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NUR350 FINAL > Respiratory HA and Ventilation Skills > Flashcards

Respiratory HA and Ventilation Skills Flashcards

1
Q

Explain the process of breathing

A
  1. The Autonomic Nervous System sends a signal to the muscles, which flattens the diaphragm and contacts the intercostal muscles.
  2. The air enters through the mouth or nose, travels through the trachea, divides into left or right bronchi into the lungs.
  3. In the lungs, air divides into bronchioles (thousands), and into alveoli at the end of the bronchioles.
  4. Alveoli are surrounded by capillaries with high CO2 concentrated blood, and the alveoli have high concentration of O2. CO2 and O2 travel to the lower concentration of their kind, so gas exchange occurs
  5. Oxygenated blood is transported to muscles,
  6. CO2 in alveoli triggers us to exhale.
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2
Q

What are the 4 functions of the Respiratory System

A
  1. Supply oxygen to the body
  2. Remove carbon dioxide
  3. Maintain homeostasis (acid-base balance)
  4. Maintain heat exchange
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3
Q

How does CO2 affect blood acid-balance?

effects of Hypo and Hyperventilation

A

Hypoventilation: increases CO2 in the blood (increase blood acidity)
Hyperventilation: decreases CO2 in the blood (decrease blood acidity)

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4
Q

Describe the alveolar cells:

A
  • Type 1: form the structure of alveoli
  • Type 2: release surfactant (lipoprotein that reduces surface tension during expiration so alveoli do not collapse)
  • Alveolar Macrophages: immune component; digest foreign particles and remove via lymphatic system
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5
Q

Describe the pleura

A

Pleura: double-walled sac that holds the lungs (2 layers)
-Visceral Pleura: the inner layer, closer to the lung
-Parietal Pleura: the outer layer
Pleural Space: the space in between the two layers (visceral and parietal).

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6
Q

What is the stimulus to breathe in most people? people with COPD?

A

-Hypercapnia: normal stimulus to breath in most people is an increase in CO2
-Hypoxemia: a decrease in O2 also increases respiration, but is less effective than hypercapnia (in MOST people)
(COPD: patients are chronic CO2 retainers- their stimulus to breath is low O2 concentration)

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7
Q

Describe the vertical diameter and anterior-posterior diameter during inspiration and expiration:

A

Inspiration: vertical diameter increases as the diaphragm moves down. A-P increases (intercostal muscles).
Expiration: opposite effect; decrease verticle and A-P diameter

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8
Q

Explain the 3-step process of oxygenation:

A
  1. Ventilation: moving gases in & out of the lungs. Relies on the coordination of muscles, nerves and elastic properties of lungs
  2. Perfusion: oxygenated blood to tissues. Deoxygenated blood to lungs.
  3. Diffusion: Movement of molecules from high concentration to low concentration. Exchange of respiratory gases at the level of alveoli
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9
Q

Examples of Factors that COMPROMISE Oxygenation:

A
  1. Physiological:
    - Cardiac disorders (arrhythmias, heart failure)
    - Anemia (impacts O2 carrying capacity)
    - Pregnancy
    - Fever
    - Infection
    - CNS (can impact chest wall movements)
    - Chest wall conditions
  2. Developmental:
    - Age-related changes resulting in a decreased ability for the lungs to expand
  3. Lifestyle:
    - Smoking
    - Malnourishment
    - Obesity
  4. Environmental:
    - Smog, asbestos (associated with a high risk of pulmonary disease)
    - High altitude (reduces the amount of O2 being inhaled)
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10
Q

Alterations in Respiratory Function:

A
  1. Hyperventilation: alveoli level
  2. Hypoventilation: alveoli level
  3. Hypoxia: cellular level
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11
Q 
Hyperventilation:
What is it?
Clinical presentation?
Treatments?
Causes?
A

Ventilation > than required (to eliminate normal venous CO2)
-Clinical presentation: increased rate and depth of respiration.
-Treatment: treat the underlying cause to treat hyperventilation
-Causes:
Anxiety
Infection
Fever
Shock
Acid-base imbalance
Meds (e.g., ASA, amphetamines)

