Week 2 : Nursing interventions for patients with altered gas exchange Flashcards
concept extension : gas exchange
what is the basic concept of 02 and C02 and how it contributes to gas exchange?
02 is transported to the cells and C02 away from cells ( via the bloodstream)
what does gas exchange require interaction between ?
interaction between neurologic, respiratory, and cardiovascular systems
what are the 3 important terms we must know in gas exchange.
ventilation
diffusion
perfusion
what is the definition of ventilation?
the process of inhaling oxygen into the lungs and exhaling carbon dioxide from the lungs
what are some examples of altered ventilation?
COPD ( bronchitis ), cancer, chest trauma
what is the definition of diffusion?
the movement of gases down their concentration gradients across the alveolar and capillary membranes
what are some examples of altered diffusion ?
copd ( emphysema ) lung infection
what is the definition of perfusion?
the ability of blood to transport oxygen containing hemoglobin to cell and return carbon dioxide containing hemoglobin to the alveoli
what is this describing : the ability of blood to transport oxygen-containing hemoglobin to cells and return carbon dioxide-containing hemoglobin to the alveoli
perfusion
what are some examples of altered perfusion?
pulmonary embolism, heart failure
what is this describing : interruption of the blood flow into the lungs . BONUS : what is the biggest example.
altered perfusion
biggest example : pulmonary embolism
what are some important ideas when it comes to gas exchange ** sees in the slide **
hypoxia, and hypercapnia
decreased gas exchange results in what ? ( name one )
inadequate transportation of 02 to body cells ( hypoxia )
- results in cell necrosis and death
recall that decreased gas exchange results :inadequate transportation of 02 to body cells ( hypoxia )
- results in cell necrosis and death.
what else ?
build of c02 combines with h20 to produce carbonic acid . ( Hypercapnia )
- results in respiratory acidosis and acid base imbalance
what is the value that is considered as hypoxemia
( oxyegnation failure )
Pa02 < or equal to 60 mm Hg on 60% oxygen
what is considered ( value ) as a hypercapnic ? ( ventilatory failure )
PaC02> 45 mm hg and pH <7.35
what is a intrapulmonary shunt vs a dead space ventilation ?
intrapulmonary shunt
perfusion without ventilation ( V=0 )
description : decrease in ventilation such as pulmonary edema and ARDS
pneumonia or atelactasis
what does VQ stands for ?
ventilation for v
perfusion for q
what is considered as normal ?
v and q matched
what is a dead space ventilation ?
ventilation without perfusion ( Q = 0)
decrease in perfusion - segmental PE
decrease in pefison - massive pulmonary embolism , right to left shunt severe pulmoanry arterial hypertension ( PAH )
think about why your patient is short of breath. what is happening that is causing this ? name one exmaple set in the slides
pneumonia affects gas exchange because alveoli are filled with infectious fluid causing inadequate ventilation
recall : pneumonia affects gas exchange because alveoli are filled with infectious fluid causing inadequate ventilation. what else is happening that might be causing shortness of breathe of your patient ?
High cervical spinal cord injury has decreased ventilation due to damage to the spinal nerves that control the diaphragm.
what would be the cause of inadequate ventilation ? ( name one in the slides )
mva with chest being crushed by steering wheel
true or false. COPD is not an example of inadequate ventilation?
false, it is.
explain copd and how it can cause inadequate ventilation
secretions that can narrow the airway/destruction to the alveoli
altered ventilation or diffusion is damaged
true or false. trauma / injury to function of the respiratory system
lung muscle itself ( this is going to cause problem to ventilation ) only coming in if the lung can expand
true
as we recall from last week recognizing , analyzing, prioritizng/planning, and taking action along with evaluating is important.
what should we look upon when we are recognizing those cues?
patient history
there age, and environment ( areas of high pollution, highly populated areas, extremes in weather, aging increases risk )
what elsee shoud we be recognizing as nurses when our patient has altered gas exchange ?
