Week 3: Oxygenation Flashcards
Assessment of the respiratory system includes:
ABGs
Breath sounds
Meds
PFTs
Structure & function
Common symptoms
Normal changes of aging
Respiratory risk factors
Physical exam
Diagnostic tests
Prednisone (Deltasone)
Action: synthetic corticosteroid that is effective as an immunosuppressant; decreases inflammation
Used to treat inflammatory diseases
Route: PO or IV
Side effects: weight gain, N/V, restlessness, insomnia, headache, thinning skin, GI ulcer formation, hyperglycemia, HTN, cushingoid appearance, opportunistic infection
Contraindications: pts with HIV, concomitant immune system disease because it suppresses the immune system
Proair, Ventolin, proventil (albuterol)
Action: synthetic sympathimimetic agent, beta 2 adrenergic agonist (relax bronchial smooth muscle), inhibits histamine release, produces bronchodilatation
Relief of bronchospasm
Route: PO/inhalation
Contradictions: pregnancy 🤰 category C (risk/benefit), lactation, children younger than 2 years
Albuterol continues
Precautions: CV disease, HTN, hyperthyroidism, DM
Side effects: tremor, anxiety, nervousness, restlessness, convulsions, headache, increased HR, palpitations, HTN, hypotension
Drug interactions: epinephrine, additive effect with other bronchodilators
Atrovent (ipratropium bromide)
Action: inhaled anticholinergics; produce a little bronchodilation by preventing bronchoconstriction
Route: inhaled
Side effects: memory impairment, confusion, hallucinations, dry mouth, blurry vision, urinary retention, constipation, tachycardia, increased intraocular pressure, acute angle glaucoma
Duoneb is a respiratory inhalant combo of 2 bronchodilators: albuterol sulfate and ipratropium bromide to open the airways usually in COPD
AsthmaNefrin (Epinephrine)
Action: nonselective adrenergic agonist. Increased activation of the sympathetic system; increased peripheral resistance via alpha 1 receptor-dependent vasoconstriction and increased cardiac output via binding to beta 1 receptors
Epinephrine/adrenaline is the drug of choice to treat anaphylaxis. Increased HR and facilitates bronchial dilation
Route: IV, SQ, IM, inhalation
Dose: variable depending on situation
Adverse reactions: palpitations, tachycardia, arrhythmia, anxiety, panic attack, headache, tremor, HTN, and acute pulmonary edema
Pulmicort (Budesonide)
Actions: bronchodilator
Inhaled corticosteroid for 6yo+
Route: sterile suspension for inhalation via jet nebulizer
Contraindications: should NOT be used to treat an acute asthma attack
Montelukast (Singulair)
Actions: Leukotriene receptor antagonist/ anti-inflammatory: leukotrienes released in response to inhaling an allergen; decreases asthma and allergy symptoms: reduces swelling and inflammation
Route: PO
Used for prevention and long-term Tx of asthma attacks in adults and children as young as 12
Side effects: headache, drowsiness, rash
Fluticasone (Flovent)
Action: corticosteroid with potent anti-inflammatory activity
Used for asthma
Dose: starting doses above 100mcg BID for adults and adolescents; 50mcg BID for children 4-11 yo; may be considered for pts with poor asthma control
Side effects: may mask signs of infection
Max benefit may not be achieved for 1-2 weeks or longer after starting Tx
Contraindications: in the primary Tx of status asthmaticus or other acute episodes of asthma where intensive measures are required
Organs/tissues needed for oxygenation
Lungs for oxygen intake
Heart for oxygen delivery
Blood vessels and RBCs for oxygen delivery
Respiratory defense mechanism
Nose and sinuses
Warm, humidify and filter: insensible loss = 250 ml/d
Larynx: closure of glottis ➡️ intrathoracic pressure (cough)
Lower airway: carina (landmark= angle of Louis); Right main stem bronchus, smooth muscles in bronchioles; terminal respiratory unit (resp, bronchioles➡️ alveoli): surfactant
A&P alterations in disease: inspiratory and expiratory muscles
Inhalation- active process
Includes:
Diaphragm (phrenic nerve)
External intercostals
Scalene muscles
A&P alterations in disease: intrathoracic pressure changes
Chest tubes and ventilators alter oxygen
Muscles of respiration
Sternomastoid muscles
Scalenes