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12
Q 
Hypoventilation
What is it?
Clinical presentation?
Treatments?
Causes?
A

Alveoli ventilation is inadequate to meet body demand. As hypoventilation increases, CO2 increases in the body.
- Clinical presentation: changes in mental status, dysrhythmias and cardiac arrest
- Treatment: treat the underlying cause
- Causes:
Atelectasis
Inappropriate O2 administration in patients with COPD
COPD patients stimulus to breath is low O2, if the O2 concentration is increased, their respiratory rate decreases. (can cause respiratory arrest)

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13
Q 
Hypoxia: 
What is it?
What can it cause?
Causes?
S/S?
A

inadequate tissue oxygenation at the cellular level
-Can lead to cardiac dysrhythmia, and is life-threatening, death
-Causes:
Decreased Hgb & lowered O2 carrying capacity
Decreased concentration of inhaled O2 (ex: high altitudes)
Inability of tissues to extract O2 from blood (ex: CO2 poisoning)
Decreased diffusion of O2 from alveoli to blood
Poor tissue perfusion (ex: shock)
Impaired ventilation (ex: trauma, fractures)
-Signs and Symptoms of Hypoxia:
Restlessness (can’t lie down or sit still)
Apprehension/agitation
Declining LOC
Dizziness
Fatigue
Usually increased P, RR & B/P (initially, then decline)
Exceptions: shock (B/P would not be raised initially); Overdose (may see bradycardia)
Cyanosis

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14
Q

Atelectasis:

A

the collapse of the alveoli that prevents normal gas exchange between carbon dioxide and oxygen

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15
Q

Orthopnea

A

shortness of breath (dyspnea) that occurs when lying flat, causing the person to have to sleep propped up in bed or on a chair

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16
Q

Vital Capacity (VC)

A

the maximum amount of air a person can expel from their lungs after a maximum inhalation

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17
Q

Tidal Volume (VT or TV)

A

the lung volume representing the normal volume of air displaced between normal inhalation and exhalation when extra effort is not applied.

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18
Q

What are signs of respiratory distress in children?

A
  • Intercostal Retraction (skin retracts between ribs)
  • Substernal indrawing: depression below sternum when inhaling
  • Tracheal Tugging: skin sucks in above substernal notch
  • Nasal flaring
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19
Q

Pleural Effusion:

A

too much fluid in pleural space

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20
Q

Pneumothorax

A

too much air leaks into pleural space, pushes on the lung, causes one or both to collapse. (can happen spontaneously or from trauma)

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21
Q

Hemothorax

A

accumulation of blood and fluid in pleural cavity between parietal and visceral pleura (usually from trauma)

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22
Q

What is pulmonary consolidation?

A 
lung tissue (alveoli) filled with fluid instead of air, making it denser, which amplifying sound and decreasing vibration
(Instead of resonant, it would be dull)
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23
Q

What is crepitus (respiratory)

A

air leaked into subcutaneous tissue, feels like bubble wrap under the skin (can happen from chest tubes)

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24
Q

Adventitious breath sounds:

A
  1. Crackles: fluid in the lungs
    - Fine crackle: rubbing hair between fingers
    - Coarse crackle: 2 pieces of velcro being torn apart (fluid in alveoli)
  2. Wheezes: lower airway narrowing (ex: swelling or secretions). High pitched, squeaky sound.
  3. Rubs (pleural friction rubs): two layers of pleura become inflamed and rub together. Grating sound; 2 pieces of leather rubbing; walking on fresh snow)
  4. Stridor: narrowing of the upper airway (swelling or secretions). Sounds like whales talking. High pitched, can often hear without a stethoscope

(Note what phase it is heard in: inspiration or expiration)

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25
Q

Abnormal/unexpected breath sounds

A
  1. Diminished, decreased sounds: cannot hear air entry as well on one side. Could be something blocking the transition of air from moving down.
  2. Absent sounds: total absent air entry to part or all of the lung (ex: no air entry to left lower lobe)
  3. Increased sounds: increased transmission of sound when alveoli are fluid-filled. Could indicate pneumonia or consolidation
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26
Q

