Respiratory Flashcards
hypoxia
Less than normal levels of 02 in the cells
Hypoxaemia
less than normal levels of 02 in the blood
Pa02 <80mmHg (<60mmHg significant hypoxaemia)
Hypercapnia
greater than normal levels of C02
PaC02 >45mmHg
Hypocapnia
less than normal levels of C02 (can occur when someone hyperventilates)
PaC02 <35mmHg
mechanical insufficiency: structural damage
- nervous system (could be brain stem injury, nerve impulses that are interrupted, high spinal injury, altered respiration and depth, ventilation is affected)
- intercostal muscles (trauma to the chest of diaphragm, can’t take a deep breath or expire air properly, pain, bruising, break in chest, affects ventilation)
- diaphragm
- abdominal muscles (if you have normal breathing you shouldn’t need muscles, forced breathing uses abdominal muscle, or if nerves are affected in the abdominal muscles you loose the ability to ventilate in that way)
mechanical insufficiency: air way obstruction
physiological and foreign objects (asthma, allergen, ventilation is affected)
mechanical insufficiency: medication
CNS depressants (anastasia, or opioids, ventilation affects rate and depth of breathing, benzos, alcohol sedatives anything that affects RR)
Functional insufficiency
- cardiac compromise (anything that changes conductivity of contractility of the heart= less cardiac output = less perfusion less blood going back to the heart efficiently from the lungs oxygenated)
- pulmonary embolism (obstruction, blocks off blood vessels in the heart, perfusion problem, anything under the embolism doesn’t get blood flow)
- HB (haemoglobin, if you don’t have enough Hb you can’t carry enough oxygen)
- Tumor (blockage that will affect perfusion)
- infection
- COPD
- compliance (ability for the lungs to expand and recoil)
- resistance (losing fluid in the alveoli increases resistance)
- surface area
perfusion problem (air in/air out) (any problem in the airways causes problems with gas exchange and getting C02 out)
inflammation of bronchial walls: causing epithelial oedema = decreased air entry, decrease gas exchange (creates swelling, constricts the area to expand and recoil)
exudate in lower airways: causing obstruction to airflow= decrease air entry , decrease gas exchange
exudate in alveoli: causing increased diffusion distance= decreased gas exchange
inflammation in alveolar walls: causing increased diffusion distance = decreased gas exchange
perfusion problem (blood to lungs and body) heart problem, blood not getting into the lung, if your not getting oxygen blood into alveoli the blood gets shunted to somewhere else
- partial or complete obstruction to pulmonary artery: causing blood flow= decreased gas exchange (vale problem, clot, partially or fully closing off of the blood flow)
- ineffective functioning alveoli (from exudate or oedema): causing vasoconstriction of surrounding pulmonary capillaries = further decrease in gas exchange
clinical presentation: respiratory rate (RR)
always start with RR as that is usually the first to decline
- tachypnoea (abnormally rapid breathing/ bradypnoea (abnormally slow breathing rate)
- orthopnoea (difficulty breathing, feels like they are drowning)when lying down , is relieved when sitting up
- dyspnoea (person reports difficulty of laboured breathing)
- rhythm and depth (is the patient breathing normally in a normal rhythm, gasping can’t take a deep breath ect)
clinical presentation: breath sounds
- wheeze
- crackles
- stridor (upper airway sound, barking or seal sound on inspiration, always bas, airway is obstructed)
- reduced air entry
- cough
clinical presentation: accessory muscle use
increase work of breathing
- sternocleidomastoid
- scalenes
- trapezius
- pectoral minor/major
- abdominals
clinical presentation: positioning
(always in rapid assessment, if they are slumped over the airways is getting obstructed, thinking about sitting them upright, expand the thoracic cavity, open airways)
- upright
- tripod
- chest symmetry
clinical presentation: neurological changes (SNS response or gas exchange, hypoxaemia, hypoxia, maybe not enough oxygen going up to the brain cells, are they ventilating properly, sit upright, medication support)