recall we know about patient history, age, and environment . What else ?
respiratory hx, smoking, vaping, drug use, travel, allergies
true or false. family hx and genetic risk ( questions such as is their any respiratory illnesses that run in family ( asthma ) that we should know when it comes to recognizing cues to our pt who happen to have altered gas exchange ?
true
apart from recognizing the patient’s history what else is important ?
patient symptoms this is still apart of that recognizing cues and altered gas exchange.
what are signs of altered gas exchange ?
changes in RR, o2 sats, RR pattern
abnormal breath sounds
cough +/- sputum
dyspnea/orthopnea/chest pain
true or false. it is important to listen to bilateral and upper and lower lobes ( to hear airway entry )
true
true or false. a patient who has altered gas exchange , there breathing is worst when they lay own, therefore what should our non pharmacological intervention be ?
needing pillows to put their head up
what else are signs of altered gas exchange?
cyanosis, anxious ( could be red as well )
anxious/eyes are big
nervous
apart of recognizing cues : is analyzing data
what would you look for in your assesment ?
vital signs
inspection
palpation
is there any work of breathing ?
recall that within recognizing cues comes with analyzing data
what type of diagnostic tests should we be looking at for someone who has an altered gas exchange ?
ABGs
cbc ( rbc, hgb)
sputum culture
skin ( tb )
imaging ( cxr, Ct, Vq scan )
bronchoscopy*, thoracentesis
true or false. symmetry , should expand symmetrically ( if not further investigation is required) bonus: what could this indicate?
true and could indicate trauma
what is this describing ? common test to see a respiratory disroder
thoracentesis
define the scientific deinfition for thoracentesis
needle aspiration of pleural fluid or air from the pleural space
what could be happening if there is fluid in the pleural space?
interfering with ventilation if there are fluid pressing on them
what is alectasis?
collapsed of the lung
what could be happening post procedure ( thoracentesis )
cxr
vital signs ( make sure there is air entry , make sure to check bilaterally )
assess lung sounds
risks : infection, tension pneumothorax
why would we want a chest xray after thoracentesis?
to see if anything is damaged
what position would help breathe better for a pt?
tripod position ( leaning over the bedside table )
what is tension pneumothorax?
opening in the pleural space in which allows air in , causing it to collapse - this is a big respiratory problem
what is the worst case scenerio that could happen to a pt who has an altered gas exchange?
worse case scenario is resp failure
resp failure could be due to what ?
ventilation failure, oxygenation failure or combination of both
what are mild, moderate, and severe impairment like ?
mild impairment –> changes to vital signs
moderate impairment –> changes to blood work
severe impairment –> changes to tissue perfusion
what could we do as inteventions when we have mild impairment ?
change position
for a moderate impairment we could measure P02 by abg
true
for severe impairment what do we see?
changes in tissue perfusion ( things like cyanosis )
what stats drops too much - changes in _____ can indicate what ?
blood work ( hypoxemia )
the value we consider is sats below 92%
P02 is less than 60
what is an example of urgent problem ?
pulmonary embolism
what is pe ?
blockage of pulmonary artery by thrombus ( dead space )
commonly caused by dvt that breaks off and travels to lungs
what can pe be caused by ?
caused by fat embolism, can cause by air, commonly the reasonhas dvt and broke off and travelled to the lungs
what are the symptoms of pe
sudden onset of dyspnea, stabbing chest pain, apprehension, restlessness, cough, hemoptysis, crackles, abnormal lung sounds, diaphoresis, increase in RR, increase in HR, increase in temp, and decrease in 02 sats , petechiae over chest
true or false. decrease air entry in one entry , crackles can be caused by fluid. there is fluid due to inflammation as damage tissues causes inflammation.
true
why might you be feeling sharp and stabbing chest pain when you have pe
this is ishcemia ( we have it in the lungs ) there is tissues that is not getting perfusion
altered gas exchange : take action
what can we do ?
