Resp. 1 (Exam 3) Flashcards
What is the purpose of the respiratory system
exchange of carbon dioxide and oxygen between external environment and the blood.
Structures of the upper respiratory tract
nose, pharynx, adenoids, tonsils, epiglottis, larynx, trachea
(conducting airway)
Structures of the lower respiratory tract
Bronchi, alveoli, lungs, pleura, pleural cavity
conducting airways and gas exchange airway
What is tidal volume
total air volume inspired and expired during one breath cycle
normal tidal volume
500mL
What conditions may affect the tidal volume and why is this important
asthema, COPD leads to an insufficient air movement which causes hypoxia
What is the significance of the angle of louis? the carina?
The carina is highly sensitive and touching it during suctioning causes vigorous coughing.
- the carnia is the end of the upper respiratory tract
Ventilation
- movement of air into and out of the lungs
- involves inspiration expiration and the actual act of breathing
- getting air where it needs to go
- gas flows from an area of higher pressure to an area of lower pressure
What is the main control center for respiration
Brainstem Medulla
The 2 basic mechanisms for ventilation
Chemical and mechanical
Chemical mechanism
A change in respiratory rate and depth (tidal volume) is based on chemical changes in body fluids
Chemorecetors
- receptors that communicate the changes in the main control center
- there are central and peripheral chemoreceptors
- a receptor that changes to the change in the chemical composition of the fluid around it
- increase in H+ (acidosis) causes the medulla to increase resp. rate and tidal volume
- decrease in H+ (alkalosis) opposite effect
Central chemo receptors are located
in the medulla
Peripheral chemo receptors are located
in the carotid bodies above and below the aortic arch
chemoreceptors respond mainly to
changes in pH, H ions, and CO2
peripheral receptors are secondarily respond to changes in O2
How chemoreceptors work
- your body attempts to rid itself of excess CO2 and to inhale O2
- as the CO2 elevates the body gets rid of it so respiration increase in rate and depth
- CO2 converts to acid and H ions so the same thing happens when the pH drops or the H ions concentration increases
- to the lesser degree as O2 levels decrease the body needs more oxygen so respirations may increase in rate and depth
Increased CO2, increase H, and Decrease pH (decrease O2) =
increased respiratory rate and tidal volume
Decease CO2, Decrease H, and Increase pH (Increase O2) =
decreased respiratory rate and tidal volume
Asouration is more likely to occur in which lung
Right lung
oxygen and carbon dioxide exchange takes place in
the respiratory bronchioles
Alveoli
are small sacs that are primary site of gas exchange in the lungs
- interconnected by pores of Kohn allow movement from alveoli to alveoli
Surfactant
is a lipoprotein that lowers the surface tension in the alveoli and decreases the tendency of the alveoli to collapse
How will a paper bag improve the patients respiratory status?
This will increase the carbon dioxide level in the bag. As you rebreath the air you just exhaled, the increased level of carbon dioxide in the air you’re taking in will increase the level of CO2 in your blood stream and restore calcium levels
Mechanical mechanisms
change respiration based on mechanical factors
- are located in the lungs upper airways chest walls and diaphragm
insipration
active
diaphragm
lowers and causes negative pressure to pull air from atmosphere
intercostal muscles
aid in expanding the chest
accessory mucles
patients who have respiratory problems or who are in distress may have to use the accessory muscles of the neck and shoulders
compliance
refers to the strechability of lungs
- if compliance decreases the lungs are not able ot expand
expiration
- passive
- stretch receptors sense that the lungs have stretched to the normal limits
- Hering - breuer reflex is stimulated (this makes sure the lungs dont overinnflate)
Perfusion
- blood flows through the pulmonary circulation
- blood has to be circulated to the lungs and then to the tissues
- Getting the blood where it needs to go
V/Q ratio
V- ventilation
Q- prefusion
- normal V/Q ratio = 1:1
- this represents a comparion of how much ventilation (air) is available in relationship to the perfusion (blood supply)
- You want them to match, when they dont it is called a V/Q mismatch
* hypventilation most common cause
Normal Ratio
the amount of blood equals amount of gas ratio = 1:1
2 different types of mismatches
- shunt
2. dead space
Shunt
this occurs when ventilation decreases ( blood has to go or shunt to somewhere else to get adequate air) occurs when blood exits the heart without having participated in gas exchange
anatomic shunt
occurs when blood passes through an anatomic channel in the heart and bypass lungs
intrapulmonary shunt
occurs when blood flows through the pulmonary capillaries without participating in gas exchange
dead space
this occurs when perfusion decreases ( the air is dead without the proper blood supply to hook up with)
Nursing care for V/Q mismatches can be placed in 3 main categories
treat the cause of the mismatch
oxygenation therapy
positioning
positioning
when decided on a position; remember that air travels up and blood travels down (laws of gravity)
oxygenation
the presence of of oxygen within the body. Process of making sure the air and blood are good (O2 supply available)
- remember that you can have oxygenation even if it is not getting where it needs to go
- ventilation, perfusion and oxygenation work together but they all have to play their own part, they work on 3 different terms
Diffusion
describles the process of actual gas exchange.
