Test 3 Flashcards
Lung Structures-
Left Lobe (2) LL
Right Lobe (3)
Left Lung (LL)- Superior & Inferior
Right Lung (3)- Superior, Middle, & Inferior
What is the mediastinum?
The space between both lungs inside chest cavity
Structures within the Thorax
Mediastinum
Right pleural cavity (3 Lobes)
Left pleural cavity (2 Lobes)
3 lobes right
2 lobes left
External Thorax
12 thoracic vertebrae
12 pairs of rubs
Sternum
Xyphiod Process- bottom of sternum (gets broken during cpr)
The parietal hair, the chest wall, and diaphragm are protected in
The visceral (outer lining) as the lungs protect it
Why is it important for there to be a small amount of fluid around the structures within the thorax?
It lubricates the space between these to reduce friction
If fluid is lost, gets inflamed, then it becomes thick like molasses and we can hear sounds of it rubbing against the side of chest wall or lungs
What are the major functions of the respiratory system?
- Supplies O2 to the body for energy
- Removes CO2 as a waste product
- Maintains acid-base balance of our body/blood (blows off or retains acid for balance)
Respiratory Physiological Functions
Ventilation
Inspiration/Expiration
Pulmonary Circulation
Oxygen transport
Diffusion
Carbon Dioxide Transport
What is ventilation?
Process of moving gases into and out of the lungs during inspiration
What is inspiration and expiration?
Active process stimulated by chemical receptors in the aorta and a passive process for expiration
What is pulmonary circulation?
Moves blood to and from the alveolar capillary membranes for gas exchange
What is diffusion?
Exchange of respiratory gases in the alveoli and capillaries
O2 & CO2 go from high to low concentration
Where does oxygen transport happen?
Lungs- transfer O2 from atmosphere to the alveoli where the blood is, exchange the O2 or O2 is exchanged for CO2
Cardiovascular System-
Brings RBC containing HGB w/ O2 to area and diffuse the exchange of gasses bt environment/blood
What happens during active phase of inspiration?
Diaphragm contracts pushing abdominal contents down
Intercostal muscles move/push chest forward
What happens during passive phase of expiration?
Body expels the gas/CO2
Costal Margin & Angle
Teepee shaped
When people are sick the costal angle tends to increase because more air is trapped inside
Thoracic Reference Lines
(Front)
Midsternal
Midclavicular
Anterior axillary
(Back)
Scapular Line
Vertebral Line
(Side)
Anterior Axillary
Posterior axillary
Midaxillary
Assessment: Nursing History
What type of questions should you ask?
Find out client’s ability to meet the O2 demands that the body needs
Pain (OLD CARTS)
Dyspnea- (shortness of breath)
Wheezing/ cough (air thru narrow airway) (ask duration, production)
Respiratory infections (how often, vaccines)
Health risks (family history)
Smoking(direct vs indirect), years
Fatigue (scale 0-10)
Environmental/ Geographic exposures (work etc.)
Allergies
Medications (all types)
Pack Year History Calculation
Pack per day X number of years
How can we help our patient quit smoking?
Advising them to quit
Offering brief counseling
Prescribing cessation medications
Connecting them to additional resources, like a quitline
Following up with continued support to help prevent relapse
Routine Respiratory Assessment
INSPECT client for general appearance, posture, & breathing (skin, clothes, tiredness etc.)
