Respi Flashcards
The clinical history of the respiratory system is divided into six components:
(1) chief complaint,
(2) history of present illness,
(3) past health history,
(4) family history,
(5) personal and social history, and (6) review of systems.
The patient’s history starts with the
chief complaint and information about the present illness.
Data about the present illness and any symptoms are thoroughly investigated using the
NOPQRST
Principal symptoms that should be investigated in more detail commonly include
-Dyspnea
-Chest Pain
-Sputum production
-Cough
-Shortness of breath
-Wheezing
-Sleep disturbance
What is NOPQRST?
N: Normal - describe normal baseline. what was it like b4 the symptoms
O: Onset - kanus a nag sugod ang gibati
P: Precipitating and palliative factors - what brought the symptom? unsay naka trigger?
Q: Quality and quantity - how does it feel, i-describe unsa
R: Region and radiation - where does the symptom occur
S: Severity - pain scale
T: Time - how long does symptom last? how often do you get the symptom?
When should you begin physical examination?
After taking patient’s history
What should you do if patient is in respiratory distress?
establish the priorities of your nursing assessment, progressing from the most critical factors (airway, breathing, and circulation [the ABCs]) to less critical factors.
Respiratory Monitoring
- Pulse Oximetry
- Arterial Blood Gas Analysis
- Capnography/ETCO2 Monitoring
This provides continuous, noninvasive measurement of oxygen saturation in arterial blood (SpO2). Pulse oximetry is used to assess for hypoxemia, to detect variations from the patient’s oxygenation baseline
(e.g. due to procedures or activity level), and to support the use of oxygen therapy.
Pulse Oximetry
is frequently performed in critically ill patients to assess acid-base balance, ventilation, and oxygenation.
ABG Analysis
commonly assessed ABG values and what the findings indicate:
-pH measurement of the hydrogen ion (H+) concentration is an indication of the blood’s acidity or alkalinity.
-Partial pressure of arterial carbon dioxide (Paco2) reflects the adequacy of ventilation of the lungs.
-Pao2 reflects the body’s ability to pick up oxygen from the lungs.
-Bicarbonate (HCO3 – ) level reflects the activity of the kidneys in retaining or excreting bicarbonate.
measures the level of carbon
dioxide at the end of exhalation.
CAPNOGRAPHY / END TIDAL CARBON DIOXIDE (ETCO2) MONITORING
ETCO2 values are obtained by
monitoring samples of expired
gas from an
endotracheal tube,
an oral airway, or a
nasopharyngeal airway.
The exhaled carbon dioxide waveform is displayed on the monitor as a plot of ETCO2
versus time called a
CAPNOGRAM
On a capnogram, the waveform is composed of FOUR PHASES, each one representing a specific
part of the respiratory cycle:
1st phase - baseline phase
2nd phase - expiratory upstroke
3rd phase - plateau phase
4th phase - inspiratory downstroke
Capnography
which represents both the inspiratory phase and the
very beginning of the expiratory phase, when carbon dioxide–free air in the anatomical dead
space is exhaled.
1st - baseline phase
Capnography
which represents the exhalation of carbon dioxide from the lungs. Any process that delays
the delivery of carbon dioxide from the patient’s lungs to the detector prolongs the _______________.
2nd phase - expiratory upstroke
capnography
begins as carbon dioxide
elimination rapidly continues; a ____ on the capnogram indicates the exhalation of alveolar
gases
3rd - plateau phase
capnography
The downward deflection of the
waveform is caused by the washout of carbon dioxide that occurs in the presence of the
oxygen influx during inspiration.
4th - inspiratory downstroke
Respiratory Diagnostic Studies
- Chest Radiography
- Ventilation-Perfusion scanning or V/Q scan
- Pulmonary angiogram
- Sputum Culture
- Bronchoscopy
- Pulmonary Function Test
- Thoracentesis
This is an essential noninvasive diagnostic tool for evaluating respiratory disorders, infiltration, and abnormal lung shadows, as well as identifying
foreign bodies.
Chest radiography
in critical care settings are also used to check and monitor the effectiveness and placement of tubes and lines such as an endotracheal tube, chest tubes, and pulmonary artery lines.
Chest x-ray
Normal lung fields appear ______ because they are air-filled spaces.