Describe the 12 ribs:

A

1-7 attaches to the sternum via costal cartilage
8-10 “false ribs” attached to rib above via cartilage
11-12 “floating ribs” do not connect to the sternum

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27
Q

Expected vs unexpected thoracic cage configurations:

A

EXPECTED: symmetrical, downward sloping ribs, costal angles within 90 degrees, scapula equally positioned, A-P less than the vertical diameter.
UNEXPECTED:
-Barrel chest: equal or greater vertical diameter than A-P
-Scoliosis: can affect breathing, not always
-Kyphosis: can affect breathing, not always
-Pectus excavatum: depression in the sternum
-Pectus carinatum: end of the sternum protrudes

28
Q

What are the lines of reference on anterior, lateral and posterior?

A 
ANTERIOR:
- midsternal
- midclavicular
- Anterior axillary
LATERAL: 
- anterior axillary
- midaxillary
- posterior axillary
POSTERIOR:
- left scapular
- vertebral
- right scapular
29
Q

What is the Mediastinum?

A

the space between both lungs in the chest cavity; Middle column between the right and left lung, contains the heart and great vessels

30
Q

Describe right lung

A

3 Lobes (upper, middle, lower). Shorter because of the liver.

  • Horizontal fissure
  • Oblique fissure
31
Q

Describe left lung:

A 
2 Lobes (upper, lower). Narrower, heart pushes into that side.
- Oblique fissure
32
Q

Respiratory Considerations: Infants and children

A
  1. Surfactant: lipid substance; not adequate amount until 34 weeks gestation. Sometimes steroid injection is given to mother to increase surfactant
  2. Smaller size of respiratory system: easier to be blocked by inflammation, secretion of foreign bodies. The trachea is narrow at the bottom (like a funnel) instead of being circular like in adults, so more likely to get something lodged
    - Nasal passages
    - Diameter of airway
    - Distance between structures
  3. immune system immaturity: easier for respiratory airway to become severe. Does not fully mature to 5-6 years of age
33
Q

Respiratory Considerations: Pregnancy

A
  1. Decreased space for lung expansion: Diaphragm gets pushed upwards decreasing space in the chest cavity
  2. Increased circumference of the thoracic cage: Decrease in vertical diameter, increase in A-P diameter, due to increased ligament laxity
  3. Increased O2 demand: Easy to compensate because of tidal volume increases
    → little change in RR, but because of increased pressure from the diaphragm (especially towards the end) there is an increased awareness of the need to breathe (uncomfortable)
34
Q

Respiratory Considerations: Older Adults

A
  1. Costal cartilage calcification (like arteries)
  2. Decreased respiratory muscle strength: after age 50, muscle strength begins to decline
  3. Decreased elasticity within the lungs: aging lung is less easily inflated and delated; more rigid.
  4. Increase in small airway closure: as a result of the above, and collapse of alveoli, so there is less gas exchange. Therefore the older person has increased risk of SOB beyond regular levels of exertion.
35
Q

Hemoptysis:

A

blood in sputum, blood-tinged or streaked

36
Q

What type of chest pain does pneumonia vs bronchitis cause

A

Pneumonia: sharp stabbing pain
Bronchitis: can cause intercostal mucles to strain when breathing and moving

37
Q

What are expected and unexpected O2%

What would you do if 02% was too low?

A 
healthy - 98% +
acceptable -95+
<90% - requires immediate action
(COPD pts - high 80s, low 90s)
<70% = critical

High fowlers, deep breathing exercises, oxygen (up to 2L/min), get help

38
Q

What is the goal of ventilation?

PaO2, PaCO2

A 
PaO2 = 80 - 100 mmHg
PaCO2 = 35-45 mmHg
39
Q

What are common respiratory tests (4)

A
  1. Pulmonary Function Test (PFT): measures lung volume and capacity by taking deep breath and forcefully exhaling into machine
  2. Arterial Blood Gases (ABG): measures tissue oxygenation
    pH: 7.35-7.45
    PaO2: 35-45 mmHg
    PaO2: 80-100 mmHg
  3. Pulse Oximetry: indirect measure of oxygen saturation.
    Normal: 95-100%
    High 80s - low 90s: can be normal for certain chronic conditions (ex: COPD); requires attention if not COPD
    70% or lower: life-threatening
  4. Imaging (x-ray or ct)
40
Q

What is the goal of Airway Maintenance?