OBSERVE respirations for rate, quality & depth (fast/slow, labored/unlabored, shallow/deep)
INSPECT the client’s nails, skin, & lips (color, uniformed, clubbing, smooth, cracked, lesions)
INSPECT the thorax
AUSCULTATE the thorax
Inspection for Respiratory
Level of consciousness (LOC)
Facial expression (scared, anxious, calm)
Color (pale, warm, red)
Respiratory rate (12-20)
Shape and configuration of chest wall (AP Diameter (1/2 of lateral), if square then chest is pushed out
Respiratory pattern (regular, irregular)
Positioning
Use of accessory muscles ( shoulders involved to help breathing)
INSPECT Client for General Appearance, Posture, & Breathing
Normal:
Appearance relaxed -upright, breathing w/o difficulties
Posture relaxed-straight not hunched
Posture upright
Breathing effortless
INSPECT Client for General Appearance, Posture, & Breathing
Abnormal:
Apprehension, restless-anxious when blood oxygen drops and need to breathe from nose
Nasal flaring- opening up to get more air
Use of accessory muscles- shoulder involvement
Tripod position -bending to breathe
OBSERVE Respirations for Rate, Quality & Depth
Normal:
Appropriate rate
Smooth pattern
Even depth
Chest wall rises & expands symmetrically without effort
OBSERVE Respirations for Rate, Quality & Depth
Abnormal:
Chest retraction
Frequent sighing
Abnormal breathing patterns (next slide)
Abnormal Breathing Patterns
Bradypnea- regular slow inspiration/expiration <12 rate
Tachypnea- regular, not full inspiration >20permin rate
Hyperventilation- Full inhale/exhale, fast, increase depth/rate
Kussmaul’s- Ketoacidosis (high blood sugar, fruity sugar smell,
Cheyne-Stokes- regular periods of crescendo (accelerates)/decrescendo (slows), then apnea (nothing)
Fast, slow, nothin
Biot- Bizarre, no pattern (high low, none), everywhere, (major injury), end of life or very sick (the other stokes)
Air Trapping- Coastal angle expand (COPD, alveoli do not get rid of air like it should)
Rapid inhale, slow exhale
INSPECT the Client’s Nails, Skin, & Lips
Normal
General color consistent with color for that individual
Abnormal
Cyanosis (blue)/Pallor (pale, reduced # of HGb) of nails, skin, or lips
Clubbing of nails (long term low oxygen)
What is cyanosis?
Cyanosis is a LATE sign of hypoxia and is not a reliable measure of O2 status.
What causes clubbing of nails?
Long term of low oxygen
INSPECT the Thorax
Normal:
Thorax symmetrical- Ribs slope down
Spinous processes in a straight line
Scapulae bilaterally symmetrical
Abnormal
Asymmetry or unequal muscle development
Skeletal deformities
Inspection: Shape/Configuration of Chest Wall
AP Diameter vs Transverse(lateral)
Normal vs Barrel Chest
Front to back=1/2 distance of transverse (normal)
Inspection: Shape/Configuration of Chest Wall
Pectus Excavatum- pressing on heart
Pectus Carinatum- doesn’t affect body
Scoliosis- lungs are getting squished and can’t fully inflate
Kyphosis- aging, thoracic spine is sticking out and getting pushed further away, getting convex (can’t hear lungs)
AUSCULTATE the Thorax
Normal
Bilaterally clear
Vesicular, bronchovesicular, & bronchial sounds heard in various parts of the thorax
Abnormal
Adventitious breath sounds
Absent
Diminished
Stridor (trachea closing)
Location of Breath Sounds
Anterior
Posterior
Adventitious Breath Sounds
Crackles- cracking or popping (inspiration, fluid in lungs)
Wheezes- high pitched musical (squeak), common during expiration (small airway, asthma), lower abdomen
Rhonchi- snoring or moaning sound (low pitched), during expiration mainly (mucus blocking bronchi) (ask patient to cough to clear it)
Pleural Friction Rub- coarse rubbing/grating sounds (heard in both)
Stridor- up in trachea, things are closing need help asap
Where are bronchial sounds heard?
Over the main airway (Trachea)
Sounds raspy like darth vader
Where are vesicular sounds heard?
Outside, all the way down the back and at the bottom, more from boobs down (nice & breezy), not in major airway area
Where are bronchovesicular sounds heard?
Around the sternum and spine in the back (in btween)
Breezy and deep sounds
Auscultating Breath Sounds
Use diaphragm
Compare sounds in each lung field to opposing lung field (latter pattern)
Lower lobes best heard in back
Where you hear sounds in the sounds.