Black
Thin, wispy ____ streaks are seen as vascular markings.
white
Blood vessels can also appear ____
gray
However, grayness in the lung fields usually suggests
Pleural effusion
______ areas indicate fluid, blood, or exudate.
Light white
is a nuclear imaging test used to evaluate a suspected alteration in the ventilation– perfusion relationship. A ventilation–
perfusion scan is helpful in detecting the percentage of each lung that is functioning normally, diagnosing and locating pulmonary emboli, and assessing the pulmonary vascular supply.
Ventilation–perfusion scanning
The ventilation–perfusion scan
consists of two parts:
Ventilation Scan
Perfusion Scan
is the preferred test for a
critically ill patient with a
suspected pulmonary
embolus.
Pulmonary angiography
First part of V/Q
Radioactive material is breathed in, and pictures or images are taken to look at the airflow of the lungs.
Second part of V/Q
(different radioactive material) is injected into a vein in the arm, and images are taken to see the blood flow going to the lungs. It is like COPD, and can impair airflow th a little effect of pulmonary blood flow resulting in low ventilation and nearly
normal perfusion. This is usually described through a VQ scan.
V scans aren’t commonly used for
patients on mechanical ventilators because the
ventilation portion of the
test is difficult to perform
Pulmonary angiography
-NPO 6-8 hours before test
-mag insert ug needle sa arm or groin (pero mag local anesthesia sa una)
-insert dayon ug catheter sa vein padung sa right-sided heart chambers padung sa pulmonary artery. then after ana kay mag inject dayon ug dye
-x ray images are then used para maklaro how the dye moves padung sa arteries aron ma detect if naa bay blockages or blood clots sa lungs or blood flow.
-after needle cath is removed, mag apply kag pressure sa puncture site for 20-45 minutes to stop bleeding
-tight bandage is applied
-keep legs straight for 6 hours
Abnormal results from pulmonary angiography
-Aneurysms of pulmonary vessels
-Blood clot in the lungs
-Narrowed blood vessel
-Primary pulmonary hypertension
-Tumor in the lung
RISKS of pulmonary angiography
-abnormal heart rhythm
-allergic reaction
-damage to blood vessel
-blood clot travelling to the lungs causing embolism
-excessive bleeding
-heart attack or stroke
and more *see photos
Is a test that checks for bacteria or another type of organism that may be causing an infection in your lungs or the airways leading to the lungs.
Sputum Culture
Different color of sputum and what it indicates
o Clear - no disease present but large amounts of clear sputum may be a sign of lung disease
o White or Gray - may be normal but increased amounts may mean lung disease
o Dark yellow or green - bacterial infection e.g pneumonia
*yellowish green sputum is common in cystic fibrosis
o Brown smokers, common sign of black lung disease
o Pink - pulmonary edema (common in people with CHF)
o Red - early sign of lung cancer. may also be a sign of pulmonary embolism
Sputum culture is often done with another test called ____.
it is a test that checks for bacteria at the site of a suspected infection or in body fluids such as blood or urine. it can help identify the specific type of infection you may have
Gram Stain
Sputum Culture Process
-rinse mouth wwith water before sample is taken
-if bronchoscopy, NPO 1-2 hours before test
common types of harmful bacteria found in a sputum culture include those that cause:
-Pneumonia
-Bronchities
-Tuberculosis
An abnormal sputum culture result may also mean a flare-up of a chrinis condition, such as cystic fibrosis or COPD
Is a test to view the airways and diagnose lung disease. It may also be used during the treatment of some lung conditions.
Bronchoscopy
Is a device used to see the inside of the airways and lungs. this scope can be felxible or rigid.
what is its size?
1/2 inch/ 1 cm wide and >2 feet or 60 cm long
in bronchoscopy, your health care provider may send saline solution through the tube. This washes the lungs and allows your provider to collect samples of lung cells, fluids, microbes and other materials inside the air sacs. This part of the procedure is called ______
Lavage
Bronchoscopy process
-NPO 6-12 hours before test
-dont take aspirin or blood thinning drugs
-cough reflex will return in 1-2 hours.
-You are not allowed to eat or drink until cough reflex returns
Are a group of tests that measure breathing and how well the lungs are functioning
Pulmonary Function test
measures airflow. By measuring how much air you exhale, and how quickly you exhale, ______ can evaluate a broad range of lung diseases.