Name the 3 methods

A

the goal is to make sure trachea, bronchi and large airways are free from obstructions

  1. Mobilization of Pulmonay Secretion (humidification, nebulization, chest physio (percussing/vibration), postural drainage
  2. Suctioning: oropharyngeal, nasopharyngeal; orotracheal, nasotracheal; tracheal
  3. Artifical airways: oral, nasal and trachea
41
Q

What is Humidifcation?

when would you do it?

A

(Airway Maintenance- mobilization of pulm. secretion)
The process of adding water to gas. Keeps airway moist and helps to loosen secretions
*needed for pts receiving O2>4 Lpm (nice for less)
*Tracheal tubes- air is bypassing mouth/nose, which warms and moistens air, so this mimics the natural process

42
Q

What is Nebulization?
Common Meds?
How does it work?

A

(Airway Maintenance- mobilization of pulm. secretion)
- Process of adding moisture and medication to inspired air.
Improves clearance of pulmonary secretions (b/c increases moisture)
- Often used for bronchodilators and mucolytic agents (thins secretion)
-Uses aerosol principle to suspend a maximum number of water drops or particles of the desired size in inspired air

43
Q

What is Chest Physiotherapy?

What patients should get CP?

A

(Airway Maintenance- mobilization of pulm. secretion)

  • Chest Percussions: striking the chest wall with your hand, over the areas that need to be cleared
  • Vibration: apply to help loosen secretions, contradictions include bleeding disorders, fractured ribs, steroid medications (increase risk of fractures)
  • For patients who produce large volumes of sputum
44
Q

What is Postural Drainage?
Contraindications?
How long?

A

(Airway Maintenance- mobilization of pulm. secretion)
Different position techniques to help draw secretions from parts of the lungs. As it flows into the trachea, the patient can cough it out. (use clinical judgement to determine position)
-Contraindications: tolerance levels for head down (no for pts with head injuries, abdominal aortic aneurism, cognitive status to follow instructions
-more than 5 minutes. Often use these positions in conjunction with chest physio, so it can take 20-40 minutes

45
Q

What are the suctioning techniques and when are they used?

A
  1. Oropharyngeal, Nasopharyngeal: pt has effective cough but unable to clear by spit or swallow
  2. Orotracheal, Nasotracheal: pt can’t cough, spit or swallow
  3. Tracheal: suction via artifical airway (endotracheal or tracheal tube)
46
Q

Describe 2 suctioning devices

What size suction catheter is used on adults and pediatrics?

A
  1. Yaunkauer (hard suction catheter): like a dentist’s office. Used for oropharyngeal suctioning (one size)
  2. Flexible suction/soft suction catheters: comes in different sizes
    - Measured in “french” (fr). Smaller the french, the smaller the diameter.
    - Pediatrics: 6 to 10 fr
    - Adults: 12 to 16 fr, 14 fr average
47
Q

What are suctioning considerations for each type of suctioning?

A
  1. Oropharyngeal and orotracheal:
    Yankauer for an oropharyngeal, soft catheter for orotracheal
  2. Nasopharyngeal and Nasotracheal:
    Nasal route is preferred to prevent gag reflex stimulation
    Contraindications: nasal occlusions, nose bleed, epiglottitis, croup, some head/face/neck sx, irritable airway/bronchospasms, MI
  3. Tracheal Suctions:
    Choose a suction catheter no bigger than 50% of airway diameter
48
Q

Suctioning principles:

