NCLEX RESPIRATORY Flashcards
Nose
Humidifies warms and filters inspired air
Pharynx
- THROAT
- Passageway for respiratory and digestive tracts
- Divided into nasopharynx, oropharynx, and laryngopharynx
Larynx
- VOICE BOX
- Has 2 pairs of vocal cords True and False
- Opening between true vocal cords is glottis
- Glottis plays important role in coughing this is most fundamental defense mechanism of the lungs
Epiglottis
- Leaf shaped at the top of the larynx
- Prevents food from entering the trachea by closing over glottis when swallowing
Trachea
- WINDPIPE
- Located in front of esophagus
- Branches into the right and left main stem bronchi
Bronchioles
- Branch from secondary bronchi and subdivide into the small terminal and respiratory bronchioles
- Depend on elastic recoil of the lung for patency
- Contain no cilia and no gas exchange
Alveoli
O2 and CO2 exchange
What descends into the abdominal cavity during inspiration? causing negative air pressure
Diaphragm
Air passes through the terminal bronchioles into the alveoli to oxygenate the body tissues
Lungs
What happens at the end of inspiration ?
- DIAPHRAGM and INTERCOSTAL MUSCLES RELAX
- LUNGS RECOIL
What does effective gas exchange depend on?
- VENTILATION and PERFUSION OF LUNGS
What happens when air passes through the lungs ?
- TERMINAL BRONCHIOLES —> ALVEOLI —> OXYGENATE TISSUES
Chest X Ray (RadioGraph)
ANATOMICAL LOCATION and APPEARANCE OF LUNGS
Pre-procedure
- Remove ALL JEWELRY
- ABILITY TO INHALE/ HOLD BREATH
- DETERMINE POSSIBILITY OF PREGNANCY (will effect fetus)
- MUST WEAR APRON IF OF CHILD BEARING AGE
Thoracentesis ( Pre - Procedure )
- RELIEVE PRESSURE
- DETERMINE CAUSE FOR ASPIRATION OF AIR OR FLUID FROM PLEURAL SPACE
PRE- PROCEDURE
- Explain
- Take vital signs
- PREP client for ULTRASOUND or CHEST RADIOGRAPH , CT SCAN
- CHECK for COAGULATION STUDIES (D- DIMER)
- Position SITTING UPRIGHT
- Arms on pillows on over bed table LYING ON SIDE
- UNAFFECTED SIDE
- HOB ELEVATED
- STINGING EXPECTED with injection of local anesthesia
- PRESSURE when needle inserted
Post-Procedure
- Listen to breath sounds
- MONITOR VS FREQUENTLY (PRE/POST)
- CHECK
LEAKAGE
BLEEDING
PT TOLERANCE
- NO MORE (1000ml removed at one time)
- POST PROCEDURE (STERILE DRESSING)
What is a pulmonary angiography?
Evaluates specific areas of the arterial system
Is a pulmonary angiography invasive ?
- YES
- SEDATION and LOCAL ANESTHESIA
- CATHETER THROUGH GROIN (artery)
- UNTIL REACHES PULMONARY
What are two important things that are used for an angiography?
- HEPARIN ( Clotting )
- IV CONTRAST ( To visualize )
What do you tell the patient Pre/Post procedure for an Angiography ?
Pre:
- Explain
- Remove jewelry
- ALLERGIES TO
Iodine
Seafood
Radiopaque dyes
- MAINTAIN NPO for (8 hours before procedure)
- Monitor VS
- CHECK RESULTS OF COAGULATION STUDIES
- IV ACCESS
- Aminister sedation (AS PRESCRIBED)
- REQUIRES PT TO LIE DOWN
- May feel an urge to cough, flushing, nausea, or salty taste from dye injection
- EMERGENCY EQUIPMENT AVAILABLE
Post:
- VITAL SIGNS MONITORED FREQUENTLY - ASSESS for HEMATOMA/DISTAL PULSES - COMPARE SKIN, TEMP, COLOR, SENSATION (Both Extremities) - AVOID BP FOR 24 HOURS ( Extremity used for the injection) - KEEP ACCESSED LEG STRAIGHT NO BENDING - Check for peripheral and neurovascular status in the affected extremity - CHECK BLEEDING ON INSERTION SITE - Monitor delayed reaction to dye
ABG ( Allen’s Test)
- PATENCY OF RADIAL or ULNAR ARTERY
- PERFORMED PRIOR TO ABG needle stick
Is an Allen’s test performed before or after an ABG needle stick?
