Week 2 - Respiratory Health 1 Flashcards
Functions of the Respiratory System
1) Ventilation
- Inspiration - bring air into lungs
- Expiration - expelling air from lungs
2) Gas Exchange
- Gas exchange With pulmonary capillaries occurs in alveoli
3) Regulation of pH and bodily fluids
- CO2 in blood effects body pH
- Respiratory rate influence the elimination and/or accumulation of CO2 in the body impacting pH of body fluids
4) Sound Production
- Passage of air through vocal folds of larynx generates sounds with variations in pitch (frequency) and amplitude (volume)
5) Olfaction
What are the 3 components of a Respiratory Assessment?
1) History
2) Physical Assessment
3) Lab Data
What is Involved in a Health History?
- Biographical data
- Health status/medical history
- Environmental factors
- Lifestyle factors
- HPI-OLD CARTSS
○ HPI - history of present illness
What is Involved in a Physical Assessment?
1) Inspection
2) Palpation
3) Auscultation
- Type of breath sound: bronchial, bronchovesicular, vesicular
Inspection
LOC
- Colour-skin, nails
○ If assessing cyanosis or pallor on a dark-skinned individuals, look beneath tongue
- Respiratory rate (12-20)
○ Bradypnea - RR < 12; if low, get them to sit up; drops the diaphragm and allows better chest expansion
○ Usually due to problem with SNS - Respiratory rhythm (regular/irregular)
○ If breathing is irregular: count for a full minute to ensure more accuracy
○ If documenting apnea, document how long apenic periods last - Mouth breathing, pursed-lip breathing
Palpation
- Chest expansion
- Tenderness
○ If there is tenderness, it points to a musculoskeletal problem rather than a resp one - Tactile fremitus
○ Holds hands over thoracic cavity in different places and ask to repeat “99”
○ Chronic conditions with fibrous lugs will be flatter and have less vibration - Masses
- Crepitus - escaped air under skin, feels like rice crispies
5 Adventitious Breath Sounds?
1) Wheezes
2) Rhonchi
3) Fine crackles (Rales)
4) Stridor
5) Pleural Friction Rub
Wheezes
- high-pitched, usually on inspiration, due to narrowed/inflamed airways
Rhonchi
- low-pitched wheezes, continuous, bubbling, due to secretions from inflammation, in large airways (sounds like snoring)
Fine Crackles
- brief, usually at end of inspiration, popping/cracking sound, due to fluid in alveoli, coarse crackles longer, louder than fine crackles
Stridor
- loud, high-pitched sound on inspiration, due to upper airway narrowing
○ Life threatening
○ Emergency treatment required
Pleural friction rub
- low pitched grating/crackling due to inflammation of pleura
○ Accompanied with pain
Normal Hemoglobin Values
Males: 140-180 g/L
Females: 120-160 g/L
Normal Hemogtocrit Values
Males: 0.42-0.52
Females: 0.37-0.47
What is an Acid Base Balance
- balance between input and output of hydrogen ions
-Acid: substance that releases H ions
- Base: substance that accepts H+ ions
Normal pH
pH: measure of concentration of H+
Normal pH: 7.35-7.45
- if pH drops (increase in H+) = acidosis (pH<7.35)
- if pH rises (decrease in H+) = alkalosis (pH>7.45)
How do the lungs maintain acid balance
- lungs take in O2 and expel CO2
- CO2 is acidic
How Lungs Adjust Breathing
* If blood too acidic (low pH), breathing rate & depth increases to expel CO2
* If blood too basic (high pH), breathing rate slows to retain CO2
How do kidneys maintain acid balance?
HCO3- is a base that neutralize acids in blood
Kidneys can:
-reabsorb HCO3
- from the urine back into the blood to maintain pH
- excrete (H+): remove excess hydrogen ions (excrete
them into urine)
- produce HCO3
- Process takes longer but effects are longer lasting
How is Hyperkalemia caused by an acid base imbalance?
If acidosis occurs:
- High H+ ions outside the cell move into the cell to balance pH
- In response, K+ moves outside the cell to balance electric forces ↑ serum K+
- ACIDOSIS CAUSES HYPERKALEMIA
How is Hypokalemia caused by an acid base imbalance?
