Resp Flashcards
High risk groups for pneumonia
Smokers Immobility Immunosuppressed Depressed gag/cough reflex Sedated Neuromuscular disorders Nasogastric intubAtion Hospitalized client
Nursing assessment of pneumonia
Tachypnea (often shallow resp with use of accessory muscles)
Abrupt onset of fever with shaking and chills
Productive cough
Rapid bounding pulse
Pain and dullness to percussion over affected lung area
Bronchial breath sounds crackles
Arterial blood gas=hypoxia
Older adults may present confused, lethargic, anorexic, tachypnea, tachycardia
A major concern with fever is
It can cause dehydration bc of excessive fluids loss due to diaphoresis
Increased fever also increases metabolism and demand for O2
Nursing intervention for pneumonia
Assess sputum for color, volume, consistency, and clarity
Assist client to cough
Provide fluids up to 3 L per day
Assess lung sounds before and after coughing
Assess rate, depth, and pattern of resp regularly
Assess skin color, mental status, temperature
Promote rest and conserve energy
The best way to assist with a client coughing
Deep breathing every 2 hours (incentive spirometer)
Use humidity to loosen secretions
Suction air way
Chest physiotherapy
Ambulatory
Fluids
Patients should sit in semi fowler or high fowler bc it lessens the pressure on the diaphragm by abdominal organs
What are the two early signs of cerebral hypoxia related to pneumonia?
Irritability and restlessness
Chronic bronchitis
Chronic sputum with cough production on a daily basis for a minimum of 3 months in each of 2 consecutive years
Chronic hypoxemia, cor pulmonale
Increase in bronchial wall thickness which obstructs air flow
Reduced responsiveness of resp center go hypoxemia stimuli.
Higher incidence in smokers
Chronic bronchitis assessment
Generalized cyanosis Blue bloaters Right sided heart failure Distended neck veins Crackles Exploratory wheezes
Emphysema
Reduced gas exchange surface area
Increased air trapping
Decreased capillary network
Increased work, increased O2 consumption precipitating factors- smoking, environmental, genetic
Emphysema assessment
Pink puffers Barrel chest Pursed lip breathers Distant, quiet breath sounds Wheezes
Asthma
Narrowing or closure of the airway due to variety of stimulants
Precipitating factors- mucosal edema, beta blockers, infection, allergic reaction, emotional stress, exercise, environmental, reflux esophagitis
Asthma assessment
Dyspnea, wheezing, chest tightness
Assess precipitating factors
Medication history
Chronic bronchitis nursing interventions
Lowest FiO2 possible to prevent CO2 retention
Monitor for s/s of fluid overload
Teach purse lip breathing and diaphragmatic breathing and tripod position
Administer bronchodilators and anti inflammatory agents
Emphysema interventions
Same as chronic bronchitis
Asthma interventions
Administer bronchodilators
Administer fluids and humidification
Education about what caused attack
Ventilatory patterns
The primary cause of COPD in US is
Tobacco smoke
Tripod position
In bed: sit with arms resting on over bed table
In chair: lean forward with elbows resting on knees
Suctioning (tracheal)
Suction when adventitious breath sounds are heard, when secretions are present at endotracheal tube, and when gurgling sounds are noted
Aseptic/sterile technique
Wear mask and goggles
Advance catheter until resistance is met
Apply suction only when withdrawing (gently rotate when withdrawing)
Oxygenate 100% 1-2 mins before
Ventilator setting maintenance
Verify that alarms are on
Maintain settings and check often to ensure they are set as prescribed
Verify functioning of ventilator every 4 hours
Nasal cannula
Low O2 flow
Good for COPD patients
Simple face mask
Low flow but effectively delivers high O2 concentrations.
Can’t deliver
Non rebreather mask
Low flow, but delivers high O2 concentrations (60-90% O2)
Partial rebreather mask
Low O2 flow reservoir bag attached. Can deliver high O2 concentrations
Venturi mask
High flow system can deliver exact O2 concentration
Proper use of inhaler
Exhale completely
Grip mouth piece in mouth
Use bronchodilator before steroid inhaler
Wait 1 min between puffs
After steroid inhaler client must perform oral care to prevent final infections
Pneumonia
Inflammation of the lower resp Tract
Infection can be through aspiration, inhalation, or hematogeneous spread
Can be bacterial, viral, fungal (rare), or chemical
Can be community or nosocomial (hospital) squired