BEFORE
Explain Allen’s Test Procedure
- Explain
- APPLY PRESSURE TO ULNAR AND RADIAL ARTERIES simultaneously
- Ask the Pt to OPEN AND CLOSE HAND REPEATEDLY
- PRESSURE RELEASED FROM ULNAR ARTERY WHILE COMPRESSING RADIAL ARTERY
- COLOR OF EXTREMITY distal to the pressure point is checked
- DOCUMENT
PALM SHOULD RETURN TO ITS NORMAL COLOR IMMEDIATELY PERSISTANCE OF PALLOR IN THE PALM AREA INDICATES OCCLUSION OF ULNAR ARTERY A+ Allen’s Test means that the pt DOES NOT HAVE DUAL BLOOD SUPPLY
Explain how to do an ABG Test
- Obtain VS
- PERFORM ALLEN’S TEST
- Identify factors that may affect the accuracy of the results
- Changes in oxygen respiratory assistive devices
- Suctioning within the past 20 min
- Pt. Activities - Provide emotional support
- Assist with specimen draw by prepping heparinized syringe. UNCLOTTED BLOOD (NO AIR BUBBLES can be present in specimen)
- Check arm for swelling, discoloration, pain, numbness, or tingling
- APPLY PRESSURE for 5 min to prevent hematoma
- 10-15 min with Pt receiving anticoagulants
- Record Pt. Temp and what type of oxygen they are receiving on lab form (ex; room air or oxygen)
- SEND SPECIMEN ON ICE, OCCLUDE NEEDLE (to avoid air in syringe)
What is a sputum analysis
IDENTIFIES CAUSE OF PULMONARY INFECTION AND ABNORMAL LUNG CELLS.
EXPECTORATION OR TRACHEAL SUCTIONING TO COLLECT SPECIMEN IS ACCEPTED
Explain Sputum Specimen procedure
- FLUID INTAKE ENCOURAGED NIGHT BEFORE
- Instruct to RINSE MOUTH WITH WATER BEFORE SPECIMEN COLLECTION
- DO NOT BRUSH TEETH, EAT, or USE MOUTHWASH BEFORE TEST
- STERILE CONTAINER USED
- Ultrasonic/heated nebulizer treatment 10-15 min prior aids in collection
- Teach Pt. how to expectorate
- Collect SPECIMEN EARLY MORNING/BEFORE EATING AND DRINKING
- Specimen should be representative of pulmonary secretions and NOT SALIVA
- NOTE ANY CURRENT ANTIBIOTIC THERAPY ON LAB SLIP
- SPUTUM COLLECTED MUST BE AT LEAST 5 ML
- Culture requires at least (48 HRS FOR COMPLETION)
- Sputum culture for fungus and mycobacterium may take 6-8 weeks
- Tell the Pt. to notify the nurse as soon as the specimen is collected
Pulmonary Function Test
EVALUATES LUNG MECHANICS, GAS EXCHANGE, and ACID BASE DISTURBANCE THROUGH SPIROMETRIC MEASURMENTS lung volumes, and arterial blood gas levels
Explain pulmonary function test procedure
Pre:
- DETERMINE WEATHER ANALGESIC IS BEING USED ( MAY DEPRESS RESPIRATORY SYSTEM
- CONSULT HCP ON WITHHOLDING BRONCHODILATORS BEFORE TESTING
- PT. MUST VOID/WEAR LOOSE CLOTHING BEFORE PROCEDURE
- Remove dentures
- REFRAIN FROM
SMOKING OR EATING HEAVY MEALS 4-6 hrs before the test
Post:
- May resume a normal diet
- Bronchodilators/respiratory treatments that were withheld before the procedure resumes
Bronchoscopy
- Visualization of trachea and main stem bronchi with a FIBEROPTIC SCOPE
Explain Bronchoscopy procedure
- Explain
- NPO STATUS (6-12 hours prior to test)
- Remove dentures if any
- INSPECT MOUTH FOR INFECTIONS
- PRE- MEDICATE
(Valium, versed, Demerol)
Post:
- LIE ON SIDE
- NPO UNTIL GAG REFLEX RETURNS
- OBSERVE RESPIRATORY DIFFICULTIES
- SORE THROAT EXPECTED POST OP
Bronchoscopy with Biopsy Expect:
Dry cough, blood streaked secretion but CLOSELY MONITOR for HEMOPTYSIS (Coughing out blood)
NURSE ALERT! MONITOR FOR: - Bleeding - Dyspnea - Oxygen saturation - Tachycardia - Tachypnea - Hypotension
What is a CT scan of the chest ? Explain procedure
3- dimensional assessment of the lungs and thorax
- Explain
- CT of the chest may require iodinated intravenous contrast
- Check for pregnancy
- Check for iodine allergy
- Recognize claustrophobia
- Medicate with lorazepam Ativan (DO NOT GIVE TO CHILDREN)
Fusion
Lung imaging used to find cancer cells in the body in their early stages
Lung Biopsy. Explain procedure.