- anxiety
- agitation
- confusion
- drowsiness
- pain
clinical presentation: skin
always look at the skin, mucous membranes, like the lips
- diaphoresis (excessive sweating) different normal sweat, clammy all over, dripping feel cold. increase metabolic effort, hypocapnia also causes this)
- pallor (pale)
- cyanosis (bluish colour of the skin due to poor circulation or oxygenation in the blood, peripheral shut down in the peripheries, shinting the blood to the core, causing problems, in the peripheries, looking at core cap refill, then looking at the mouth or face)
- flushing (face becomes red)
- digital clubbing
- mucous membranes 9( if its nice and pink and well perfused, pale or cyanosis is bad)
clinical presentation: sputum
- colour
- odour
- haemoptysis (coughing up blood)
WOB: 5 signs of respiratory distress
DiapHRaGM
- Diaphoresis (excessive sweating) different to normal sweating, clammy al over dripping in sweat and they feel cold. increased metabolic effort. hypocapnia
- Hypoxia (less than normal level of 02 in the cells
- Respiratory rate
- Gasping associated with running out of breath, RR starts to drop and they start gasping, rhythm changes too)
- Accessory muscle
Need to intervene quickly or they can go into respiratory arrest
what we can measure: RR, depth and pattern
can be measured but a degree of subjectivity depending on how it is calculated
what we can measure: Work of breathing
- accessory muscle use
nasal flaring/ pursed lip breathing - speaking long/short sentences, single words only, not speaking
- intercostal indrawing
what we can measure: peak flow measurement
- measurement of maximal forced exhaled air flow (L/min)
- baseline and to measure effectiveness of interventions
- useful for people with asthma
- used to keep an eye on maximal force
what we can measure: specialist tests
- CXR (chest X-ray)
- spirometry
- CT/MRI
- ABG (arterial blood gas)
Airway assessments
patency is it open and is it fully open, partial obstruction?
- is the airway patent
- partial obstruction- snoring, stridor, you can hear something
- complete obstruction- silence, no extra sounds
- under threat?
- what your assessing for, patency, expecting to find the airway patent, or patent and concern that it is under threat.
possible cause of obstruction
- tongue
- vomit
- epiglottis
- uvulitis
- secretions
- inflammation
- neurological impairment
- foreign body
Airway interventions
rationale: to ensure airway patency and allow for maximal air entry
positioning (if the patient cant open their airways, we do that for them
- maintain head and neck alignment (chin tilt/jaw thrust)
- consider elevating head of bed/ side positioning on OSA
- recovery position
clear secretions
- encourage airway clearance with coughing (getting them to do it themselves)
- consider suctioning (yankauer/ suction catheter)
- promote hydration to thin secretions for expectoration
THREAT TO AIRWAY PATENCY= THREAT TO LIFE
Breathing assessment
general appearance - work of breathing - rate, depth and pattern - accessory muscle use - nasal flaring/ pursed lip breathing - cough - colour - skin moisture positioning - supine/ erect - tripod - pillow to support level of activity - what is the patient doing chest - AP measurement - symmetry - paradox - drains? - barrel chest? supplement oxygen use - nasal cannula - airvo (humidified 02) - CPAP/ BiPAP machine - used in acute as exacerbation of COPD, and obstructive sleep apnea
Breathing assessment (listen and feel)
posterior chest auscultation - air entry - quality of breath sounds - wheeze - crackles - adventitious sounds percussion - resonance - hyper resonance - dullness
breathing interventions: rationale: to maximise air entry to enable optimal gas exchange