A
  • Have O2 at the bedside
  • Assess pt (including SpO2)
  • Semi-fowlers position (or high fowlers)
  • No suction during insertion of the catheter
  • Rotate catheter and apply intermittent suction during WITHDRAWAL
  • Suction pressure should be maintained between 100-150 mmHg (adult) but check local policy
  • Suctioning should not exceed 10 seconds per pass
  • Administer oxygen between passes
  • Wait 1-2 minutes between each pass
  • Encourage patient to cough
    Don’t forget mouth care!
49
Q

Suctioning Red flags:

A
  • O2 level going below 90% (unless normal for baseline)
  • Guideline: you don’t want O2 to drop more than 5%
  • Stop and reassess if HR:
    Drop more than 20 bpm
    Increase more than 40 bpm
50
Q

Suctioning undesired side effects:

A
  • Trauma to airway (scarring)
  • Dry out airways by taking away secretions
  • Lower O2 levels, as the patient isn’t breathing while suctioning, could lead to hypoxia
  • Can trigger bronchospasm
  • Some cases can lead to cardiac arrhythmia due to vagus nerve stimulation, which causes lower pulse and lower BP
  • Nosocomial infection (HAI)
51
Q

Suctioning sizes for each type and Techniques for inserting:

A

**Use water-soluble lubricants and insert during inhalation
- Oropharyngeal: the oropharynx extends behind the mouth from the soft palate to the level of the hyoid bone (contains the tonsils)
- Nasopharyngeal: the nasopharynx is located behind the nose and extends to the level of the soft palate approximately 15-20 cms (length of the tip of the nose to the angle of mandible)
- Nasotracheal: approx. 20 cm. If you hit resistance, pulls back by 1-2 cms
Turn head to L for R bronchus, and R for L bronchus
-Tracheal Suctions: Insert catheter until resistance is met (approx. 13-15 cm) and pull back 1-2 cm
Choose a suction catheter no bigger than 50% of the airway diameter
**Hyperoxygenate before starting: leave O2 on, encourage pt to take deep breaths for 30 seconds to 2 minutes. Give extra O2 before turning off for suctioning.

52
Q

What are types of artificial airways?

Indications?

A

(Airway Maintenance)

  1. Oral airway
  2. Nasal Airway ( or nasal trumpet)
  3. Tracheal Airway (Endotracheal and Tracheostomy)
  • Decrease LOC
  • Airway obstruction
  • removal of secretions
53
Q

Describe oral artificial airway:
measurement:
how to insert:
contraindications:

A

(Airway Maintenance)

  • Prevents tongue from falling back to the oropharynx, to prevent obstruction of the trachea; extends from teeth to the oropharynx, made of rigid plastic
  • Measure: from the corner of the mouth to the angle of the mandible
  • Insert upside down so the bottom will touch hard pallet, then flip over as it gets to the side of the pallet. OR sideways and flip it down as you get to the back of the mouth (oropharynx)
  • Contraindications: oral surgery, if they have a gag reflex (they will try expelling it the whole time), not typically used on conscious patients
54
Q

Describe Nasal Airway
Measurement:
How to insert:

A

(Airway Maintenance)
Made of soft flexible plastic. Maintain an airway for patients who are conscious, but maybe diminished in consciousness
Measure: Tip of nose to earlope
Insert: Sideways, so beveled end is going towards septum, then flip down as it gets to the end of nasal passage.

55
Q

Describe the two types of tracheal tubes

A
  1. Endotracheal Tube (ETT)
    - Tube from mouth to trachea
    - Patient with a decreased level of consciousness or airway obstruction and aids in removal of tracheal bronchial secretions
    - Generally short term (no longer than 14 days). If still needed, the patient moves on to trach tube.
    - A balloon at the end keeps the tube in place, markings on the tube to make sure it doesn’t move
  2. Tracheostomy Tube (Trach tube)
    - tube entering trachea via stoma
    - more permanent. Used when a patient will be on a ventilator for a long period of time
    - Some tube have air holes so air can pass over vocal cords, so the patient can speak.
56
Q

Big Valve Mask (Ambu-bag)
Why is it used?
How do you use it?

