Respiratory System Flashcards
What is the primary purpose of the respiratory system?
Gas exchange
What structure within the body is responsible for gas exchange?
Alveoli
Oxygen diffuses from the alveoli into the red blood cells, attaching to hemoglobin, and then travels to body tissues
If the alveoli are not functioning properly, what happens?
Decreased gas exchange Decreased oxygen diffusion into red blood cells Decreased oxygen attached to hemoglobin Decreased oxygen delivery to the tissues Decreased oxygen saturation
Why is the epiglottis important?
It closes when anything by mouth is consumed/ingested
Protects the lungs from any foreign objects traveling into them
Prevents aspiration
If a patient is using accessory muscles at rest, what does the nurse suspect?
Respiratory issues/ Respiratory distress
When does inspection of the respiratory system begin?
As soon as the nurse lays eyes on the patient!
Inspection: only look, don’t touch/talk!
What is involved in inspection of the respiratory system?
Assess chest symmetry Assess chest shape Assess respiratory pattern Assess respiratory rate Assess respiratory rhythm Assess use of accessory muscles Assess color of lips, skin, mucous membranes, extremities Assess is there is fingernail clubbing
Describe eupnea
Regular respiratory rate (12 - 20 breaths per minute)
Even pattern
Unlabored effort
Describe bradypnea
Decreased respiratory rate (< 12 breaths per minute)
Describe tachypnea
Increased respiratory rate (> 20 breaths per minute)
Pattern may be even or uneven
Effort may be labored or unlabored
Describe hyperventilation
Deep respirations
Increased respiratory rate (> 20 breaths per minute)
Uneven pattern
Labored
Describe kussmal respirations
Deep respirations
Increased respiratory rate (> 20 breaths per minute)
Regular pattern
Labored
Describe cheyne stokes respirations
Deep respirations
Increased respiratory rate that will eventually slow and a period of apnea is experienced
Then breathing begins again, cycle repeats
Describe apnea
Absence of breathing
Describe orthopnea
Difficulty breathing in the supine position
Requires elevation of the head/back/chest to improve breathing
Example: propping body up on a few pillows while lying down or sleeping in a recliner chair
Describe paroxysmal nocturnal breathing
Feelings of suffocation in the supine position
In attempts to improve these feelings, patient usually sits upright or in a tripod position to catch breath
Describe agonal breathing
Irregular/abnormal pattern
Gasping for breaths
Labored
What is subjective data collection?
Asking questions to assess the system at hand. Base questions asked off of patient’s response to previous questions. Ask additional questions if follow up is required or to further assess an issue.
Describe the “WHAT’S UP” acronym. Relate it to the respiratory system
W: Where is it? Location
H: How does it feel? Describe issue at hand, SOB, cough, chest tight?
A: Aggravating and alleviating factors? Makes it worse and/or better?
T: Timing? When did it start?
S: Severity? Rate the issue at hand (0-10 scale)
U: Useful other data? Any other s/s present?
P: Patient’s perception? What does the patient think is causing this?
If a patient is reporting severe shortness of breath in the semi-fowlers position (rating is 9/10 on a scale from 0-10) what can the nurse do to immediately aide in this issue?
Sit patient upright or sit on the edge of bed.
Allows for maximum lung expansion.
What does SpO2 measure?
The amount of hemoglobin saturated with oxygen
When may SpO2 readings be inaccurate or false?
When a patient is anemic
If a patient has peripheral arterial disease
If a patient has edema
If a patient has carbon monoxide (CO) poisoning
If the patient is experiencing tremors
If the skin is cool/cold
If the patient is wearing nail polish
What does a pulse oximeter pleth tell us?
It tells us if the SpO2 reading is appropriate.
If the pleth is “good” (wave form, even pattern) this tells us our SpO2 reading is accurate
If the pleth is “bad” (no wave form, uneven pattern) this tells us our SpO2 reading is inaccurate and not to trust what the machine is telling us
For a healthy individual without respiratory issue, what is a normal pulse oximeter (SpO2) reading?
94 - 100% on room air
If the nurse applies to pulse oximeter and receives a reading < 94%, what is the first thing the nurse must do?
ASSESS!
Always assess if other data is not given. Ask yourself, is this a true reading? Assess the respiratory system. Perform inspection, ask subjective questions (such as “are you SOB?”), are the fingers cold? Is there an appropriate pleth? Is this patient in respiratory distress? What is their mental status?
What are signs and symptoms of respiratory distress?
Complains of shortness of breath, rating it high on a severity scale from 0-10 Tachypnea Labored Breathing Accessory Muscle Use Blue skin/lips
Where can SpO2 be assessed?
Fingers
Forehead
Earlobe
Toes
Wherever you are assessing it, ensure the pleth is appropriate
Can the nurse solely rely on the pulse oximeter machine?
No! Never rely solely on a machine. Always look at and assess the patient. Use the machine as a tool.
If a patient has an SpO2 reading less than 94%?
Step One: Assess! Perform full inspection, ask subjective questions, listen to lung sounds, patients mental status?
Step Two: Intervene if necessary. Cough, deep breathing, apply O2 if necessary.
Step Three: Reassess! Perform inspection, ask subjective questions, listen to lung sounds. Do not leave patient if they are in respiratory distress! Call for help.
Step Four: Report findings to instructor. Ensure when reporting you state initial findings, assessment, interventions, reassessment. Tell instructor where patient is. Do this every time.
What is the proper method of auscultating the lungs?
Listen to each lobe on both sides before moving elsewhere. Example: Listen to right upper lobe, then left upper lobe. Move down to listen to right lower lobe, then left lower lobe.
What education should be given prior to auscultating the lungs?
Each time the stethoscope is placed on the chest take a deep breath in and out of the mouth
If an adventitious sound is heard upon auscultation, what should the nurse do?
Assess the same lobe on the other/opposite side. Then ask the patient to cough a few times. Reassess.
