contour (convex), Movement (symmetrical), Color (warm/dry- check for scars) Rate/Rhythm (assess for 1 min./ nasal flaring)
Techniques for assessment (resp) Palpation
Palpation- Excursion or movement- (trach centered b/t clavicles). Vocal Fremitus (capacity to feel sound in the chest, non-bony area/ Pneumonia), Temp- (check in certain areas) Crepitus - air pockets (rice krispies).
Techniques for assessment (resp) Percussion
Percussion- Resonance (loud, hollow, high pitched over normal lungs. Hyperresonance (emphysema/ loud boom), Flat tone (bone, heavy muscle), Tympany (high pitched, drum like sound heard in the stomach). Dullness (medium pitch, intensity / liver)
Techniques for assessment (resp) Auscultation
Auscultation- apex to the base, Vesicular, low pitch (base on inspiration) Bronchial, high pitch (along the trachea, expiration longer then inspiration), Brochovesicular, medium pitch (blowing sound during expiration, equal I and E.
Adventitious Sounds (Resp function) Crackles
Crackles/Rales- discontinuous (intermittent, low, high pitched sound on inspiration. Never cleared by a cough.)
Adventitious Sounds (Resp function) Wheezes
Wheezes- continuous ( high pithced on I and E)
Adventitious Sounds (Resp function) Gurgles
Gurgles/Rhonchi- continuous (loud, low, course. Snoring, can clear with a cough. Large airway obstruction)
Adventitious Sounds (Resp function) Pleural Friction Rub
Pleural Friction Rub ( dry, grading sound. Inflammation of pleural space. “screeching”)
Adventitious Sounds (Resp function) Stridor
Stridor- (mostly w/ infants. Upper airway inflammation, gasping of air)
Diagnostic Tests for Resp. Function
CBC, PFT, ABG, SPO2, Cytologic, Bronchoscopy, Skin, CXR/CT, Thoracentesis (pleural effusion)
Nursing DX: Altered Respiratory Function
Ineffective airway clearance, R/T thick secretion, fever, fatigue, dehydration, poor nutrition as manifested by: restlessness, inability to walk w/o coughing.
Manifestations of the for O2 (subjective)
verbalize- diff. breathing, pain, anxiety, fear, fatigue, dizziness, drowsiness, lightheadedness, numbness in extremities.
Manifestations of the for O2 (objective)
observes-use of accessory muscles, flared nostrils, abnormal breath sounds, cyanosis, coughing, tachy, sputum, distended neck veins, restlessness, and skin changes
Nursing interventions (promote effective cough)
sit upright-flat footed, reminder to cough, specific coughing schedule, coughing exercises (productive/nonproductive)
Nursing interventions (pollution free environment)
job change, protevtive equipment, enforce laws, dust/vacuum, wear a mask when needed, restrict exposure, pat attention to pollution alerts, avoid smoking.
Measures that promote comfort
Positioning (high Fowlers) b/c of orthopnea (inability to breath lying flat), adequate fluid intake, humidified air (cool mist), percussion (cupping), vibrating, postural drainage, good nutrition, meds