Positioning - sit patient upright - support with pillow if needed - mobilise as able - regular turns/ repositioning cough techniques - huff cough - incentive spirometry (a handheld medical device that measures the volume of your breath) - deep breathing Administer prescribed medications (always write prescribed) - bronchodilators (inhaler with spacer) oxygen - corticosteroid (check) Physiotherapy referral - education - loosen secretions Secretions - promote hydration to thin secretions - consider humidification of 02 Anxiety reduction - Education and reassurance to reduce respiratory effect and SNS response - intervention, reassurance, provide education to reduce anxiety, sympathetic nervous response. Raises HR and RR by itself, anything we can do to reduce SNR education and reassurance
Circulation assessment
general appearance - skin colour: flushes, cyanotic - temperature: raised (core), peripherally cool - capillary refill time - diaphoresis Heart rate - tachycardia, bradycardia - Rhythm (regular/irregular) - quality (weak/bounding) - using correct terminology, rhythm what does it feel like regular? affects how oxygen gets to blood and tissues blood pressure - hypertension - normal - hypotension Renal function - urine output - eGFR (estimated glomerular filtration rate) - fluid balance
Circulation intervention
rationale: to ensure adequate tissue perfusion
hydration - oral - intravenous fluid as prescribed Administer prescribed medication - consider DVT prophylaxis Mobilizing - foot pedaling - frequent mobilisation as able - regular repositioning
Disability assessment
Level of consciousness - AVPU (if you get anything other then alter you need to do GCS - orientation to time place and person - restlessness/ agitation (hypoxaemia) Anxiety - breathlessness - fear of dying - dyspnoea - increased WOB - Mood SNS response Pain - COLDSPA - pleuritic pain will contribute to alveolar hypoventilation (decreasing gas exchange) - opioid analgesia causing decreased RR and LOC
disability interventions
Rationale: to maintain patient safety and prevent further complications
pain management - select appropriate analgesia administer analgesia as prescribed Anxiety reduction to reduce SNS response - patient education - communication of plan - involvement of family/whanau not "reassuring patient" false reassurance ( reducing SNS response
Environmental assessment
Patient risk assessment - falls - braden - smoking Past medical/ surgical history - previous respiratory issues (COLDSPA) - medications - drug reactions - allergies - any previous respiratory issues Early warning score - Trends (small rise in EWS, what's happening, do they need extra treatment RR slightly increased why? - action required? - do they need a different ward, is this the best place for them, do they need a different type of care - EWS helps you receive different or higher treatment from other or higher people or different wards
Other assessments
- occupation (hazzards)
- living situation
- family and whanau support
- self-management of health issues
- alcohol and drug use
- cultural and spiritual needs (rationale to provide culturally safe care)
Emphysema (air or gas trapping)
- loss of elasticity allows the alveoli to expand with inspiration, but reduces its ability to recoil in expiration
- results in C02 being “trapped” increasing the alveolar PC02
- A rise in alveolar PC02 means C02 cannot diffuse readily from pulmonary capillaries, causing a build up in arterial blood = hypercapnia too much C02 in the blood
Emphysema (damaged alveolar walls)
- accumulation of damage cause large air spaces to develop
- surface area is reduced, reducing gas exchange between alveoli and pulmonary capillaries = hypoxemia and hypercapnia
- direct contact of alveoli with capillary beds is reduced, reducing gas exchange
Nursing Assessment: COPD expected findings: Airways
- patent but potentially under threat if decreased LOC due to hypercapnia/ hypoxemia
- if they are breathing very fast, they are at risk of exhaustion and going into respiratory arrest
Nursing Assessment: COPD expected findings: Breathing
- increased WOB due to hypercapnia body is trying to breath of C02, it is going to work harder
- pursed lip breathing to assist with expiration and overcome gas trapping- creates PEEP positive end expiratory pressure, holding open alveoli as long as possible to expire C02