If alkalosis occurs:
- H+ ion inside the cell move outside the cell to balance pH
- In response, K+ moves inside the cell to balance electric forces ↓ serum K+
- ALKALOSIS CAUSES HYPOKALEMIA
Arterial Blood Gas Values
- pH - 7.35-7.45
- PaO2 - 80-100 mmHg
- PaCO2 - 35-45 mmHg
- HCO3 - 22-26 mEg/L
Respiratory Acidosis
- Caused by any condition that depresses ventilation (more CO2 stays in body=acidic) (ex. pneumonia, atelectasis, sedating meds, head injury)
- Hypoventilation, shallow resps, low RR
- Increased CO2, H+, H2CO3
- Decreased pH
- Compensatory response to HCO3 - retention by kidneys
Respiratory Alkalosis
- Caused by excessive exhalation of CO2 (hyperventilation)- sepsis, anxiety, pain, fever, pulmonary embolism
- Hyperventilation, Increased RR
- Decreased CO2, H+
- Increased pH
- Compensatory response of HCO3− excretion by kidneys
Metabolic Acidosis
- Caused by increase in acid or decrease in HCO3
- due to starvation,
renal failure, dehydration, diarrhea, DKA, medications - pH decreases
- Compensatory response of CO2: excretion by lungs
Metabolic Alkalosis
- Caused by loss of acid or increase in HCO3
-. Most common cause is
vomiting. Also due to diuretic therapy, K+ deficit, excess NaHCO3 intake
- H+ decreases, HCO3 increases
- Increased pH
- Compensatory response of CO2; retention by lungs
What is Compensation
- Process by which compensatory mechanisms (respiratory/metabolic
systems) return pH toward normal without correcting underlying problem - Respiratory system compensates for disorders in metabolic system
- Metabolic system compensates for disorders in respiratory system
Uncompensated VS. Partial VS. Full Compensation
Uncompensated:
- pH abnormal
- 1 other measure
abnormal
- 1 measure normal
Partially compensated:
- pH abnormal
- other measures
abnormal + opposite
Fully compensated:
- pH normal
- other measures abnormal
+ opposite
Nursing Interventions in Acid-Base Balance
- Assess ABG (only way to detect imbalance, pH)
- Assess vitals - RR, heart rate/rhythm (remember impact on potassium)
○ Acid-base imbalance causes K imbalance - Assess electrolyte, BUN, creatinine, hematocrit (fluid status)
- Electrolyte, fluid replacement as needed
- O2 if required (if a resp problem)
- Look for underlying cause and treat (ie. Vomiting, diarrhea)
Nasal Prongs
- Fits into nose
- Delivers up to 6L/minute (4%/L)
Advantages
○ Can eat/drink while wearing
○ More comfortable
Limitations
○ Easily dislodged
○ Drying to nose
○ Not effective for mouth breathing
How to Determine Delivery System and Flow Rate
- Look at diagnosis/case of resp dysfunction
- General rule: lower the SpO2 and/or more difficulty breathing, the more supplemented oxygen required
- Oxygen is not a cure
○ Treat underlying condition causing hypoxia to manage and improve patient outcomes
What is/causes Respiratory Dysfunction?
- Disturbance in resp function (respiration, gas exchange)
- Dyspnea, abnormal rate, rhytmn, effort, inability to maintain normal SpO2, abnormal acid-base imbalance
Causes
- Infection (pneumonia, TB, etc) - Trauma (pneumothorax) - Pathological (COPD, ASTHMA, CANCER)
- Genetic (cystic fibrosis)
Nursing Interventions for Resp Dysfunction
- Elevate head of bed, tripod position
- Breathing techniques
○ Deep breathing and coughing (mobilizes secretions)
○ Sit up, breathe in through nose, hold for 10 seconds, breathe out through their mouth, repeat 4x, on 5th one, breathe in and cough out
□ If can not cough, try huffing (say huff and breath out)
○ Huffing - for clients who are in pain and can not deep breath - Maintain fluids - loosens secretions
- Asses SPO2, resp rate
- Auscultate lungs
- Apply oxygen PRN
- Suction PRN (to remove secretions)
- Consider meds to enhance breathing
- Rest between activities
- Manage anxiety
- Consider other causes of dyspnea
When would Oxygen be used?
- Conditions where ventilation of all areas of lung is impaired
- Conditions in which has exchange is impaired
- Conditions in which oxygen delivery to tissue is decreased
- Conditions in which cells are unable to use oxygen efficiently
Simple Face Mask
- Mask fits over nose and mouth
- Ventilation holes to allow cO2 to be exhaled
- Delivers up to 60%
Advantages
○ Provides moderate oxygen concentrations
○ Efficiency depends on how well mask fits and patients resp demands
Disadvantages
○ Confining feeling
○ Difficult to eat/drink while wearing
Non-Rebreather
- Simple mask with small reservoir bag attached to oxygen tubing connecting to flow meter
- Series of 1 way valves between the mask and the bag and covers on exhalation ports
- On inspiration, the patient only breathes in from the reservoir bag
- On exhalation, gases are directed out through the exhalation ports
Advantages
○ High flow
○ Delivers 60-80%
Disadvantages
○ Short-term use only
○ Risk of suffocation (if bag is not full of air)
○ Requires tight seal
Venturi Mask
- High flow system with mask, corrugated tubing
- Delivers up to 50%
Advantages
○ Delivers more precise flow
Disadvantages
○ Mask may be hot and confining
○ Interferes with talking and eating
○ Need a properly fitted mask
Nursing Care of Patients Receiving Oxygen
- Check flow rate and equipment at BEGINNING of every shift and whenever entering room for care
○ Oxygen is considered a medication- Assess resp rate frequency (q1-4 hours), depending on patient status
- SpO2 may be assessed continually or intermittently
○ Check skin integrity if probe on finger continuously, change location frequently to prevent skin breakdown
- Adjust oxygen delivery rate based on SpO2 changes in breathing
- Oxygen is drying - frequent oral care (q1-2 hours)
- Keep hydrated to loosen secretions (1500-2000mL/day)
- Monitor for nosebleeds (common for ppl with nasal prongs)
○ Check if someone is on anti-coagulants - Monitor for skin breakdown around mask, nares, chin, ears, head
- Tubing is a safety hazard - keep off floor, keep clean, check for proper positioning to avoid choking
- Significant decreases to O2 saturation levels or large increases to maintain O2 saturation should be reported to healthcare provider
- Changes in oxygen flow rates should be in 5%-10% increments
- Changes in L flow should be in 1 - 2 L increments
- Consider changing O2 delivery device if O2 saturation levels are not maintained at target range
- Do not pause oxygen therapy to transfer/ assist a patient out of bed
○ Mobility increases oxygen demand - Do not withhold oxygen in emergency situation if there is no order. Apply O2 THEN obtain the order
- Typical order for oxygen: titrate oxygen to keep SpO2 at or greater than 95% (may vary). Use clinical judgement