What happens when air and blood meet
- movement of gas from areas of higher pressure or concentration to areas of lower pressure or concentration
Where does diffusion take place
across the alveolar capillary membrane
Nose inspection
check naris are occluded, patency, inflammation, deformities , inspect turbinales for polyps
nose symmetry
look for spetial devation, or broken nose
nose patency
can they breath out of each nostril
nose mucosa
should be pink and moist
nose discharge
seasonal allergies clear, or cerebral spinal fluid, dry or yellow infections process, or brown due to old blood, Presence of purulent and maloclerous discharge could indicate the presence of a foreign body
Mouth
pale grey or blue, if there is a lack of oxygen check color and for lesions, masses, bleeding, poor dentition, check tongue for symmetry and lesions
pharynx
check pressing tongue blade to middle back of tongue should be smooth and moist, no exudate, ulcerations, swelling, nasal drip
tonsils
do they have tonsils do they have pus pockets are they swollen
neck
is it symmetrical are they using accessory muscles to breath or due they have masses
- note any enlargements gagging normal responses
tracheal position
should be midline
- to test use your index fingers to see if its midline, but most of the time you will see it and patient will be in resp. distress
- it likes to deviate away from attention pneumotherectomy
Chest symmetry
movement should be symmetrical
if ribs are broken they could be passing bad air
Anteroposterior (A/P) diameter
should be twice as wide as deep
- copd patients often have the barrel chest due to hyperinflation of the lungs and they cant get the CO2
Respirations normal rate
12-20 per min
Respirations
rate depth, rhythm
depth are they breathing shallow and getting air into the base of their lungs , is their rhymth is it fast or slow or a different pattern are they inhaling faster than exhaling 2:1
bradypnea
breaths less than 12 per min (sedation)
tachypena
20+ breaths per min
hypoventilation
decreased rate and depth of respirations
overdose
hyperventilation
increases in rate and depth of respirations
Kussmauls
rapid deep breathing because of too much acid
DKA, renal problems
Agonal
end of life breathing long periods of apnea
Cheyne Stokes
sometimes breath rapidly and then stop and breath rapidly again this is also associated with end of life
Accessory muscles
abs, neck, shoulders, deep intercostals
- use of accessory muscles is more of a late sign of hypoixa
- should be using diaphragm and intercostals
Nail beds
clubbing is when the angle of the nail flattens out, you will see this in COPD patients, may have delayed cap refill, this may be with peripheral cyanosis
Auscultation
lung sounds
normal sounds
bronchi, bronchovesicular, vesicular (clear lung sounds)
Bronchial
high pitched and longer
loud sound
heard over main airways if you hear them in the lower lungs you may have fluid in the lower lung
Bronchovesicular
medium pitched, dont last long
anterior on each side of the sternum and positeror between scapular
Vesicular
high pitched
breezy
lower lobes
Adventitous sounds
abnormal include crackles rhonci wheezes pleural friction rub
Diminished
increased density or decreased air flow
- patients who arent taking deep breaths COPD patients
Crackles
short pops high pitched increased fluid
- think fluid, either extracellular fluid leaking into the lungs or patient is receiving fluids
Precaution when giving patients fluids
if you pump this patient with fluid too fast, check lung sounds and ejection fraction because this could cause them to go into acerbation of heart failure
- heart failure patients who need blood give them blood then Lasix then other bag of blood
What type of patient would you hear crackles in?