Spirometry
Lung volume measurement can be done in 2 ways:
- The most accurate way is called body plethysmography.
You sit in a clear airtight box that looks like a phone booth. The technologist asks you to breathe in and out ..of a mouthpiece. Changes in pressure inside the box help determine the lung volume. - Lung volume can also be measured when you breathe nitrogen or helium gas through a tube for a certain period of time. The concentration of the gas in a chamber attached to the tube is measured to estimate the lung volume
To measure diffusion capacity, you breathe a harmless gas, called a _____, for a very short time, often for only one breath.
The concentration of the gas in the air you “breathe out is measured. The difference in the amount of gas inhaled and exhaled measures how effectively gas travels from the lungs into the blood. This test allows the health care provider to estimate how well the lungs move oxygen from the air into the bloodstream
Tracer gas
PFT process and prep
-Do not eat heavy meal before test
-Do not smoke for 4-6 hours
Abnormal value result from PFT
approximately less than 80% of your predicted value.
is a procedure to remove fluid from the space between the lining of the outside of the lungs (pleura) and the wall of the chest.
THORACENTESIS
Thoracentecis prep and process
-mo ingkod tas bith arms nakabutang sa table
-magbutang needle sa kilid itusok ddto sa pleural space (mag gamit ug ultrasound para mahibaw an asay good location sa pag insert)
-then i-drain dayon ang fluid then i-test
No special preparation is needed before the test.
A chest x-ray or ultrasound will be done before and after the test.
A buildup of too much fluid between the layers of the pleura is called a
Pleural Effusion
risk of thoracentesis
Bleeding
Infection
Collapsed lung (pneumothorax)
Respiratory distress
refers to the obstruction of
the pulmonary artery or one of its branches by a thrombus (or thrombi) that originates somewhere in the venous system or in the right side of the heart.
Pulmonary embolism
Major syndromes of interest in Pulmonary Embolism
Air
Fat
Amniotic fluid
Septic and bland thrombotic emboli
Risk Factors of Pulmonary Emblism
- Deep Vein Thrombosis
- Post Partum Hemorrhage
- Fracture of Long Bone
- Central Venous and PA Catheters
- Immobility
The hazards of PE can be summarized by Virchow’s triad
- Venous stasis
- Injury to blood vessel
- Hemoconcentrated blood
can be caused by immobility from bedrest and riding in the same position in a car, train, or airplane.
Venous stasis
can be injured through any
instrumentation or surgery, especially of the pelvis
and lower extremities such as total knee surgery and prostatectomy.
(injury to) Blood vessels
can result from pregnancy or dehydration.
Hypercoagulability or hemoconcentrated
blood
Pulmonary emboli can result in any of the following:
- Embolus with infarction: an embolus that causes infarction (death) of a portion of lung tissue
- Embolus without infarction: an embolus that does not cause permanent lung injury (perfusion of the affected lung segment is
maintained by the bronchial circulation) - Massive occlusion: an embolus that occludes a major portion of the pulmonary circulation (i.e.,
main pulmonary artery embolus) - Multiple pulmonary emboli: multiple emboli may be chronic or recurrent.
The effect of the obstruction will cause inflammatory changes, which will lead to increased pulmonary artery vasoconstriction causing
-Pulmonary hypertension
-Subsequent coronary edema
-Right ventricular dilation
-Afterload
Signs and Symptoms of pUlmonary Embolism
SMALL TO MODERATE EMBOLUS
-Dyspnea
-Tachypnea
-Tachycardia
-Chest pain
-Mild fever
-Hypoxemia
-Apprehension
-Cough
-Diaphoresis
-Decreased breath sounds over affected area
-Rales
-Wheezing
Signs and Symptoms of pUlmonary Embolism
MASSIVE EMBOLUS
A more pronounced manifestation of the above signs and symptoms, plus the ff:
-Cyanosis
-Restlessness
-Anxiety
-Decreased urinary output
-Confusion
-Hypotension
-Cool, clammy skin
-Pleuritic chest pain: associated with pulmonary infarction
-Hemoptysis: associated with pulmonary infarction
DIAGNOSTIC ASSESSMENT IN PULMONARY EMBOLISM
-Worsening hypoxemia and hypercapnia with respiratory acidosis.