- tachypnea anything above 20 RR is bad but for someone who has COPD their normal may be over 22 an acute episode is 30- 40
- Sp02 <90% due to hypoxemia patients with COPD, might be sitting at a lower Sp02 normally maybe 90% normally for them (understanding what their baseline could be)
- Positioned upright or tripod to expand thoracic cavity and maximize air entry for gas exchange
- Adventitious sounds- wheeze due to bronchoconstriction, possible rhonchi describe fully, audibly, or with a stethoscope, bronchoconstriction, narrowing on bronchi
- Possible decreased air entry on auscultation due to alveolar collapse, resonant percussion due to lung hyperinflation
Nursing Assessment: COPD expected findings: circulation
- Cool pale peripheries and/ or cyanosis due to hypoxaemia peripheries, cap refill, shunting of blood)
- CRT> 3 seconds due to peripheral vasoconstriction
- Possible elevated core temperature due to increase metabolic rate or infection
- Diaphoresis due to increase WOB or hypoxaemia and/or bronchodilators (B2 agonist)
- Possible hypertension due to hypoxaemia or hypotension due to systemic inflammatory response
- Tachycardia (>200Bpm) due to hypoxaemia and/or bronchodilators B2 agonist)
Nursing Assessment: COPD expected findings: circulation
- Cool pale peripheries and/ or cyanosis due to hypoxaemia peripheries, cap refill, shunting of blood)
- CRT> 3 seconds due to peripheral vasoconstriction
- Possible elevated core temperature due to increase metabolic rate or infection
- Diaphoresis due to increase WOB or hypoxaemia and/or bronchodilators (B2 agonist)
- Possible hypertension due to hypoxaemia or hypotension due to systemic inflammatory response
- Tachycardia (>200Bpm) due to hypoxaemia and/or bronchodilators B2 agonist)
Nursing Assessment: COPD expected findings: Disability
- Possible disorientation or confusion due to hypoxaemia>which can then lead to hypoxia
- Reduced LOC due to Hypercapnia and/ or hypoxaemia
Anxiety or fear of dying due to dyspnoea
Nursing Assessment: COPD expected findings:
- Elevated EWS due to > RR, HR and < Sp02 (remember to identify trends)
- Increased falls risk due to dyspnoea, dizziness and/ or confusion
- Increased braden score due to corticosteroids, reduced mobility and possible oedema
- COLDSPA or irritants/ triggers and pervious exacerbations (plus treatment/length of hospital stay) to help inform nursing plan or care
- Identify allergies or drug reactions to avoid further complications
Nursing interventions: nursing patient with acute exacerbation of COPD: airways
Airways
- positioning- to open airway and maintain patency
Nursing interventions: nursing patient with acute exacerbation of COPD: Breathing
Breathing
- Ensure patient upright to optimize air entry and facilitate gas exchange
- Encourage pursed lip breathing to facilitate exhalation of C02 (reduce gas trapping) and reduce dyspnoea
- Administer oxygen as prescribed to reverse hypozaemia
- Administer bronchodilators as prescribed for relaxation of smooth muscle in airways to facilitate gas exchange
Administer corticosteroids as prescribed to reduce inflammation in respiratory system
Nursing interventions: nursing patient with acute exacerbation of COPD: Circulation
- Administer IV fluids as prescribed/encourage oral fluids to prevent dehydration and thin secretions
- Administer DVT prophylaxis as prescribed to prevent clot formation from venous stasis
- Administer antibiotics as prescribed to treat infectious exacerbation
Encourage patient to foot pedal to encourage venous return to prevent venous stasis
Nursing interventions: nursing patient with acute exacerbation of COPD: Disability
- Maintain a low stimulus environment to reduce anxiety and further dyspnoea
- Educate the patient on interventions and plan of care to reduce anxiety and encourage compliance with therapeutic interventions
Consider hospital aide special or a family member to sit with the patient if confused to maintain patient safety and/or to reduce anxiety and further dyspnoea
Nursing interventions: nursing patient with acute exacerbation of COPD: environment