Generally, from the lower lungs (Right Middle Lobe from the front best)
Special Circumstances or Advanced Practice Techniques for Anterior & Posterior Thorax
Normal:
PALPATE anterior & posterior thoracic muscles of tenderness, bulges, & symmetry
Abnormal
Crepitus: crinkly/crackly sensation under your fingers (air leak)
Pleural friction rub: coarse, grating sensation during inspiration
Asymmetrical thorax: indication of thoracic disorder (ex. fractured ribs)
Techniques for Anterior & Posterior Thorax
Normal:
PALPATE the anterior & posterior thoracic wall for vocal (tactile-touch) fremitus
“99”
Abnormal
Unequal vibrations
Decreased or absent fremitus
Lung is collapsed
PALPATE the trachea for position
Normal: Midline
Abnormal: Not midline
Acute or Traumatic Conditions
Both will need chest tubes for lungs to reinflate
Collapsed Lung (Pneumothorax)- air in space
Hemothorax- air w/blood in space
Atelectasis- Collapsed avelioi
from tumor, fluid, air in pleura spaces
caused by hypoventilating patients
Don’t fully breath (post ops)
Diff btween pneumothorax and atelactasis
A- not lungs- just avelio
P- whole lungs
Lung cancer- presenting sign persistent dry cough
Hemoptysis
-tobacco
-Radition
abestos
\Normal Air filled lungs
-vesicular predominantly
-Tactile fremitus (vibrations) normal
Lobar Pneumonia- we’ll hear bronchial or bronchv over area where we should hear vesicular
tells us they have pneumonia
Increased tf due to fluids
air acs now have fluid pus
Diagnostic Testing ABG (Arterial Blood Gas) (invasive)
- provide valuable information in assessment and managing a patient’s respiratory & metabolic acid-base & electrolyte homeostasis
Assess oxygenation (how well it moves O2)
-Info on respiratory, cardiac, and renal (kidney) system
-Pulmonology- determines the gas exchange levels in the blood related to lung function
Normal Findings:
pH: 7.35-7.45
PCO2: 35-45
HCO3: 22-26
PO2: 80-100
Acid Base Disturbances:
Respiratory Acidosis
Metabolic Acidosis
Respiratory Alkalosis
Metabolic Alkalosis
-Procedure: during drawn from artery
-Indicates how efficient lungs provide O2 to the body and how it removes CO2
-Measures the blood pH
Diagnostic Testing: Chest X-Ray
-Creates pictures of the structures inside your chest, such as your heart, lungs, and blood vessels
-taken anterior, posterior, and laterally
- can identify tumors, inflammation of lungs, fluids, fractures, location of central line
ex. pneumonia
-patient can be lying, sitting, standing
Expected/Normal Findings
-Nail bed angle 160 degrees
-Respiratory Rate 12-20/minute
-Trachea midline
-Vesicular breath sounds in lung periphery
-Coastal angle <90 degrees
Unexpected/Abnormal Findings
-Unilateral chest wall movement w/ inhalation
-Frequent sighing
-Respiratory rate >20/min
-AP to lateral diameter 2:1 ratio
-Bronchovesicular sounds heard over the trachea
Diagnostic Testing: Chest CT
-Evaluate suspected disease in the chest
-Questionable or vague abnormalities on the routine chest x-ray can be more thoroughly evaluated
-more specific
-helps diagnose tumors, abscessess, pleural effusion (w/ and w/o contrast)
-spiral ct- identify clots pulmonary embolus
Diagnostic Testing: Bronchoscopy
-Permits endoscopic visualization of the larynx, trachea, and bronchi by either a flexible fiberoptic or rigid bronchoscope
-Can take out/clean things while in there
Diagnostic Testing: Lung Biopsy
-Determines the nature of a pulmonary nodule that has been identified on plan chest x-ray or CT scan
Obtain tissue sample
Diagnostic Testing: Lung V/Q Scan
-Helps to diagnosis pulmonary embolism & identifies blood perfusion defects within the lung
-Nuclear medicine procedure
-study air flow (ventilation) and how well blood is coming in to provide oxygen (perfusion) of lungs
-Procedure: inject substance into veins that travels to pulmonary arteries where it illuminates and pictures are taken
Diagnostic Testing: Sputum Culture & Sensitivity (c&s)
-Growth on dish and see what drugs work/don’t
-Can distinguish between fungus, bacteria, or virus
-1-3 days to complete
-sterile procedure, best in morning (cough up sample)
Indicated for any patients with (persistent, productive, coughs, fever, hemoptysis coughing blood, infections)
-can diagnose pneumonia, respiratory infections, bronchitis
-
Diagnostic Testing: Sputum Cytology
-looking for cancers
Indicated for any patient in which the diagnosis of cancer of the lung is considered
Diagnostic Testing: Tuberculin Skin Test (TST)
-Interdermal
-read between 48-72 hrs for accuracy
-measured in area of indirection (raised area)
-don’t measure redness (erythema)
Preformed in individuals suspected of having TB
-aka PPD testing
-negative: generally <5mm but will vary depending on pt
-once positive, pt is + for life
Respiratory: Age Considerations for older adults
Costal cartilages become calcified (not able to expand as well)
Respiratory muscle strength declines after age 50 years and continues to decrease into the 70s
The elastic properties within the lungs decrease, making them less distensible and lessening their tendency to collapse and recoil.