there are 5 things we need to remember
- optimize oxygenation
- optimize ventilation
- administer medications
- manage secretions
- optimize nutrition
what should we do if the gas exchange is not working , and we need intervention
oxygen
nasal prongs
face mask
bag with non debrief
[pressurize oxygen
do not add humidity to non debrief
what is a pressurize oxygenation
force into the lungs, into the airways if none has worked based on the oxygenation saturation
optimizing oxygeneation is important what undergoes this characteristic ?
monitor oxygen saturation , supplemental oxygen as needed
nasal prongs–> masks
what should u do if u are increasing the oxygen of your patient
if you are increasing their oxygen , you need to notify someone ( that pt is detoriating )
Which statements about oxygen and oxygen therapy are true? Select all that apply.
* A. Clients must provide informed consent to receive oxygen therapy.
* B. Excessive oxygen use is a contributing cause of chronic obstructive pulmonary disease.
* C. In nonemergency situations, a health care provider’s prescription is needed for oxygen therapy.
* D. Oxygen can explode when handled improperly.
* E. Oxygen is a beneficial element but can harm lung tissue.
* F. Unless humidity is added, therapy with oxygen dries the upper and lower mucous membranes.
c, e, f
The nurse is caring for a client with a possible pulmonary embolism who has symptoms of chest pain and difficulty breathing. The nurse assesses a heart rate of 142, BP 100/60 mm Hg, and respirations of 42 breaths/minute. Which of the following actions should the nurse implement first?
a. Elevate the head of the bed to 45–60 degrees. b. Administer the ordered pain medication.
c. Notify the client’s health care provider.
d. Offer emotional support and reassurance.
a
altered gas exchange : take action
what can we do ?
what undergoes optimizing ventilation
positioning
breathing techniques
incentive spirometry
exercise therapy
mechanical ventilation
surgeries/procedures
what is the best position that allows for maximum lung expansion?
tripod position
what is the prone position?
lying face down
name some breathing techniques we can utulize for an altered gas exchange patient
purse lip breaathing, trying to slow down their breathing
what does incentive spirometry mean ?
this is for pneumonia or collapsed airway ( not expanding their lungs ) so they have a higher risk of alectasis or penumonia therefore this helps
what is pulmonary rehab ?
maximize the muscle they have
what is huff breathing?
slow deep breaths and the huff is the exhalation
trying to gett excretion of the lungs ( mobilize ) usually ppl with copd
what is mechanical ventilation
they can become depenent so we hesitant on doing this
muscle weaken even more if they are dependent
what are some procedure/surgeries that increase ventilation
tracheostomy ( alternative way )
thoracentesis ( remove fluid from around lung )
chest tube ( drain fluid/air from around lung )
true or false. lung volume reduction surgery can help increase ventilation?
bonus : how does this help?
remove hyper inflated lung tissue containing stagnant air where no gas exchange occurs
true or false. trancheostomy can be permanent or temporary ( inflammation adn osbstruction in the upper airway not adequate ventiation )
true
true or false. for lung volume reduction surgery ( gas exhcange is not occuring and when that part is gone that kung tissue is working can actually expand )
true
what type of medication can we adminsiter ? ( name 3 )
antibiotics - amoxicillin rifampicin
SABA’s/LABA’s- Ventolin/Serevent
* Anticholinergics- Atrovent
- Anticholinergics- Atrovent
- Corticosteroid: Fluticasone
- Diuretics: Furosemide
- Analgesics: Morphine, Fentanyl
can be use to administer medication
for altered gas exchange
true
how do we consider to take iv or oral ?
depends on the severity of the infection , need supplemental oxygen or more supportive care ( works quickly )
what is rifampicin ?
treat lung infection ( contagious ) or tb
recall that managing secretions is important when a pt has altered gas exchange, what undergoes this ?
db & C
suctioning
hydration
where do we suction?