- Ensure regular position changes as appropriate to prevent pressure injury
- Ensure hazards are away from bedside, call bell is in reach and patient’s and patient is educated on falls prevention
- Refer patient to physiotherapist/occupational therapist for rehabilitation
- Identify a self-management plan with the patient to prevent future exacerbations and recognise early signs of deterioration
Consider which interventions are priority interventions. You focus should be one ensuring immediate patient safety first
Analysis: actual problem
- SOB, increased RR, increased OWB/ accessory muscle use, inability to speak in full sentences, impending sense of doom, audible wheeze
analysis: potential problem
- decreased Sp02, increased RR, increasing HR, increasing NZEWS, decrease BP (hypotension), central cyanosis, increased confusion/ agitation, increased fatigue, loss of consciousness, respiratory arrest
Plan (goals)
relate these back to the problems that you have identified
- increase gas exchange
- reduce SOB, WOB and RR
- maintain Sp02 within prescribed levels
- decrease anxiety
- educate patient about condition
- educate patient about space use and technique
- discharge home with asthma plan
interventions
- administer medications as prescribed (bronchodilator) either through nebuliser or spacer
- administer oxygen as prescribed
- sit patient upright to maximise air entry for gas exchange
- reassure/ educate patient and family members to lower anxiety and reduce SNS stimulation and decrease RR and WOB
- observe/ educate patient re; use of spacer
- mobilize/ rest as tolerated
- educate re: asthma plan on discharge
Evaluation
- medications were administered as prescribed with good effect- decreased RR decreased WOB increase PF
- oxygen titrated as required to maintain 02 saturations as charted
- patient maintained upright position with good air entry, mobilized as able
- vitals recorded and reported to RN. NZEWS recorded and acted on as needed
- reassurance/ education provided to the patient and family as appropriate
- effective use of spacer noted
Asthma: how would we treat it
- bronchodilator (inhaler/nebuliser)
- corticosteroids (oral/IV/inhaled)
- metered dose inhaler (MID) spacer/ nebulizer)
- oxygen therapy
- positioning (sit upright/ tripod)
- reassurance to decrease anxiety which reduced SNS response
Bronchodilator: B2 agonist: Short acting (SABA’s) reliever
- Provide relief for 4-6 hours
- Rapid onset of action- 5-10 minutes
- Can be used in an acute asthma attack (usually blue inhaler)
- Salbutamol (ventolin)
Terbutaline (bricanyl)
Bronchodilator: B2 agonist: long acting (LABA’s) controller
- Long duration of action (12 hours)
- Slow onset of action
- Not to be used to relieve acute symptoms
- Salmeterol (serevent)
Eformoterol (oxis)
inhaled corticosteroids - ICS (preventers)
- Potent anti-inflammatory agent
- Given via inhaler route greatly reduced systemic adverse effects
- E.g. fluticasone (flixotide), beclomethasone (beclazone)
- Reduce the hyperresponsiveness of the bronchial smooth muscle to irritants
- Must be taken continuously
Use a space and rinse mouth after administration to avoid pharyngeal irritation and oral fungal infection
oxygen therapy
02 is a medication - it must be prescribed, and it can have adverse effects
02 is a gas and supports combustion, all electrical appliances should be working properly. Smoking is prohibited a spark may cause a fire
NASAL PRONGS
- Used when low to medium concentration of 02 Is required
- Greater then 4L/min way dry out the nasal mucosa
- Useful when patient is eating and cannot use a face mask
SIMPLE FACE MASK ( may also be called a Hudson mask)\
- Inspired oxygen concentration caries with liter flow, rate and depth of respirations
- There are other types of masks, i.e. patient disease specific
How will you evaluate whether oxygen therapy has been effective
- Decrease in respiratory rate
- Increase in depth of respirations
- Increase in tissue oxygenation (mucous membranes, not just Sp02)
- Decrease in work of breathing/ accessory muscle use
- Decrease work of myocardium in patients with cardiac disease
Increase Sp02
