T1-Ch 24: Assessment of the respiratory system Flashcards
Difficulty breathing
dyspnea
respirations greater than 20 breaths/min
tachypnea
respirations less than 12 breaths/min
bradypnea
shortness of breath that occurs when lying gown that is relieved when sitting up
orthopnea
low levels of oxygen in the blood
hypoxemia
alveolar collapse
atelectasis
right-sided HF caused by pulmonary disease occurring with bronchitis or emphysema
cor pulmonale
symptoms of atelectasis(4)
dyspnea
rapid/shallow breathing
wheezing
cough
treatment of atelectasis (6)
-deep breathing exercises
-incentive spirometry
-elevate HOB
-early ambulation post-procedures
-bronchodilators
-humidity
alveolar collapse due to giving too much oxygen
absorptive atelectasis
nitrogen ________ airways and alveoli; an increase in oxygen ________ the nitrogen, and as the oxygen diffuses into the blood, the alveoli ________
-nitrogen maintains patent airways
-increase in oxygen dilutes the nitrogen
-alveoli collapse
signs of atelectasis (2)
-new onset of crackles
-decreased breath sounds
5 A’s for treating tobacco use
-Ask about use
-Advise to quite
-Assess willingness
-Assist in attempt
-Arrange follow up
Which of the 5 A’s?
Identify and document tobacco use and status at every patient visit
Ask
Which of the 5 A’s?
Communication with patient in a clear, strong, and personalized manner
Advise
Which of the 5 A’s?
Determine whether user is willing to attempt to quit smoking
Assess
Which of the 5 A’s?
OTC nicotine replacement therapy, counseling, support groups, reinforce
Assist
Which of the 5 A’s?
Arrange follow-up appointments within the first week after quitting
Arrange
Values above normal range:
1. pH:
2. pCO2:
3. pHCO3
- Basic
- Acidic
- Basic
Values bellow normal range:
1. pH:
2. pCO2:
3. pHCO3
- Acidic
- Basic
- Acidic
Purpose of pCO2 in ABG
Determine if its respiratory
Purpose of pHCO3 in ABG
Determine if its Metabolic
CO2 or HCO3 are normal while pH is abnormal
uncompensated
No values are within normal range
partially compensated
pH is within normal range, CO2 and HCO3 are not
Compensated
pH is closest in acidity to HCO3
Metabolic
pH is closest in acidity to CO2
Respiratory
abnormal values are acid
acidosis
abnormal values are basic
alkalosis
maximum amount of air that can be exhaled as quickly as possible after max inspiration
Forced vital capacity (FVC)
Max amount of air that can be exhaled in the first second of expiration
Forced Expiratory Volume in 1 sec (FEV1)
FEV1/FVC
Expiratory volume in 1 second/ Forced vital capacity
Forced expiratory flow over the 25-75% volume of the FVC
Functional Residual Capacity (FRC)
Amount of air in the lungs at the end of max inhalation
Total lung capacity (TLC)
amount of air remaining in the lungs at the end of a full, forced exhalation
Residual Volume (RV)
Reflects the surface area of the alveolocapillary membrane
Diffusion capacity of lung for carbon monoxide(DLCO)
non-invasively identifies hemoglobin saturation with oxygen (SpO2)
Pulse Oximetry
Perks of using pulse oximetry
Can detect desaturations before symptoms of respiratory distress appear
Normal SpO2 value
95-100%
T/F: SpO2 saturation is usually higher in those with darker skin
False; SpO2 is usually lower
Low SpO2 indicates:
impaired ability of hemoglobin to release oxygen to tissues
SpO2 <_____% in patients w/out chronic respiratory issues are emergent
91%
SpO2<_____% is emergent in all patients
86%
SpO2 <_____% is life threatening
80%
SpO2 measurement locations (5)
-finger
-toe
-nose
-earlobe
-forehead
Nursing consideration: Things that can cause low reading (7)
-movement
-hypothermia
-decreased peripheral blood flow
-ambient light
-decreased hemoglobin
-edema
-fingernail polish
Most accurate location for SpO2 measurement:
forehead
Nursing consideration for SpO2: readings are ______ accurate at lower values
Less accurate
digital images to evaluate chest and pulmonary status
chest x-ray
chest x-rays are often used for comparison with :
previous or future images
chest x-rays are taken in ______ and ____ positions
-posteroanterior (back to front)
-left lateral
Chest x-rays can be used to identify: (6)
-pneumonia
-atelectasis
-pneumothorax
-tumor
-fluid
-tube/catheter placement
Nursing consideration: chest x-ray may appear normal with: (3)
-severe chronic bronchitis
-asthma
-emphysema
insertion a tube in the airway as far as the secondary bronchi to view airway structures and obtain tissue samples
bronchoscopy
purpose of a bronchoscopy (7)
-diagnose and manage pulmonary disease
-evaluate airway
-verify placement of ET tube
-collect specimens
-diagnose infections
-stent placement