in the mouth or the nose back of the throat for children ( down a breathing tube )
true or false, drink 2 a day to thin secretions ( so no airway contractions )
true
what is our pt typically when they have altered gas exchange ( hint talkng abt a weight )
malnourish
optimizing nutrtion is important in taking action what undergoes this
rest before meals
bronchodilator prior to meal
frequent small meals
high calorie, high protein
altered gas exchange : evaluate/educate
did it help ?
give 3 ( keep in mind thsi si a chronic illness )
pace and plan adls with rest periods ( conserve energy conversation require may be reduced to imporve lung health )
encourage smoking cessation
promote hand hygience and stay away from corwds
true or false. Review medication schedule and understand their use and how to take inhalers properly.
Exercise using pursed lip breathing. Walking daily for 20 min is best.
true
can infection lead a person with altered gas echange to the hospital ?
yes
true or false. if symptoms are not improoving ( medications may need to be stronger or different )
true
cancer in RESP tract
exemplar :1 upper airway - laryngeal
what does early stages look like and what about late stages
Early stages
* Lump in neck, sore throat, hoarseness
Late stages
* Pain, dysphagia, airway obstruction, * SOB, Weight loss, unilateral ear pain, numbness
stridor and wheezing is not present in the early stages of cancer in resp system
false it is
where canu find wheezing and stridor
lower down for wheezing
stridor for upper
true or false. laryngeal cancer
early cancer not a lot of symptoms ( laryngeal nerve can cause hoarseness )
changes in the boice may be seen more symptomatoc
true
Lower Airway- Lung
cancer in resp system
Symptoms appear late in the disease process.
* persistent cough, blood tinged
sputum, wheezing, chest pain, weight loss, dyspnea
sign of pulonary emoblism ( blood tinged sputum ) ***
how do we know if its cancer or pe ?
vital signs
ct scan
cancer comes on slowly ( not sudden change )
why is it only unilateral ear pain
nerves is damaged
pe is more stable with vital signs and cancer is not
false the other way around
what is worst case scanerio for someone who has cancer in resp system
airway obstruction
what would this look like ?
** airway obstruction **
stridor
acc muscle use
wheezing
restlessness
tachycardia
cyanosis
which one would be more concering , inspiration or expiration when it comes to airway obstriction on someone who has cancer in resp system ?
inspiration is more concerned ( the progression is inaudible or audible )
if i can hear wheezes with stehoscope but if not then thats worst ( in distress )
cancers in respiratory tract are treated with one or combinatin of the following medical interventions
radiation
chemo
biotheraphy
laser surgery
surgery
ppl are at risk for thick secretion ( which can worsen airway ) when they have cancer in resp trat , how can we manage ?
by managing their secretions through suctioning and hydration
what is a surgery for laryngeal cancer
entire larynx/vocal chords removed
permanent stoma created in neck
require alternate method to talk
is there a such thing such as a partial surgery for laryngeal cancer?
yes
altered gas exchange : nursing inteventions post partial laryngectomy
optimizen oxygenation
optimize ventilation
- position midline/HOB elevated ( for positioning keep it midline –> keep it elevated ( secretions to drain)
adminiter medication
-pain medication
exemplar: cancer in resp system
nursing interventions post partial laryngectomy
re-call that optimizing oxygenation, optimize ventilation ( position midline/HOB elevated )
adminsiter medication ( pain medication )
what else?
manage secretions
- suction to keep stoma clear
optimize nutrtion
- prvent aspiration
-npo for 24-48 hours then tube feed
- must re-learn how to swallow
physio ( prevent frozen shoulder )
true or false. emotional support ( risk for depression can be seen with post partial larygectomy therefore managing this is also important.
