Week 10 Nursing Flashcards
Health History Questions
▪ Cough
▪ Shortness of breath
▪ Chest pain with respiration
▪ History of respiratory infections
▪ Environmental exposure
▪ Self-care behaviours
▪ Smoking
▪ Exposure to secondhand smoke
▪ Medication
Inspection - General
▪ Colour
– Face, lips, mucous membranes and nailbeds
▪ Accessory muscle use
▪ Shape of the chest wall
▪ Nasal flaring
▪ Pursed lip breathing
▪ Positioning
▪ Dyspnoea and/or cough
▪ Oxygen administration
▪ Presence of sputum
▪ Finger Clubbing
Inspection – Nasal Flaring
▪ Seen mostly in infants and young children
▪ Sign of respiratory distress in children
▪ Increases upper airway diameter and reduces airway resistance
▪ Attempt to increase airflow through airways
Inspection – Pursed Lip Breathing
▪ Common in respiratory conditions such as COPD
▪ Breathing out through narrowed lips
– Pursed lip breathing
▪ Reduces breathlessness possibly by continuous positive airway pressure
– Similar to use of a CPAP machine for sleep apnoea
Inspection – Tripod Positioning
▪ Common in infants and older adults
– Croup (infants)
– COPD (older adults)
▪ Position is similar to that of a camera tripod
▪ Attempt to open airways and support chest
– Helps to reinstate normal dome shape of diaphragm
Inspection – Sputum
▪ Sputum, if present, should be examined
– Colour
– Volume
– Type
▪ Check for presence of blood (haemoptysis)
▪ Consider aspiration and presence of food/fluids
Palpation
▪ Chest expansion
▪ Apex beat
– Performed during cardiovascular assessment
▪ Fremitus
▪ Ribs
▪ Regional lymph nodes
▪ Subcutaneous air
– Crepitus
Percussion
▪ Percussion is performed for different reasons
– Produce sounds
– Perform physiotherapy
▪ Sounds determined by density of underlying structures
– Dull / Flat
– Resonance
– Hyper resonant
– Tympanic
Auscultation
● Ideally to be done in sitting position
● Auscultate symmetrically
● Note the character and type of breath sounds
● To assess breath sounds, ask the patient to breather in and out slowly and deeply through the mouth
● Begin at the apex of the each lung and zigzag downward between intercostal spaces. Listen with the diaphragm portion of the stethoscope.
Abnormal breath sounds
▪ Stridor is an abnormal breath sound that occurs when there is a blockage in the upper airway, typically in the larynx or trachea.
▪ Wheezes are abnormal breath sounds characterized by a high-pitched, whistling sound that occurs during expiration.
▪ Rhonchi is an abnormal breath sound characterized by a low-pitched, continuous, and snoring or rattling sound during breathing.
▪ Abnormal breath sounds “rales” refer to crackling, bubbling, or rattling noises heard during breathing.
▪ Abnormal breath sounds called “crackles” may be an indication of fluid in the lungs, such as in pulmonary edema or pneumonia.
Obstructive
● Obstructive lung diseases obstruct the flow of air out of the lungs.
● In other words, these genre of diseases cause a problem with the exhalation phase of the breathing cycle.
● The lung tissue loses its recoiling capabilities and thus, finds it difficult to push air out during exhalation.
● “Air trapping” occurs and the lungs appear like over-inflated balloons.
● Examples: Asthma, emphysema, chronic bronchitis etc.
Restrictive
● Restrictive lung diseases are quite the opposite. This type of disorders restrict the flow of air into the lungs. So, the problem is with the inhalation phase of the breathing cycle.
● The lung tissue develops scars (just like how our skin scars after a cut or a bruise). The scarring makes the lung unyielding to the incoming air. The total lung capacity reduces and the lungs appear as rigid, under-inflated balloons.
● Examples: Any diseases that cause deposition of fibrous tissue in the lungs. Fibrous tissue forms scars. Tuberculosis, pneumonitis, acute respiratory distress syndrome, etc.
Nebuliser Mask
● A nebulizer mask is a medical device used to deliver medication directly to the lungs by converting liquid medication into a mist that can be inhaled.
● It consists of a small cup that holds the medication, a compressor or air source that creates a stream of air to atomize the medication, and a mask that fits over the nose and mouth to allow the patient to inhale the mist.
● The nebulizer mask is typically used to treat respiratory conditions such as asthma, chronic obstructive pulmonary disease (COPD), and bronchitis.
Chest Physiotherapy
▪ Chest physiotherapy involves techniques to improve breathing by removing mucus from the airways
▪ Mucus reduces airway diameter, increases airway resistance and promotes growth of microorganisms
▪ Chest physiotherapy is often utilised in asthma, chronic obstructive pulmonary disease (COPD) and after surgery
Effective Coughing
▪ Coughing helps clear the airway of excess mucus and facilitates opening of the airways
▪ The huff coughing technique is a series of coughs performed whilst saying the word “huff”
▪ This technique prevents the glottis from closing during the cough to facilitate removal of mucus
▪ Patient should be sitting upright to maximise airflow to the lung bases
Airway Suctioning
● Suctioning and aspiration of secretions through a catheter connected to a suction machine or wall suction outlet
● Rationale for suctioning include:
- to remove secretion that obstruct airway
- to facilitate ventilation
- to obtain secretions for diagnostic purposes
- to prevent infection that may result from accumulated secretions
● Although the upper airways ( oropharynx and nasopharynx) suctioning is not sterile, sterile technique is recommended for all suctioning to avoid introducing pathogens into the airways
Tachypnea
a condition that refers to rapid breathing
Bradypnea
abnormally slow breathing
Orthopnoea
discomfort when breathing while lying down flat
Dysponea
difficult or labored breathing; shortness of breath
Central cyanosis
a bluish discoloration of the skin or mucous membrane due to low oxygen levels in the blood
Peripheral cyanosis
when the hands, fingertips or feet turn blue because they are not getting enough oxygen rich blood
hypoxia
a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis
nasal prongs/nasal cannula
1-4L oxygen
22-45%
Risks:
- Pressure injury around the nares and behind the ears as well as corneal irritation is dislodged from nose
Nursing care:
- check the nares and behind the ears for pressure areas
- ensure skin hygiene is attended regularly. Apply moisturiser to lips
- consider lubricating eye drops. monitor for epistaxis (nose bleeding)
hudson mask/ simple face mask
6-15L oxygen
35-60%
Risks:
- Pressure injury to the bridge of the nose and behind the ear
- Claustrophobia from the mask. Accidental aspiration of vomitus
Nursing care:
- Check at the bridge of the nose and behind the ears for pressure areas
- Change the position of the strap to reduce pressure on the ears
- Monitor for epistaxis
non- rebreather mask/non-rebreather face mask
15L oxygen
60-90%
Risks:
- suffocation
- aspiration of vomitus
- pressure injury behind the ears and bridge of nose
nursing care:
- check bridge of nose and behind ears for pressure injury
- do not leave patient alone!!!
