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.
Refer to the lab values note cards to review appropriate lab values that relate to the respiratory system! Review diagnostic imaging tests that relate to respiratory system!
See lab values note cards.
If a WBC level is elevated and the patient has complaints related to the respiratory system, what may that tell us?
Possible infection within the respiratory system
In what respiratory disease are RBCs elevated?
Chronic Obstructive Pulmonary Disease (COPD)
In what physical/outside environment will RBCs be elevated?
When living at a higher elevation
In what type of situations will RBCs be decreased?
Blood loss via trauma, internal bleeding, GI bleed
Anemia
Describe what happens in the body with anemia?
There is a decreased production of RBCs
Because of this, there are lower amounts of Hgb and Hct
All available Hgb will be saturated with O2. This means SpO2 readings will be in normal range
Because there isn’t enough Hgb available to carry enough O2, there won’t be enough O2 delivered to supply and nourish tissues
Because of this, the tissues will suffer.
May find cool, pale extremities. The patient may report feeling SOB with dyspnea (even though O2 sat is in an appropriate range)
What does a d-dimer test tell a provider?
If elevated, it will indicate further testing required to rule out a blood clot in the body.
This test does not prove a blood clot is present, just informs provider that further testing is required
If a d-dimer is elevated (> 500), what two tests can be ordered to rule out a blood clot? When would each test be ordered?
An ultrasound. This would be ordered if the patient had a suspected blood clot in the extremities
A CTA scan. This would be ordered if the patient had a suspected blood clot in the lungs (pulmonary embolism)
How does a nurse obtain a sputum culture?
Ask patient to take deep breaths and cough to produce a sample.
After sample has been obtained, collected, sent to the lab, the nurse should document.
What can a nasal swab tell us?
If a respiratory infection is present
What do Arterial Blood Gases show?
Amount of gas (both O2 and CO2) present in the arterial blood. Only performed in an acute setting (hospital).
A patient has a CTA Scan of the chest ordered. The nurse has confirmed no allergies to contrast dye or shellfish. What is the nurses next step?
Educate on the procedure.
When will a ventilation perfusion scan be ordered? What does it tell us?
It will be ordered if the patient is unable to receive a CTA Scan. It will show how well the lungs are working and if a blood clot is present.
Describe clear lung sounds.
When breath sounds are normal, no adventitious noises heard.
Describe course crackles (lung sounds). What is the cause of this sound? What disorders are associated with this sound?
A moist bubbling sound
Caused by fluid in the airway
Occurs with pulmonary edema, bronchitis and pneumonia
Describe fine crackles (lung sounds). What is the cause of this sound? What disorders are associated with this sound?
Sounds like velcro being torn apart, hair being rolled between fingers, or the crackling of a fire
Caused by alveoli popping open on inspiration
Occurs with heart failure and atelectasis
Describe wheezes (lung sounds). What is the cause of this sound? What disorders are associated with this sound?
High pitched noise, squeaky musical sounds
Caused by narrow airways
Occurs with asthma
Describe stridor (lung sounds). What is the cause of this sound? What disorders are associated with this sound?
Loud crowing noise heard without a stethoscope
Caused by airway obstruction
Occurs with obstruction in upper airway
Describe diminished lung sounds. What is the cause of this sound? What disorders are associated with this sound?
Faint lung sounds, sound like they are far away, difficult to hear
Caused by decreased air movement
Occurs with obesity, hypoventilation, emphysema, very muscular chest wall
Describe absent lung sounds. What is the cause of this sound? What disorders are associated with this sound?
No sound heard
Caused by no air movement
Occurs with pneumothorax or a pnuemectomy (removal of a lobe)
Describe rhonchi (lung sounds). What is the cause of this sound? What disorders are associated with this sound?
Low pitching rattling sound, similar to snoring
Caused by obstructions or secretions
Occurs with COPD and pneumonia
This sound may clear after a course (removing secretions from lungs)
How does aging affect the respiratory system?
Weakened respiratory muscles (diaphragm muscle) Decreased ability to cough Decreased cough reflex Deteriorating cilia Increased risk for infection Reduced number of alveoli Decreased diffusion capacity Decreased gas exchange Decreased elastic recoil of lung tissue Increased anteroposterior diameter of chest
How does the nurse improve the gas exchange of the older adult, knowing that the older adult has reduced number of alveoli?
Promote movement, turning while in bed, ambulation.
Encourage coughing and deep breathing.
What vaccines are important for older adults to get? Why?
Pneumoccocal and Influenza Vaccines
Older adults have weakened defense mechanisms within their lungs/respiratory system, increased risk for respiratory infections
Why should the nurse promote smoking cessation to improve the respiratory system?
Decreases and slows the progression of respiratory issues. Decreased inflammation within the lungs.
What is the benefit of deep breathing and coughing? When is it helpful?
Encourages full expansion of the lungs
Opens the alveoli
Clears lungs of any “junk” and secretions
Helpful is a patient has an inffective cough (such as an older adult), the deep breaths will get air behind the secretions, promote a cough and help get secretions out of lungs.
What population benefits from the huff cough? How is the huff cough performed? What is the purpose of it?
COPD population
Patient breathes in and as the exhale they make a “huff” sound
This technique forces air out and removes excess CO2
Why is diaphragmatic breathing useful?
Aides in relaxation of the patient
Conserves energy during SOB exacerbations
Why is pursed-lip breathing useful? How is it performed?
Useful when patient feels SOB
Helps keep airways open during exhalation
Patient breathes in through nose, breathes out through mouth with “pursed” (duck) lips
What is the benefit of moving and turning for the respiratory system?
Causes patient to become exerted, which makes them take larger/deeper breaths.