true
what would be normal that can look like a risk when we are trying to manage secretions? ( in post partial laryngectomy )
blood tinged would be normal since there is trauma, suction very frequntly so there is an open airway
true or false. neevr go back to a full diet - becasue swallowing might be a problem ( post partial laryngectomy )
true
altered gas exchange : exemplar #1 cancer in resp system
what undergoes voice restoration/voice rehabilitation
vocal cords gone
communicate using pen/paper or communication board immediately post op
define if these undergoes the voice restoration/voice rehabilitation
possible options for voice restoration
- electrolarynx
-esophageal speech
-prosthetic voice device
all
what does electrolarynx
esophageal speech
prosthetic voice device
they talk using esophagus
forcing air up learning how to make sounds
acts like a voice box
exemplar #1 : cancer in resp system
what undergoes stoma
nutrition
define the description
stoma- airway safety
- cover for protection
-humidification
nutrition
- difficulty with eating/chewing
-can’t smell
what undergoes environmental hazards/safety for altered gas exchange ( someone who has cancer in resp system )
smoke detectors, medic alert bracelet, when to seek help
psychological support for altered lifestyle.
altered gas echange : take action
exemplar #1 : cancer in resp system
a) surgery for lung cancer
a) thoracotomy with b ) lobectomy
what is the description
(a)Surgical opening into thoracic cavity, part of lung removed, incision is large and cuts into bone, muscle, and cartilage
(b) removal of one lobe of lung, most common lung sx
- Pt will have postoperative insertion of chest tubes
post op care for thoracotomy
what should we monitor ?
monitor respiratory status
monitor chest tube
position changes ( semi fowlers or up in chair as soon as possible )
so recall
o Monitor respiratory status– treat hypoxia with O2
o Monitor chest tube and collection device
o Position changes (semi fowlers or up in chair as soon as possible)
is important in post op care for thoracotomy
what else?
assist with db & c / incentive spirometry, encourage early mobility
optimal pain management
monitor for s/s infection at surgical site or of pleural fluid ( empyema)
what does incentive spirometru prevent ?
to prevent alectasis
what is empyema ?
infection inside the pleural space- drainage into the chest tube
what is thoracotomy ?
drain from the fluid cavity without air going back in
exemplar #1 : cacner in resp system
what is emphysema and empyema
emphysema - damage to the lung ( alveoli damage )
empyema - infection
what are some discharge teaching for lung cancer
signs and symptoms of progression, recurrent disease, when to seek medical care
- home oxygen - safe use
-encourage smoking cessation ( patient and family )
- pain management
-palliation ( cannot cure switch modes to palliative care )
altered gas exchange : what is the second exemplar ?
thoracic trauma ( pulmonary contusion )
what is thoracic trauma ? ( pulmonary contusion )
common chest injury that occurs in car crashes where hemorrhage and edema occur in and between alveoli
what are cues of thoracic trauma ( pulmonary contusion )
decreased breath sounds crackles and wheezes over affected area, brusing, tatchy, tatchypnea
true or false. thoracic trauma can lead to resp failure if severe
true
what is the treatment for thoracic trauma (pulmonary contusion )
bruise resorption sometimes occurs without treatment. Oxygen, iv fluids, increae HOB . if severe may need ventilator in ICU.
name an example of a thoracic trauma ( pulmonary contusion )
gunshot wounds or stab wound
reduced ventilation is seen when respiratory failure is severe ( not taking enough deep breaths )
true
If sat is not high enough (may need fluid if blood if lost)
true
whats another exemplar for altered gas exchange
chest trauma ( flail chest )
what is chest trauma ( flail chest )
results from multiple rib fractures, causing instability of the chest wall
what are the cues for chest trauma
paradoxical chest movement
- during inspiration, the affected portion is sucked in, and during expiration, it bulges out
- prevents adequate ventilation of the lung in the injured area
true or false. If its unilateral paradoxical chest movement
true
what is the treatment for chest trauma ( flail chest )
oxygen, pain control, DB & C, ribs will heal on own in time
- may require ICU and intubation
what is chest trauma (hemo/pneumothorax)
presence of air/blood in the pleural space
what are the three different kind of presence of air/blood in the pleural space ( chest trauma ) hemo/pneumothorax
closed or open pneumothorax
tension pneumothorax
hemothorax
what is a closed pneumothorax?