-Chest x-ray to rule out pulmonary edema or tumor. It often shows pulmonary infiltration and occasionally pleural effusion.
-ECG to rule out MI. ECG findings commonly associated with pulmonary embolism include
tachycardia and nonspecific T wave changes.
-Chest CT with contrast is the principal test used to diagnose pulmonary embolism. Chest CT
effectively shows large, central PE; newer generation scanners also can detect peripheral emboli.
-Plasma D-dimer levels are highly specific to the presence of a thrombus. D-dimer is a fragment
of fibrin formed during lysis of a blood clot; elevated blood levels indicate thrombus formation and lysis
-Pulmonary angiogram where dye is injected into the heart is the definitive test, but it has a
high mortality rate.
-Exhaled carbon dioxide (ETCO2) may be measured to evaluate alveolar perfusion. The normal ETCO2 reading is 35 to 45 mmHg; it is decreased when pulmonary perfusion is impaired.
Drug Alert for thrombolytic therapy
Thrombolytic therapy is only
recommended for patients
with acute massive pulmonary embolism who are hemodynamically unstable and not prone to bleeding.
represents a complex clinical syndrome (rather than a single disease process) and carries a high risk for mortality. ____ is defined as a type of acute, diffuse, inflammatory lung injury that leads to increased pulmonary vascular permeability and loss of aerated lung tissue
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
Common Risk factors for ARDS
pulmonary and systemic with pneumonia
have the highest associated mortality in ARDS.
Pneumonia and aspiration
ARDS Patho
The clinical presentation consists of hypoxemia, bilateral lung opacities, increased physiological dead space, and decreased lung compliance. The acute phase is
characterized by diffuse alveolar damage (i.e. edema, inflammation, or hemorrhage).
Inflammatory triggers initiate the release of cellular and chemical mediators, causing injury to the alveolar capillary membrane in addition to other structural damage to the lungs. Severe V./Q. mismatching occurs.
Alveoli collapse because of the inflammatory infiltrate, blood, fluid, and surfactant dysfunction. Small airways are narrowed
because of interstitial fluid and bronchial obstruction.
Lung compliance may markedly decrease, resulting in decreased functional residual capacity and severe hypoxemia. The blood
returning to the lung for gas exchange is pumped through the nonventilated, nonfunctioning areas of the lung, causing shunting. This means that blood is interfacing with nonfunctioning alveoli and gas exchange is markedly impaired, resulting in severe, refractory
hypoxemia.
ARDS is now categorized as
mild, moderate, or severe.
ARDS STAGES
diagnosis is difficult because the signs of impending ARDS are subtle. Clinically, the patient exhibits increased dyspnea and tachypnea, but there are few radiographic
changes. At this point, neutrophils are sequestering; however, there is no evidence of cellular damage.
Stage 1
ARDS STAGES
(within 24 hours, a critical time for early treatment), the symptoms of respiratory distress increase in severity, with cyanosis, coarse bilateral crackles on auscultation, and radiographic changes consistent with patchy infiltrates. A dry cough or chest pain may be present. It is at this point that the mediatorinduced disruption of the vascular bed results in increased interstitial and alveolar edema. The endothelial and epithelial beds are increasingly permeable to proteins. This is referred to as the “_______” STAGE. The hypoxemia is resistant to supplemental oxygen administration, and mechanical ventilation will most likely be commenced in response to a worsening ratio of arterial oxygen to fraction of inspired oxygen (PaO2:FiO2 ratio).
Stage 2 (EXUDATIVE STAGE)
ARDS STAGES
the “__________” STAGE, develops from the 2nd to the 10th day after injury. Evidence of SIRS (Systemic Inflammatory Response Syndrome) is now present, with hemodynamic instability, generalized edema,
possible onset of nosocomial infections, increased hypoxemia, and lung involvement. Air bronchograms may be evident on chest radiography as well as decreased lung volumes and diffuse interstitial markings.
Stage 3 “PROLIFERATIVE” STAGE
ARDS STAGES
the “_______” STAGE, develops after 10 days and is typified by few additional radiographic changes. There is increasing
multiorgan involvement, SIRS, and increases in the arterial carbon dioxide tension (PaCO2) as progressive lung fibrosis and emphysematous changes result in increased dead space. Fibrotic
lung changes result in ventilation management difficulties, with increased airway pressure and
development of pneumothorax management difficulties, with increased airway pressure and
development of pneumothoraces.