Decreased number of _alveoli_______
Cough reflex decreases
Respiratory: Age Considerations for infants/children
Use a pediatric stethoscope with small diaphragm
Infants have a round thorax with an equal AP and lateral diameter
Infants are obligate nose breathers until 3 months
Sneezing– normal newborn reflex
Infants have irregular breathing pattern– apnea is abnormal
Respiratory distress-stridor/ grunting/ sternal or supraclavicular retractions and nasal flaring (abnormal)
Considerations for Hospitalized Patient
Patient using a nasal cannula: Make sure it is in their nose and watch the O2 sat
Assessment of the nasal cannula—patency, rate and flow—assess O2 saturations
Patient using a Oxygen Mask: Humidify wetness, so we must watch for skin breakdowns/irritants
Using a ventimask—assess skin of face and ears for redness or indentation—assess correct O2 percentage
Patient with a tracheostomy:
Requires suctioning, evaluate secretions, lung sounds, skin near site with dressing changes
Patient with chest tubes:
Assess dressing at site and amount/color of drainage that collects in container—assess lung sounds to know it hasn’t collapsed
Documentation of expected respiratory findings
Breathing quiet and effortless.
Rate 16.
Skin, nails, lips appropriate color for race.
Thorax symmetrical with ribs sloping downwards at about 45 degrees
No tenderness noted on palpation.
Thoracic expansion symmetrical bilaterally.
Spinous process in alignment.
AP diameter 1:2.
Trachea midline.
Breath sounds clear and equal bilaterally to bases. No accessory muscle use
WBC- normal 5,000-10,000 (no infection)
HGb- normal 12-15 F normal (carrying normal o2/co2 thru blood)
HCT- 40% normal F (has right amount of rbc)
D-Dimer- positive = higher d-dimer level possible blood clots (free flowing protein that broke up from clot)
ABG-
pH-7.44 normal
PCO2- 22=low (increased ventilation)
PO2- 48=LOW- not receiving enough O2
HCO3= 23 NORMAL acid base balance
V/Q Mismatch- lung is receiving O2 W/O BLOOD FLOW OR VICE VERSA (OBSTRUCTED AIRWAY MAYBE)
Case Study:
Pt 68 yrs old
hip fracture and repaired but on 6th day post op she c/o acute onset of right sided chest pain, shortness of breath, and palpitations
Protentional issue: Pt is experiencing blood clots and obstruction of airway which results in shortness of breath and palpitations
Respiratory acidosis
How does the heart work?
Normal Vascular System: Arterial
Blood going away from heart and into the organs/tissues
Full of oxygen (red)
High-pressure vessels
Largest is the aorta
Function to deliver blood to various tissues for nourishment and temperature regulation
Normal Vascular System: Venous
Blood going back to the heart
-oxygen has been used (blue)
Large diameter, thin-walled vessels
Some contain valves to regulate one-way flow
Functions to return blood from capillaries to the right atrium for circulation and acts as a reservoir for blood volume
How is circulation and blood flow of the heart regulated?
By pressure, resistance, velocity, and compliance
What is circulation and blood flow?
Blood flow is the amount of blood moved per unit of time though a vessel, organ, or entire circulated system
What is pressure?
Stroke Volume X Heart Rate = Cardiac Output (SV X HR = CO)
Cardiac Output X Systemic Vascular Resistance = Blood Pressure
(CO x SVR = BP)
What is resistance?
determined by viscosity (thick), length of vessel, and diameter of the vessel
What is velocity?
Distance that the blood travels in the unit of time
What is compliance?
The degree that the vessel will accomodate
Heart Pumping Function- blood flow through the heart
3 structures involved w/ pumping:
Endocardium
Myocardium
Epicardium
Coronary Blood Supply
What is stroke volume?
Amount of blood ejected from the heart w/ each contraction (how much it puts out)
Systemic Vascular Resistance
Dilation/constriction amount
4 Chambers of the Heart
Upper-
Left atrium (LA)and right atrium (RA
Lower- Right ventricle (RV) and Left Ventricle (LV)
Which structures of the heart carries oxygenated blood to the right atrium?
Superior and Inferior vena cava
Blood flow of right side
Enters:
Super/inferior vena cava- right atrium-right ventricle- tricuspid valve (closes when ventricles are full)-
Leaves- pulmonary valve into pulmonary artery for oxygenation
Blood flow of left side