Inspiratory intercostals
Expiratory intercostals
Diaphragm
External obliques
Expiratory abdominals
A&P alterations in disease: factors ➡️⬇️oxygen diffusion
⬇️ Atmospheric O2 (high altitude)
⬇️ Alveolar vent (obstruction/restrictive)
⬇️ Alveolar-capillary membrane surface area (emphysema, asthma, lung cancer, PE, thiracotomy)
⬆️ Alveolar-capillary membrane thickness (inflammation, pulmonary fibrosis, sarcoidosis)
A&P alterations in disease: control of respiration
Central and peripheral chemoreceptors:
Changes in PaCO2 affect CSF pH: ⬆️ PaCO2 ➡️⬆️rate and depth of ventilation
Changes in PaCO2 (60 mmHg) affect peripheral; hypoxic drive in COPD
Bronchoscopy
Flexible or rigid
Used to diagnose/manage pulmonary diseases
Insertion of tube into airways as far as secondary bronchi to view airway structures and obtain tissue samples for testing
The mallampati score
Class I: complete visualization of the soft palate
Class II: complete visualization of the uvula
Class III: visualization of only the base of the uvula
Class IV: soft palate is not visible at all
Upper airway anatomy
Air with oxygen enters the mouth/nose
Moves through airway: trachea, bronchi, bronchioles And into alveoli (air sacs)
Gas exchange
Interaction between neuro, cardio, and respiratory systems
Chemoreceptors in medulla sense increase in CO2
Impulse to diaphragm & intercostal muscles
Diaphragm contracts, pressure pulls in O2
Bronchial system
Carries blood needed to oxygenate lungs
DOES NOT participate in gas exchange
Pulmonary system
Highly vascular
RV into pulmonary artery (PA)
PA branches into arterioles
Forms capillary networks (that are meshed around and through alveoli)
Alveoli site of gas exchange
Capillaries to pulmonary veins to LA to LV to systemic circulation
Surface Area
Alveoli significantly increase the surface area of the lungs
Due to the many surface walls of the alveoli, the lungs have a surface area that is approximately the size of a tennis court
This large surface area allows for rapid gas exchange
Respiratory processes and partial pressure
Exchange of gases between alveoli and blood occurs to simple diffusion
O2 diffusing from alveoli into blood
CO2 from the blood into the alveoli
Diffusion requires a concentration gradient
The concentration (or partial pressure) of O2 in the alveoli must be kept at a higher level than in the blood
The concentration (or partial pressure) of CO2 in the alveoli must be kept at a lower level than in the blood
Continuously breathe in fresh air (with lots of O2 and little CO2) into the lungs and the alveoli
Surfactant
Decreases surface tension which:
Increase pulmonary compliance
Reduces tendency for alveoli to collapse
Variations in gas exchange
Ventilation: inadequate function(bone, muscle, nerve); lack of O2, poor gas exchange (PE, ARDS, pneumonia); narrow airways: bronchoconstriction (asthma), obstruction (bronchitis, cystic fibrosis)
Transport: availability of Hgb and ability to carry O2 (anemia)
Perfusion: ability of blood to transport Hgb (decreased CO, thrombi, emboli, narrow vessels, vasoconstriction)
Changes with Aging
Thoracic cage gets rigid from cartilage calcification, rib osteoporosis, kyphosis or arthritic changes in spine, increased A-P diameter
⬇️chest wall compliance -> loss of elastic recoil of lungs -> ⬆️work of breathing
⬇️muscle strength (intercostals/diaphragm) which alters lung volumes, inspiratory/expiratory force leading to weaker cough; can be reversed with exercise; ⬆️ residual volume, ⬇️forced viral capacity (VC), ⬇️FEV, ⬇️max voluntary ventilation, ⬇️peak expiratory flow
Alveoli less elastic and more fibrous (dyspnea)
⬇️alveolar-capillary membrane surface area leading to ⬇️diffusion capacity
Elastic recoil capacity ⬇️
Consequences of impaired gas exchange
Fatigue, ⬆️HR, RR, T
⬇️SpO2
CO2 transport from the cells to the alveoli lead to buildup of acid
Ventilation problem= respiratory acidosis
Transport/perfusion problem= Met Acidosis
Cellular ischemia, necrosis, death
Respiratory health history: Dyspnea
Breathlessness
Environmental irritants
Orthopnea
Post nasal drip (PND)
Respiratory health history: Cough
Productive/nonproductive
Pattern
Duration (>2-3 weeks?)
