RESPIRTATORY SYSTEM Flashcards
NORMAL BREATH SOUNDS:
Bronchial: I<E
High-pitched (heard on large airways; trachea)
Vesicular: I>E
Low pitched (heard on narrow airway; Lung field)
Bronchovesicular: I=E
Blowing sounds (heard on bronchus)
ABNORMAL BREATH SOUNDS:
Bronchial breath sounds Over lung field
Pneumonia
ABNORMAL BREATH SOUNDS:
Wheezing- [ineffective airway clearance)
-asthma
-bronchitis
-smoke inhalation
-allergic reaction
-transfusion reaction
-choking
ABNORMAL BREATH SOUNDS:
Rales/Crackles [Impaired gas exchange] ; lung field
-left sided CHF
-Pulmonary Edema
-Fluid Overload
-Renal Failure
-Pneuomonia
Absence breath sounds
[altered breathing pattern];
pleural space
-Pneumothorax
-Pleural effusion (air)
-Hydrothorax (fluid)
-hemothorax (blood)
-flail chest (unequal paradoxical chest expansion)
-atelectasis
-Visceral Pleural space
RONCHI=SNORING
Obese; close pharynx; short neck
Nrsg Responsibility:
-High back rest 1st
-Sidelying 2nd
ABG( ARTERIAL BLOOD GAS)
Ph= 7.35-7.45
PCO2= 35-45
HCO3= 22-26
Terminilogy
Hypoxia= Decrease o2 in tissue (Pulse Oximeter/ o2 sat)
Hypoxemia= decrease o2 in blood = ABG
SO2= 95-100% (SO2= 92% COPD & Asthma)
PaO2= 80-100%
Buffer System (Compensate)
Lungs–> PcO2 (ACID) = Compensate Faster
Kidneys –> HCO3 (BASE) = Compensation is delayed up to 72 hours or 3 days
RESPIRATORY ACIDOSIS
PH- LOW; PCO2-HIGH; CO2 EXCESS (RETENTION)
Cause: HYPOVENTILATION (low RR)
1st sign is Decrease LOC (Confusion/Disorientation)
PLAN OF CARE:
1.Encourage Hyperventilation
2.Pursed-lip Breathing
3.Avoid Carbonated drink (SODA)
4.Mechanical Ventilator- eliminate excess CO2
5.DOC: NARCAN (NALOXONE) increase RR
RESPIRATORY ACIDOSIS
Co2 retention
HYPOVENTILATION (LOW RR)
1.Pneumothorax
2.Hemothorax
3.Hydrothorax
4.Pleural effusion
5.Atelectasis
6.Fractured ribs
7.Flail chest
8.COPD
9.Colappsed alveoli =Co2 is not released
10.Brainstem Damage= CVA
11.Near Drowning
RESPIRATORY ALKALOSIS
PH- HIGH; PCO2-LOW;CO2- DEFICIT
Cause: Hyperventilation (high RR)
1ST sign: Numbness of lips & extremities
PARESTHESIA
PLAN OF CARE:
1.Encourage hypoventilation
2.Paper bag/ Cup hands
3.Offer carbonated drinks
4.Rebreather mask
5.DOC: DIAZEPAM (VALIUM)
-decreases rr
-Anxiolytic; Muscle relaxant
CALCIUM GLUCONATE
MORPHINE SULFATE- cns depress.
RESPIRATORY ALKALOSIS
CO2 DEFICIT
HYPERVENTILATION (high RR)
1.Pregnancy- shallow breaths
2.Ascites
3.Obesity
4.Anxiety
5.Angry
6.Shock -hypo,tachy,tachy
BRONCHIAL ASTHMA
Narrowing of tracheobronchial tree due to presence of allergens
FACTORS: Intrisic= Flu, common cold, URTI Extrinsic= Dust, fur, pollens, perfume, fumes, spray, smoke inhalation, changes in climate, foods & drug allergy MANIFESTATION: SOB Expiratory wheezing Nasal flaring Use of accessory muscle Stridor Reslessness- earliest s/sx of hypoxia Somnolence (decrease LOC) Cold, clammy perspiration
ACID-BASE IMBALANCE
1.ACUTE ATTACK- Respiratory alkalosis; due to hyperventilation
2.UNTREATED- Respiratory Acidosis; due to CO2 retention
ACID-BASE IMBALANCE
PLAN OF CARE:
Priority: Establish & maintain patent airway
1.ACUTE ATTACK
DOC: Epinephrine
-rapid acting bronchodilator
-SE: Short-acting
2.LATENT PHASE
DOC: Theophylline
-long acting bronchodilator
3.Nebulize with Salbutamol (Ventolin) ; Albuterol (bronchodilator)
*SE: Tachycardia; Palpitation
4.Steroids (Prednisone) ; Anti-inflammatory
SE= Inahalation
(Fungal infection; candidiasis/ oral thrust)
Insruction: ORAL CARE (GARGLE)
Nrsg alert: Give Bronchodilators before steroids!
**If bronchodilators & steroid inhalation is given at the same time, then administer bronchodilators before steroids- to promote absorption of steroids.
5.Problem: Airway obstruction
-Bedside= ET (Endotracheal) set
PROMOTE BREATHING (Lung Expansion)
A.Position :1st Orthopneic/ Tripod- sitting leaning forward
2nd : Sitting, upright, high-backrest
*ADMINISTER EPINEPHRINE AND HIGH-BACKREST- ASTHMA
B.Cough & Deep-breathing
C.Chest physiotherapy
-Mobilize secretion
-After nebulization
Contraindicated: Collapsed Alveoli; Emphysema; ARDS; Fractured ribs; PTB w/ Hemoptysis; Lung tumor
D.Increase Fluid Intake
-to liquify secretions
E.DOC: CROMOLYN
-To decrease secretions
F.Cough Medication
DECREASE O2 ADMINISTRATION
High CO2; low O2= HYPOXIC DRIVE (Inversely proportional)
**Safest: 2LPM via Nasal Cannula
Respi Acidosis: high CO2 retention
-if CO2 is high, the pt will breath only at low level of o2 and lungs will not expand: HYPOXIC DRIVE.
*If co2 is high & o2 is high it suppress the breathing and leads to APNEA
PROMOTE REST
-To retain energy
(+) ALLERGENS
DOC: ANTIHISTAMINE
**BENADRYL (DIPHENHYDRAMINE)
SE: Drowsiness
