Quiz 1 Flashcards
Normal heart rate
60-100
Normal blood pressure
120/80
Normal respiration rate
12-20
Normal temperature
36.5-37.5 (varies with age)
Normal oxygen saturation
Sp02 greater than 95$
Early signs of hypoxia
- Anxiety, irritability, confusion
- lethargy
- Dyspnea when moving
- increased RR
- mild WOB
- increased HR
- Diaphoresis
- SpO2 slight lower and PO2 lowering
Late signs of hypoxia
- Lethargy
- combativeness
- dyspnea at rest
- pause to breath when talking
- severe (moderate) WOB
- hypotension, cyanosis, cool/clammy skin
- diaphoresis
- Sp02 below 90% and P02 below 60mmHg
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) knows that hypoxia may occur in patients with respiratory problems. What are some mild signs of hypoxia?
Lethargy, dyspnea on exertion, Sa02 of 93%, mild WOB
Nurse is caring for a patient with asthma. Which method should the nurse use to determine the patients oxygen saturation?
Least mild way - pulse oximetry
Dyspnea
Shortness of breath regardless of the position (respiratory and cardiac disease)
Orthopnea happens when
Breathlessness sensation when laying down - relieved by sitting or standing (COPD and heart failure)
Paroxysmal nocturnal Dyspnea
Wakes patient from sleep (heart failure)
Subjective data during head to toe respiratory assessment
Background info on respiratory diseases, shortness of breaths, productive cough, what ever else the patient may say
Head to toe respiratory assessment (objective data)
- using oxygen (is it working?)
- work of breathing
- symmetrical chest rise
- listening to breath sounds
- sputum
Auscultation
Listening through stethoscope
Fine crackles (BS)
Passing through small air passages and alveoli
- end of inspiration
- hair rolled between fingers
Medium coarse crackles
I’m bronchioles, bronchi, and trachea
- like hair crackles by louder and at early to mid inspiration
Wheezes (rhonchi)
Passing through small airways by secretions, swelling, tumors (common with asthma)
- continuous (expiration)
- high pitched, musical, wheezing
Stridor
Partially obstructed trachea
- crowing sound
- during inspiration
Decreased air entry
Collapsed alveoli
- decreased to no sounds of air (very quiet)
Cyanosis
Blue skin
- not enough circulating oxygen
- late sign of Dyspnea and hypoxia
Clubbing
Thinking of nail bed
How should a normal chest x-ray look
Dense materials (heart, bones) are white and lungs (air filled) should appear black
Pulse oximetry
Non invasive
- measures Sp02 (oxygen saturation) in blood
Arterial blood gas (ABG)
Measures oxygen (P02) and carbon dioxide (PC02) in the blood and tests acidity pH
More invasive
Nursing care for patient with respiratory illness
POSITION PROPERLY
- teach breathing techniques
- effective coughing
- manage fluids
- meds
- oxygen
- activities of daily living
- explore lifestyle and activities adaptations to increase quality of life
Flowers position
Help facilitate ventilation by pulling diaphragm down (gravity helps pull air into lungs)
Tripod position
Helps diaphragm move downwards to increase volume to pull air into lungs (lay sideways in bed or stand with hands on knees)
What are controlled breathing techniques
Pursed lip breathing, diaphragmatic breathing, breathing focus
Pursed lip breathing
Slows breathing, increase peep to open alveoli, breath in through nose (2) and out through puckered lips (4)
Diaphragmatic breathing
Expanding abdomen when breath in and inhaling big
ICOUGH
- incentive spirometer exercise
- cough and breath deep
- oral care
- understand icough practices
- get out of bed and move
- head of bed elevated
What areas do respiratory diseases effect
Airways and lungs
What are the 2 types of chronic respiratory diseases
Restrictive and obstructive respiratory disease
Restrictive respiratory disease
Reduces volume of air lungs can hold, lose elasticity and ability to expand (pneumonia)
Obstructive respiratory disease
Blocked/narrowed airways that are difficult to do gas exchange (asthma and COPD)
What is the number one cause of chronic respiratory disease
Smoking
Breathless scale
Grade 0: strenuous exercise
- 1: SOB when walking up hill (hurrying)
- 2: walks slower, makes stops to catch breath
- 3: stops after 100m or few mins
- 4: too breathless to leave house, dressing
What is pneumonia
Inflammation of the lung tissue and alveoli (gas exchange)
Infectious pneumonia
Caused by bacteria (fungus, Viral)
- walking pneumonia (mild)
Non-infectious pneumonia (aspiration)
Swallowed foreign substance
- people at risk have (decreases LOC, dysphasia, NG tube
What is the inflammatory process of pneumonia
Fluid goes into tissues and fluid blood goes in after to try and fight off the infection creating a wet/warm environment for bacteria to grow
Opportunist pneumonia
Lowered immune system
- HIV, chemotherapy, long-term corticosteroid use
Hospital acquired pneumonia
48hrs after admission
- most lethal, immunocompromised
Causes of pneumonia
- Congestion (fluid in lungs) COPD, Cancer, smoking
- low white blood cells (can’t fight infenction)
- microphages and microcilia damaged and can’t remove foreign objects
Risk factors of pneumonia
- weak cough (ineffective)
- aspiration
- feeding tubes
- meds slowing breathing
Phase 1 of pneumonia
- congestion days 1-2
- inflammatory response (fluid fills alveoli)
- cough
Phase 2 of pneumonia
- Red hepatization
- 3-4days
- lungs red and firm (high blood levels)
- influx of neutrophils
Phase 3 of pneumonia
- gray hepatization
- 5-7 days
- RBC broken down and blood flow decreases (gray color)
Phase 4 of pneumonia
- Resolution
- day 8-4weeks
- exudate digested and destroyed by microphages or coughed up
Signs and symptoms of pneumonia (assessment)
- varies from cause
- fever, fatigue, exercise intolerance, cough (dry to congested), chest wall pain, tachypnea (altered Sp02), complains of SOB, increased WOB, crackles or diminished air sounds (only in certain areas)
Diagnostic to pneumonia
- chest x-ray (needed)
- CBC blood test, WBC count (high with infection), neutrophils (elevated with infection), Sp02 decrease, get sputum sample if productive
Nursing interventions with pneumonia
- monitor
- raise head of bed
- balance activity with periods of rest
- high calorie and high protein
- 2-3L water
- ICOUGH protocol
Patient education (pneumonia)
- watch for symptoms
- prevention (less smoking, healthy diet and exercise, hydration
Complications to watch for with pneumonia
- respiratory failure
- sepsis (infection in blood stream)
- pleural effusion
What is pleural effusion
Fluid in between parietal and visceral pleura limiting lung capacity (lungs can collapse)
What is asthma
Inflammatory chronic condition that causes airway obstructions
What are the 2 ways airways can be obstructed with asthma
Inflammation and bronchoconstriction
Inflammation constriction in asthma obstructs where?
Interior of airway
Bronchoconstriction obstructs what airway with asthma
Exterior
- internal membranes swell
- outside muscles are less effected
- narrowing bronchi and bronchioles
- can be caused by PNS activation.
Common asthma triggers
Allergens, respiratory infections, exercise, inhaled irritants, emotional stress