patients with pulmonary edema, pneumonia, COPD patients
What would you do if you heard crackles?
stop fluids if you have fluids running and compare to baseline
Coarse crackles
more fluid in lungs
Fine crackles
just a little fluid in lungs
Where and when do you usually hear crackles?
on inspiration and in the base of the lungs
Rhonchi
continuous running snoring sounds wet obstruction, think mucus
- heard on expiration
What type of patient would you hear rhonchi in
COPD pneumonia cystic fibrosis
What do you do if you hear rhonchi
cough deep breath incentive spirometer ambulate
Pleural friction rub
bzzzzz with inspiration and expiration = inflamed pleura
- a lot of pain receptors in the pleaura it is painful to patient sounds like bee buzzing
stridor
continuous crowning sound, major obstuction
they are struggling to get air
palpation techniques
tactile fremitus, chest expansion , percussion
tactile fremitus
chest wall vibration with vocalization of 99
- compare sides, should have some vibration
- may be increased fluid or decreased air
(air doesnt contract vibrations as well as fluid, COPD you should hear more sound, pneumonia and cystic fibrosis you will have more vibration)
Chest expansion
place hands on the back with thumbs touching at midline
-with inhalation should separate approx 1 in
same indications as decreased symmetry
Percussion
indicates combination of density and air
resonance
normal combination of density and air
- low pitched sound
hyperresonance or tympany
too much air
loud lower pitched sound
dullness or flatness
too much density medium pitched (areas with mixed solid lung tissues)
Patient history
get history if they have ever had resp. problems adn if so what is their history
Dyspnea
is this new or previous rate on a scale of 1-10 ask them how its affecting their ability to take care of themselves can they eat without taking a break, if they get dyspnea on movement this can be a early sign of hypoxia
cough and sputum
quality
frequency
character
productivity
effectiveness
acute vs chronic
does it have color oder and what time of day is it most productive
how much and how often do you cough, cough regularly or sudden and periodic
is this cough related to activity/talking
any changes over time
what efforts have been made to alleviate cough
To get mucus to move
deep breath, cough, incentive spirometer, if your patient is horse is it prolonged or recent is it an obstruction/ tumor or something short term such as laryngitis
chest pain
is your body telling you your not getting enough O2 do a differential diagnosis it is due to the coronary artery or due to the lungs not getting enough o2
- if it is lung involvment it is going to be sharp and localized and not going to breath and deep
Sputum colors
is it ever blood tinged? normally - clear/ slightly whiteish Cigarette- clear/ brown specks COPD- clear white or yellow - consistency? thick thin frothy dehydration postnasal drip, pulmonary edema - no odor normal - odor suggests infection
hoarseness
irritation or obstructuion
- obstruction usually if it lasts longer than 2 weeks
Chest Pain OLDCART
onset location duration charactristics aggravating factors radiation treatment
chest pain
need for differential diagnosis
usually sharp and more localized
results in decreased expansion
pleurisy- parietal pleura has the pain receptors
Orthopnea
trouble breathing when laying flat
increase number of pillows
need to be sitting or standing to help with SOB
more cardiac and fluid status with gravity
- these patients usually get a fluid overload
Paroxysmal noctural dyspnea (PND)
awakened by shortness of breaht usually respiratory in nature Affects O2 exchange can be related to heart failure patient who ahs been standing up all day, and all the fluid in the circulation starts to move into the circulation and its an overload on the heart sleep in recliner or many pillows
Wheezing
usually some sort of airway obstruction
with asthmea it can be muscus plugs
Hemoptysis
when patient is coughing up blood
lung blood is bright red and frothy mixed with sputum
Cyanosis
late sign of hypoxia or decreased cardiac output
- pheripheral not as worry some
- central - around lips or mouth major problem
- bluish color comes from the hemoglobin if they have a low hemoglobin might turb blue
pneumothorax
is an abnormal collection of air or gas in the pleural space that separates the lung from chest wall