LUNG TISSUE REMOVAL FOR CULTURE OR CYTOLOGY
- Explain
- Maintain NPO status
- Administer pre-med SEDATIVES or ANALGESICS
- Performed with fluoroscope monitoring
- Position Pt. as for THORACENTESIS
Post:
1. Monitor VS and breath sounds every 4 hrs for 24 hrs
2. STERILE DRESSING on biopsy site
MONITOR FOR DRAINAGE OR BLEEDING
3. MONITOR SIGNS OF RESPIRATORY DISTRESS
4. Chest X-Ray take after the procedure to check for complications of pneumothorax
MONITOR for AIR EMBOLI and PNEUMOTHORAX, NOTIFY RN AND HCP IF THEY OCCUR
Positron Emission Tomography (PET)
Anatomical location of lung tumor
What are the causes of HIGH PRESSURE ALARM in ventilators ?
- COUGHING, GAGGING, or ATTEMPTING TO TALK
- BITING ORAL ET Tube
- Bronchospasm
- Increase airway pressure
- OBSTRUCTION to flow circuitry DUE TO SECRETIONS OR KINKED ET TUBE
- CONDENSATION in large bore tubing
- RESISTANCE
- SUCTIONING
What are the causes of LOW PRESSURE ALARM in ventilators ?
- ET DISPLACED
- ET TUBE DISCONNECTED
- Leaking tidal volume from low pressure cuff
- VENTILATOR MALFUNCTION
- LEAK IN VENT CIRCUITRY
Mechanical Vent Intervention
- Check VS
LUNG SOUNDS
RESPIRATORY STATUS
BREATHING PATTERNS - Skin color (NAIL BEDS/LIPS)
- Chest for bilateral expansion
- TAKE PULSE OX
- ABG levels
- IF THERE IS NEED FOR SUCTIONING and observe TYPE/COLOR AND AMOUNT OF SECRETIONS
- Check vent settings
8.Check the level of the humidifier and the temperature of the humidification system, high temps can damage the mucosa in the airway - Ensure alarm is set
- If cause for alarm can not be determined ventilate the client manually with a resuscitation bag until the problem is correct
- Empty the ventilator tubing when moisture collects
- Turn every 2 hours or get the client out of bed to prevent complications with immobility
- Resuscitation equipment ready at bedside
Peak Flow Meter
Device to measure airflow through the bronchi and degree of obstruction in the airways. Main asthmatic patients
Purposes of peak flow meter
- Evaluate the presence and degree of lung disease
- Determine severity of asthma
- Evaluate responses to change in therapy
- Diagnose exercise induced asthma
Interpreting Peak ( Green Zone )
- Green (80 - 100% of personal best)
- SIGNALS ALL CLEAR
- ASTHMA UNDER REASONABLE GOOD CONTROL
- NO SYMPTOMS PRESENT
- continue routine treatment plan
Interpreting Peak (Yellow Zone)
(50 - 80% of personal best) - SIGNALS CAUTION - ASTHMA is NOT WELL CONTROLLED - AIRWAYS NARROWING - Maintenance therapy may need to be increased IF CLIENT STAYS IN THIS ZONE , NOTIFY MD
Interpreting Peak ( Red Zone )
- (Less than 50% of personal best )
- SIGNALS A MEDICAL ALERT
- IMMEDIATE DECISIONS AND ACTIONS
- SEVERE NARROWING of airway may be occurring
- Administer a short acting bronchodilator
- Notify MD IMMEDIATELY if it does not return immediately and STAY in YELLOW or GREEN ZONES
Incentive Spirometer
- Device for MEASURING LUNG CAPACITY
- KEEPS LUNGS CLEAR
Purposes for Incentive Spirometer
- HELP IMPROVE LUNG FUNCTION
- PTs who had any surgery that may significantly affect the respiratory function
- Pts on extended use of anesthesia