when we have air inside that pleural space but no trauma
what is an open pneumothorax
stab wound, lung collapses
what is tension pneumothorax?
significant one ( air pressure ) collapsing the lung, affecting the heart ( cardiac output )
what is the best way to evacuate any extra air ?
ches tube - it allows chest to expand
what are the cues for small chest trauma ( hemo/pneumothorax )
mild tatchycardia and dyspnea
what are the cues for large chest trauma ( hemo/pneumothorax )
respi distress, including shallow, rapid respirations, dyspnea, air hunger, decreased oxygen saturation, no breath sounds on ausculation
what is a tension pneumothorax ( this is still considered as a chest trauma )
medical emerg
what is chest trauma ( tension pneumothorax )
- medical emergency
rapid accumulation of air in pleural space ( air enters during inspiration and does not exit ), causing mediastinal shift leading to pressure on vena cava/aorta
what is the cues for chest trauma ( tension pneumothorax )
inadequate cardiac output
hypoxemia
death
negative impact on the cardiac system
what are the signs
sudden drop
heart rate high
blood pressure low
oxygen levels low
if no intervention - cannot survive ( this is a medical emerg )
what would you if small hemothorax and patient is hemodynamically stable ?
no treatment is necessary
for larger pneumothorax or hemothorax or tension pneumothorax
chest tubes are inserted
for tension pneumo what do we do in terms of treatment
immediate aspiration of pleural space with large bore needle may be required until chest tubes can be inserted
what does chest tube do ?
chest trauma**
drain placed in the pleural space allows lung re- expansion and prevents air and fluid from returning to the chest
if you are trying to get rid of fluid are you looking at the top of the lungs or bottom?
bottom
what are the nursing interventions for COPD ex
exacerbation
supplemental 02 to maintain sats 88-92%
tripod position, breathing exercises
what type of medications are we giving copd patients as an interventions?
antibiotics, analgesia ( prn ), oral meds ( steroid ) –> systemic steroid may help with this exacerbation
true or false. it is not recommended to encourage 2L/day, meds to thin secretions for a copd patient, since it can cuase fluid overfluid.
false, it is encourage 2L/day, meds to thin secretions as a nursing intervention for copd exacerbation
what type of nutrients are we trying to give a copd pt
several small meals a day ( high calorie & high protein )
define if all the following are appropriate for a copd patient
Oxygen saturation stabilizes above 90%
Discharged on tapering dose of oral steroids
Education on COPD exacerbation triggers, inhaler technique, smoking cessation (if applicable), exercise therapy
all
bronscopy
is the insertion of the tube in the airway
what does bronscopy include
it can include View airway structures and obtain
tissue samples
true or false. bronscopy diagnose and manage pulmonary diseases?
true
pre procedure what are u looking for : bronscopy
cbc, plt, ptt, lytes, cxr, npo for 4-8 hrs
post procedure what are you looking for : bronscopy
monitor until sedation wears off
ensure gag prior to eating/drinking
what are the risks for bronscopy
risk of bleeding, infection, hypoxemia , hemoptosis
true or false. pts who have undergone bronscopy are more risk of what ?
falls because of sedation
in order to see if sedation has worn off what should we do in terms of bronscopy?
use a popsicle if it has been touched ( theyll gagged )
dont give them food or fluid ( need gag reflex to be intact
true or false. sticking a foregin object can cause bleeding becaue of perforation
( small risk ) but it is a possibility ( bronscopy
true
increasd work of breathing and increased in rr can be seen within bronscopy
true
is this a true statement ? whenever a tube goes down the airway or esophagus u worry about asipiration
gag reflex ( going down the throat ) for hthat reason we always fast people ( nopo) prior to these type of tests
true