A
  • Not an artificial airway. Used for emergency for O2 and ventilation
  • Found at bedside for high-risk patients, and on crash carts.
    1. Connect to O2 on high for 15 minutes
    2. Position patient with head tilted back, use C and E position. Mask placed over mouth and nose. C with hand covers mask, E used to support the jaw and open mouth. (2 people, use C).
    3. Bag at a rate of 1 half squeeze in 8 to 10 seconds = 8 to 10 breaths a min
57
Q

Promotion of Lung Expansion?

A

NON-INVASIVE:

  1. Ambulation: early ambulation is associated with better patient outcomes and lung expansion
  2. Positioning: sitting up is best to breathe (semi-high fowlers position) reduces pressure on the abdomen
  3. Cough techniques and deep breathing exercises (purse lip and diaphragmatic breathing; huff, cascade, quad cough)
  4. Use of incentive spirometer (IS): encourage pt to do 5-10 breathes every hour they’re awake. (keep pts motivated)

INVASIVE;
1. Chest tubes: a catheter inserted to remove air and fluid from pleural space, prevent air or fluid

58
Q

Oxygenation purpose:
What range can O2 therapy be delivered?
What is acceptable for a nurse to start O2 at?

A
  • Goal: prevent or relieve hypoxia
  • O2 can range from 22-100%
  • Nurses can start 2 L/min; may have titrate orders to use enough O2 to reach a certain SpO2%
59
Q

What are the adverse effects to O2 Administration?

A
  1. O2 Toxicity
  2. Atelectasis
  3. Hypoventilation in COPD pts
60
Q

List how O2 is delivered

A
  1. Low-Flow Devices: (O2 concentration varies on breathing pattern)
    - Nasal cannula
    - Simple face mask
    - Non-rebreathing mask (aka reservoir mask)
    - Face tent
  2. High-Flow Device: (fixed FiO2 regardless of breathing pattern)
    - Venturi Mask
61
Q

Nasal Cannulas

  • delivery
  • monitor
  • contraindication
A

Low-flow O2 device, aka nasal prongs
- can go up to 6 L/min; usually won’t go higher than 4 L/min
(needs humidification)
- Monitor: skin breakdown- behind ears, nose, dried nasal passages, size (especially for children)
-Contrindication: mouth breather, prone to nose bleeds

62
Q 
Face mask
what does it do?
how does it fit? how long to wear?
delivery?
contraindications?
A

Low flow, aka oxygen mask
- Administers oxygen, humidity, or heated humidity. - Should fit loosely over mouth and nose
Shouldn’t be used for an extended period of time (difficult to talk, eat, etc.)
- Delivers oxygen in concentrations of 40-60%
- Contraindications: COPD (stimulus to breath os O2 instead of CO2, so you will negate their stimulus to breathe)

63
Q

Face Mask with Reservoir Bag: (non-rebreathing mask)

  • how does it work?
  • delivery
A

Low flow device
- O2 flows into the bag, Co2 goes out the sides in the little holes in the mask
- non-rebreather mask: O2 concentration 60-80% and 10 L/min flow rate
(need high L/min to keep bag inflated- if bag isn’t full pt could be inhailing their own CO2)

64
Q

Face Tent and Trach Oxygen Mask?

A

Low flow devices
Face Tent:
- Covers full chin and mouth
- Used for a broken nose, or any reason they couldn’t use a mark (claustrophobia)

Trach Oxygen Mask:
- Simple face mask but over top of trach tube

65
Q

Venturi Mask

  • Type of device
  • delivery
  • what types of pts
A
  • High flow device
  • More precise concentration of O2 (24-60%, with flow rates 4 to 12 L/min)
  • Special meters: tells you what to set O2 at to get proper concentration
  • Ex: patients with COPD, unstable patients
66
Q

What is Oxygen Toxicity?
Risk factors?
clinical presentation?
prevention?

A
  • Receiving O2 produces free radicals that cause damage to the alveolar-capillary membrane resulting in damage to the lungs and respiratory distress
  • Risk factors: receiving oxygen at a concentration of more than 50% for more than 24 hrs
  • Manifestation: dyspnea, nasal congestion, cough, sore throat, chest pain with deep breathing
  • Prevention: use the lowest concentration of O2 possible to meet your goal

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