This opens the alveoli more, improves gas exchange
Helps to loosen and mobilize secretions
Encourage coughing after movement to promote secretions to be expelled
What is the tripod position? When is the tripod position used?
Sitting upright and leaning forward
Promotes maximum lung expansion
Used during SOB episodes
Explain high-Fowlers position.
When then head of the bed is greater than 60 degrees, no more than 90 degrees
Aides in lung expansion
Explain semi-Fowlers position.
When the head of the bed is 30 to 45 degrees
In order to give supplemental oxygen to a patient, you must have what?
An order
When should oxygen be applied?
If patient has s/s of respiratory distress
O2 sats are less than normal range
Describe a nasal cannula. How much oxygen can be delivered through a nasal cannula?
It is tubing that has two prongs that sit in the nose. The tubing goes into the nose, wraps behind the ears and in front of the neck. The other end of the tubing connects to the oxygen source.
0.1 LPM to 6 LPM of oxygen can be delivered through a nasal cannula
Describe a high flow nasal cannula. How does it differ from a nasal cannula? How much oxygen can be delivered through this device? When is this device used?
It is tubing that has two prongs that sit in the nose. The tubing goes into the nose, wraps behind the ears and in front of the neck. The other end of the tubing connects to the oxygen source. This tubing is different than a regular nasal cannula because it allows for a high pressure/amount of oxygen to be delivered.
6 LPM to 15 LPM of oxygen can be delivered through a high flow nasal cannula
This device is used when a patient is requiring higher amount of oxygen and can be used in place of a simple face mask or non rebreather. Can decrease anxiety and allows patient to eat if not NPO. Not an appropriate device when respiratory distress is present.
Describe a simple face mask. How much oxygen can be delivered through this device? What percentage of oxygen concentration is delivered with this device?
A mask that is applied over the patients nose and mouth with tubing that connects to an oxygen source.
Delivers 5 LPM to 10 LPM of oxygen
Delivers 40% to 60% oxygen concentration mixed with room air
Describe a non rebreather. How much oxygen can be delivered through this device? What percentage of oxygen concentration is delivered with this device? When is this mask used?
A mask applied over the nose and mouth. One vent on each side of the mask that act as one way valves. Reservoir bag connected to the mask filled with 100% oxygen. When the patient breathes in, the valves close, and the patient breathes in only the air that is in the reservoir bag (which is 100% oxygen). When the patient breathes out, the valves open and the exhaled air exits out of the mask into the surrounding environment.
Delivers up to 15 LPM of oxygen
Delivers 100% oxygen concentration
Used during respiratory distress
The mask can also be used when a patient is hyperventilating. The mask will not be connected to oxygen. The mask will be placed on the patient and they will rebreathe their exhaled air.
What is the most common medication administered through both a metered dose inhaler (MDI) and a nebulized mist treatment (NMT)?
Adrenergic bronchodilator
What education needs to be given with both a metered dose inhaler (MDI) and a nebulized mist treatment (NMT)?
Educate on proper use of the device - have the patient perform return demonstration
Educate on overuse of the medication causing worsening symptoms; severe bronchoconstriction can occur (worsening SOB, dyspnea, wheezing)
What is required in order for a patient to use an incentive spirometer?
An order
How often should the patient use the incentive spirometer?
10 times a hour while awake.
Nurses role to encourage this, watch it happen, and document!
What does an incentive spirometer do?
It expands the lungs and encourages deep, full breaths
Helps prevent infection such as pneumonia by expanding alveoli, getting junk/secretions out of the lungs, so bacteria cannot breed
Helps prevent collapse of the lung tissue
May be painful, can cause coughing
What two oxygen devices can be used with a nebulized mist treatment? When would each be chosen?
A handheld device; used with someone alert/oriented, able to follow directions and will hold the device up to their lips/mouth until the treatment is finished
A simple face mask; used with a child, older adult who cannot follow instructions, someone who is too tired to hold the handheld device
When is an incentive spirometer commonly ordered?
For patients who are post-op and experiencing pain (less likely to take a deep breath because it will hurt)
For patients who breathe shallow
List the steps of incentive spirometer use
- Sit upright in a chair or in bed. Hold the incentive spirometer at eye level.
- Slowly breathe out (exhale) completely.
- Put the mouthpiece in your mouth and close your lips tightly around it. Breathe in (inhale) slowly through your mouth as deeply as you can. As you take the breath, you will see the piston rise inside the large column. While the piston rises, the indicator on the right should move upwards. It should stay in between the 2 arrows
- Try to get the piston as high as you can, while keeping the indicator between the arrows.
If the indicator doesn’t stay between the arrows, you’re breathing either too fast or too slow. - When you get the piston as high as you can, hold your breath for 10 seconds, or as long as possible. While you’re holding your breath, the piston will slowly fall to the base of the spirometer.
- Once the piston reaches the bottom of the spirometer, breathe out slowly through your mouth. Rest for a few seconds.
- Repeat 10 times. Try to get the piston to the same level with each breath.
- After each set of 10 breaths, try to cough, holding a pillow over your incision, as needed. Coughing will help loosen or clear any mucus in your lungs.
- Put the marker at the level the piston reached on your incentive spirometer. This will be your goal next time.
What is the purpose of chest physiotherapy? What is the nurses role during chest physiotherapy?
Loosen and break up secretions.
Nurse is to educate and encourage coughing and deep breathing during and after the procedure to remove secretions from body
Alternative to chest physiotherapy that can be performed independently by nurse? What education does the nurse need to provide during this intervention?
Cupping hand and patting back to encourage loosening/breaking up secretions.
Nurse is to educate and encourage coughing and deep breathing during and after the procedure to remove secretions from body