- Pts with rib injury to help minimize fluid build-up in the lungs
Patient teaching for Incentive Spirometer
- Have the patient assume a comfortable position ( SEMI-FOWLER or SITTING) in chair or bedside
- Demonstrate how to place mouthpiece so that lips completely cover mouthpiece
- Instruct to inhale slowly and maintain constant flow through the unit. Hold breathe for (1-2 seconds)
exhale slowly - Instruct client to breathe normally for short period time
- Hold the incentive spirometer in an upright position. Place the mouthpiece mouthpiece in your mouth and seal lips tightly around it. Breathe in slowly and as deeply as possible, raising the yellow ball toward the top of the column. The yellow coach indicator should be in the blue outlined area
Pulse Oximeter
- NONINVASSIVE
- MEASURES OXYGEN SATURATION OF HEMOGLOBIN
- It can alert for hypoxemia before clinical signs occur
Hyperventilation causes low ____________ ?
- LOW CO2 resulting in HYPOcapnia ( reduced CO2 in blood )
Hypoventilation causes high ___________ ?
HIGH CO2 resulting in HYPERcapnia
Objective signs of Respiratory Distress
- FLARING NOSTRILS
- Circumoral cyanosis ( bluish color seen around the mouth and on the inside of lips
- Suprasternal retraction ( Inward movement of the abd, skin is inbetween ribs)
- Sternocleido muscles retraction
- Intercostal muscle retraction
- Subcostal retraction
- Tachypnea ( Rapid breathing )
- Stridor ( Upper airway )
- Cyanosis ( late sign )
- Tachycardia ( rapid heart beats ) shown on monitor
- Hypoxemia seen on pulse ox
Subjective signs of Respiratory Distress
Patient states:
“ I am having shortness of breath.”
“ I am not getting enough air.”
- Info gathered by physical exam
- Lab and Diagnostic testsHow are normal breath sounds classified ?
- Intensity
- Pitch
- Relative duration of their inspiratory and expiratory phases
Vesicular breath sounds
- Are NORMAL
- SOFT, BREEZY, LOW PITCHED
- Heard through inspiration and continue without pause into expiration
- Audible over MOST of the ANTERIOR and LATERAL areas
Bronchial breath sounds
- NORMAL
- COURSE, LOUDER, HIGH IN PITCH, LONG LOUD EXPIRATION
- Short silent period between the inspiratory and expiratory ones
- HEARD AROUND TRACH
Bronchovesicular breath sounds
- Normal
- MEDIUM SOUND
- Equal during inspiration and expiration
- HEARD OVER MAINSTEM BRONCHI
Tracheal bronchial sounds
- Normal
- LOUD/HARSH
- HEARD OVER TRACH
Adventitious breath sounds
Abnormal breath sounds
Crackles
- Intermittent and very brief
- RATTLING
- BUBBLING
- GURGLING
- SOUNDS LIKE VELCRO STRIPS PULLED APART
WHEEZES
- HISSING or SHRILL QUALITY
- OCCURS IN ASTHMA
- CROUP
- PLEURAL EFFUSION
- BRONCHIAL SPASM
- OBSTRUCTIVE EMPHYSEMA
- EDEMA ( CHF)
- ALLERGIC REACTION
- MOANING SOUND
- BRONCHITIS
RHONCHI
- SNORING QUALITY
- AIRWAY IS PARTIALLY OBSTRUCTED WITH SECRETIONS
- MUCOSAL SWELLING
- TUMOR PRESSING PASSAGE
Diminished or absent breath
- Sounds associated with
PNEUMOTHORAX
COPD
SEVERE AIRWAY OBSTRUCTION
PLEURAL EFFUSIONHow will you know when a metered dose inhaler is empty ?
It will float ( Choose this option if metered dose is not available)
When do you refill an inhaler ?
When it is 1/4 full