STAGE 4 FIBROTIC STAGE
hallmark of ARDS
Refractory hypoxemia (hypoxemia that does not improve with oxygen administration)
ARDS Management
-Administer high Fio2 levels with high-flow system or rebreathing
mask. A constant positive airway pressure (CPAP) mask may be tolerated in alert, cooperative patients
-Intubation and mechanical ventilation if cardiovascular instability is present, severe
hypoxemia persists, or if fatigue develops. The best treatment is to initiate PEEP after mechanical ventilation.
-HUmidified oxygen delivery
-PRONE POSITIONING is probably the most established of interventions because it may
enable limitation of tidal volumes
Pharmacologic Therapy in ARDS
- Low-dose corticosteroids
- Antibiotics
- Vitamins C and E, N-acetylcysteine
- Nitric oxide
- surfactant replacement
can be viewed as a failure in gas
exchange due to either heart or lung failure, or both. It is not a specific disease but can occur in the course of a number of conditions that impair ventilation, compromise the matching of ventilation and perfusion, or impair gas
diffusion.
is a condition in which the respiratory system fails in one or both of its gas exchange functions—oxygenation of mixed venous blood and elimination of carbon dioxide. The function of the respiratory system can be said to consist of two aspects: gas exchange (movement of gases across the alveolar– capillary membrane) and ventilation (movement of gases into and out of the alveoli due to the action of the respiratory muscles, respiratory center in the CNS, and the pathways that connect the centers in the CNS with the
respiratory muscles).
Respiratory Failure
respiratory failure is commonly divided into two types:
- TYPE I / HYPOXEMIC RESPIRATORY FAILURE
- TYPE II / HYPERCAPNIC/HYPOXEMIC
RESPIRATORY FAILURE
due to failure of the gas exchange function of the lung (usually caused by Chronic obstructive pulmonary disease, Interstitial (restrictive) lung disease, Severe pneumonia, Atelectasis)
TYPE I / HYPOXEMIC RESPIRATORY FAILURE
In people with hypoxemic respiratory failure, two major pathophysiologic factors contribute to the lowering of:
a. ARTERIAL PO2–VENTILATION–PERFUSION MISMATCHING
b. IMPAIRED DIFFUSION
people are unable to maintain a level of alveolar ventilation sufficient to eliminate CO2
and keep arterial O2 levels within normal range.
TYPE II / HYPERCAPNIC/HYPOXEMIC
RESPIRATORY FAILURE
Hypoventilation or ventilatory failure occurs when
the volume of “fresh” air moving into and out of the lung is significantly reduced.
Hypoventilation has two important effects on
arterial blood gases.
-causes an increase in
PCO2
-it may cause hypoxemia
It is an abnormal collection of air in the pleural space between the
lung and the chest wall.
Is a collapsed lung. occurs when
air leaks into the space between your lung and chest wall. This air
pushes on the outside of your lung and makes it collapse.
Pneumothorax
TYPES OF PNEUMOTHORAX
- Simple or closed
- Open or sucking
- Tension
- Spontaneous
results from leakage of air from the pulmonary parenchyma or an airway tear and commonly takes place after blunt trauma
Simple or closed
the ruptured site remains open and there is a communication between the pleural cavity and the bronchus forming the broncho-pleural fistula
Open or sucking
it allows air entry during inspiration but prevents it from
escaping during expiration
Tension
is the sudden onset of a collapsed lung without any apparent cause, such as a
traumatic injury to the chest or known lung disease; a collapsed
lung is caused by the collection of air in the space around the lungs.
Spontaneous
RISK FACTORS OF PNEUMOTHORAX
- Chest injury
- Lung disease
- Ruptured air blisters
- Smoking
- Genetics
SIGNS AND SYMPTOMS OF PNEUMOTHORAX
- Dyspnea on exertion: dyspnea may be severe and often
interferes with the patient’s activities. Weight loss is common
because dyspnea interferes with eating - Productive cough
- Pain
- Absent breath sounds on affected side
- Chest tightness
SURGICAL INTERVENTIONS of Pneumothorax
- Oxygenation
- Needle aspiration
- Tube thoracostomy
- Thoracoscopy
It is a condition of increased blood pressure in the arteries of the lungs.
Pulmonary Hypertension