Oxygen transport and delivery to tissues
main goal= deliver O2 to tissues to be used
Oxyhemoglobin= O2 travels with hemoglobin Hgb is the carrier
SpO2
saturation of peripheral oxygen (pulse ox will get you this #)
above 90 is great 95+ is better
Pulse oximetry (SaO2)
percentage of saturation of Hgb with O2
- dont forget the importance of Hgb level this will affect your oxygenation level
Partial pressure of oxygen (PaO2)
amount of O2 dissolved in plasma and available for diffusion to tissues
- P02 80-100
- thisis the amount of oxygen avaliable for gas exchange
Oxyhemoglobin dissociation curve
represents the relationship between the SaO2 and PaO2
- oxygen should be just sticky enough to stay on the Hgb till its deliveed to the right place
Alkalosis
decreased CO2 ,H ions, and temp; increased PH
- have greater difference between PaO2 and SpO2
shift to the left (not the right way to go)
“left loves”
Acidosis
increased CO2, H Ions, and temp, decreased pH
- shift to the right ( if you have to go one way this is the right way to go)
Right releases
* COPD patients are usually in acidosis
ABG
Are measured to determine oxygenation status and acid base balance
- can be obtained by arterial puncture or from an arterial catheter
- tells us about alveolar ventilation, oxygenation, and acid base balance
Bicarbonate (HCO3)
carbonic acid (H2CO3) buffer system
-CO2 combines with H20
controlled by lungs and fluid status
lungs attempt to compensate quickly to acid/base changes
increased CO2 (increased RR)
to blow off CO2
Decreased CO2 (decreased RR)
slow deep breaths to retain CO2
- CO2 dissolved in H2O
Normal Co2 levels= 32-48
if they have a low level of CO2 (28) then we have less acid AKA an alklotic value
if they have high of CO2 (56) then we have a lot of acid
Bicarbonate (base)
excretion and reabsorption metabolic component of ABG's = HCO3 controlled by kidneys ability to respond affected by renal funtion often in exhcange for H ions slower response to acid base changes
allens test
prefored before using an artery to ensure adequate circulation to extremity
-occlude both the ulnar an radial arteries then release one
peak flow meter
measures how well air moves out of the lungs
maximum outflow during forced expiration measured in liters per min
shows degree of airway obstruction
- often used in asthema therapy
at home used around 3x
- higher # better the control
- use the highest of the 3
Pulmonary function tests
measure lung volumes and airflow
- used in many obstructive disorders
- its a spirmetery
- helps determine treatment
- show mechanical function of the lungs
- measures volume or flow rate
- evaluates degree of airflow obstruction
Tidal volume (VT)
normal breath in and out
500 ml
inspiratory reserve volume
forced inhalation beyond VT
expiratory reserve volume
forced exhalation beyond VT
Residual volume
amount air left in lungs after forced expiration
- common in COPD
Vital capacity
total capacity of lungs
Sputum collection
sterile 1st morning specimen extract with suctioning or bronchoscopy - if there are bubbles in it its no good - do oral care first
Bronchoscopy
direct visualization of bronchi with fiberoptic scope
-lighted scope into lungs
- can be done surgical outpatient , ICU beside
consent must be given, moderate sudation, numb gag reflex, check gag, NPO 6-8 hrs before
- can be done laying down or seated
- biopsy, tissue samples, remove objects, used for treatments of removal of muscous plugs or foreign objects
Thoracentesis
needle inserted into the pleural space to obtain specimen for diagnosis, removal pleural fluid instill medication
Purpose of thorcentesis
we need to remove fluid from the pleura space in the lungs, what position should the patient be placed in so that all of the fluid may be removed
pulmonary angiogram/angiography
assess pulmonary blood vessels
- catheter inserted into groin or arm and threaded to right side of heart into pulmonary artery - dye injected
- look for clots/ blockages
- catheter is inserted into the groin or arm, what nursing assessments would be priority for this patient specific to the catheter placement
VQ scan
find out if its perfusion scan an ventilation problem
- inhale radioactive gas & radioactive isotope through IV
- pulmonary embolism affect perfusion but not ventilation
CT scan
diagnose lesions difficult to assessby conventional x-ray studies Helical or spiral CT
- can be done with or without contrast