-staging of lung cancer
two types of bronchoscopy:
-rigid
-flexible
rigid bronchoscopy requires _______ anesthesia
general
flexible bronchoscopy can be performed under _____ in ICU or _____
-mild sedation
-endoscopy
Preparation for bronchoscopy (4)
-consent
-labs
-NPO 4-8 hours
-premedication
Labs required for bronchoscopy (5)
-CBC
-Platelets
-PTT
-Electrolytes
-chest x-ray
premedication for bronchoscopy: (2)
benzodiazepine or opioids
nursing consideration for bronchoscopy: benzocaine spray used as a topical anesthetic may cause:
methemoglobinemia leading to hypoxia
During bronchoscopy, nurse: (2)
-monitors vitals
-provides supplemental oxygen as needed
Follow-up care for bronchoscopy: (2)
-monitor until sedation wears off and gag reflex has returned
-VS and lung sounds Q-15min for first 2 hours
needle aspiration of pleural fluid or air pleural space for diagnosis or management
Thoracentesis
purpose of thoracentesis (3)
-relieve blood vessel or ling compression
-resolve respiratory distress from cancer, empyema, pleurisy, or TB
-instill drugs into pleural space
During thoracentesis, nurse: (2)
-assist patient to sitting position on side of bed and provide support from the front as needle is inserted
-assess for signs of respiratory distress throughout procedure
follow up care for thoracentesis (4)
-chest x-ray to rule out pneumothorax or mediastinal shift
-monitor VS and puncture site for complications
-promote deep breathing exercises
-document procedure
Nursing considerations for thoracentesis: procedure has risks of __________ within the first 24 hours filling the procedure
subcutaneous emphysema that will make crackling sounds with pressure and pneumothorax
Respiratory assessment of external nose:
-deformities
-symmetry
-size
-shape
respiratory assessment of internal nose:
-color
-swelling
-drainage
-bleeding
-polyps
pale, engorged, or bluish-gray mucosa within nose
allergic rhinitis
S-shaped septum
septal deviation
present if light shines from one naire into the other
perforated septum
perforated septum are common in:
cocaine users
pale, shiny, gelatinous lumps on the turbinates
nasal polyps
When performing respiratory assessment of lungs, inspect: (4)
-front and back of the thorax while patient is sitting up
-respirations
-type of breathing
-AP diameter
inspection of respirations should include: (4)
-rate
-rhythm
-depth
-symmetry of chest movement
Different types of breathing include: (3)
-pursed-lip
-diaphragmatic
-use of accessory muscles
AP diameter should be ______ but may be _____ in patients with emphysema
-1 : 1.5
-1 : 1
Palpation of lungs is done to:
check for bilateral symmetry
crackling sensation under the skin
crepitus
or
subcutaneous emphysema
vibration of the chest wall when patient speaks, which should be diminshed
fremitus
auscultation of the lungs includes checking for ____, ____, and ____ lung sounds
-anterior
-posterior
-lateral
Bronchial normal breath sound:
Pitch:
Amplitude:
Duration:
Quality:
Location:
Pitch: High
Amplitude: Loud
Duration: Inspiration < Expiration
Quality: harsh, hollow, tubular
Location: Trachea & Larynx
Bronchovesicular normal breath sound:
Pitch:
Amplitude:
Duration:
Quality:
Location:
Pitch: Moderate
Amplitude: Moderate
Duration: Inspiration = Expiration
Quality: Mixed
Location: Bronchi, upper sternum, posterior scapulae
Vesicular normal breath sound:
Pitch:
Amplitude:
Duration:
Quality:
Location:
Pitch: Low
Amplitude: Soft
Duration: Inspiration > expiration
Quality: Rustling
Location: Peripheral Lung fields
Adventitious breath sound: popping, velcro, late in inspiration
Fine crackles
fine crackles is also known as
rales
Fine crackles/rales is associated with (6)
-Asbestosis
-Atelectasis
-Interstitial fibrosis
-Bronchitis
-Pneumonia
-Chronic Pulmonary Disease
Adventitious breath sound:
rattling sound due to fluid or secretions in large airways
Coarse crackles
Coarse crackles is associated with (4)
-bronchitis
-pneumonia
-tumors
-pulmonary edema
adventitious breath sounds: squeaky, musical, continuous
does not improve w/cough
wheeze
wheezing is associated with: (5)
-inflammation
-bonchoscpasm
-Edema/secretions
-pulmonary vessel
-engorgement
adventitious breath sounds: low-pitched continuous snoring from large airways
Rhonchi
Rhonchi is associated with (4)
-Thick secretions
-Sputum production
-Foreign body obstruction
-Tumors
Adventitious breath sound: grating, scratching sounds associated with pain on deep inspiration; present in lateral lung field
Pleural friction rub
Pleural friction rub is associated with: (5)
-Pleurisy
-Tuberculosis
-Pulmonary infarction
-Pneumonia
-Lung cancer