Associated with fatigue, SOB, fever?
Interfere with sleep?
Respiratory health history: sputum
Production changes:
Color
Consistency
Amount (normal is 100ml/day)
Respiratory health history: hemoptysis
Frothy
Alkaline pH & bright red
Not hematemesis- acidic pH
Respiratory health history: wheezing
Phases of respiratory cycle
Indicates obstruction
Respiratory health history: Chest Pain
COLDSPA
Respiratory health history: others and risk factors
Night sweats
Occupational and leisure activities
Risk factors: smoking, respiratory disorders, family history, environmental irritants, psychosocial history
Smoking history
Joint commission requires screening documentation and a Tx program be offered
Pack-years (cigarette smoking): # of packs smoked a day x years smoked
Note attempts to quit smoking
Exposure to second hand smoke
Other forms: cigars, pipes, smokeless tobacco, vapes, illegal substances
Normal respiratory pattern
Eupnea
12-20 breaths per minute
Fast respiratory pattern
Tachypnea
> 20 breaths per minute
Slow respiratory pattern
Bradypnea
<12 breaths per minute
Abnormal respiratory patterns
Apnea: absence of breathing
Hyperventilation (hyperpnea): increased depth
Cheyne-Stokes: crescendo/decrescendo respirations/apnea
Ataxic- periods of apnea
Kussmaul’s: rapid, deep, labored (air hunger)
Apneustic: gasping
Inspection
Shape and symmetry of thorax
A-P diameter
S/S of respiratory distress
Normal= 1:1.5 COPD= 1:1
Position of trachea, symmetry of chest expansion
Palpitation
Fremitus (vibration)
Crepitus (sq emphysema)
Percussion
Resonance- normal lung tissue
Dull- atelectasis, pneumonia, pleural effusion
Tympany- pneumothorax
Auscultation
“Normal” when heard in proper location
Abnormal:
Adventitious
Crackles
Rhonchi
Wheezes
Pleural friction rub
Respiratory Dx tests
CBC, ABG, D-dimer
Sputum analysis (organisms or abnormal cells). Best time is upon awakening after rinsing mouth
CXR:
Verify ett or catheter placement
Assess lung pathology: pneumonia, atelectasis, pneumothorax, tumor, pleural fluid
CT Scan/MRI: assess soft tissues, identify lesion or clot
Respiratory Dx Tests: VQ Scan
Ventilation and Perfusion (VQ) scan is a 2-part test:
- Ventilation scan
- Perfusion scan
No special post-procedure care
Respiratory Dx Tests: pulmonary angiography
Pre- & Post-procedure care
NPO, labs, allergy to contrast
Respiratory Dx Tests: Horowitz Index for lung function (P/F Ratio)
“P” represents PaO2 from ABG
“F” represents FIO2 expressed as a decimal (40% oxygen= FIO2 of 0.40)
P divided by F= P/F ratio
Rooms air is 20% (0.20) and each L/min of oxygen= +4% (0.04)
Respiratory Dx Tests: PFTs
Pulmonary function tests (PFTs) assess lung function and breathing problems; measure lung volumes, capacities, flow rates, diffusion capacity, gas exchange, airway resistance, distribution of ventilation
Restrictive vs obstructive disease
Tidal volume (Vt)- minute ventilation
Patient prep: no smoking 6-8 hours; no bronchodilators 4-6 hours
Forced viral capacity (FVC)
Volume of air forcibly exhaled from the point of max inspirations
Indicates muscle strength and ventilators reserve
Forced expiratory volume in one second (FEV1)
Records the max amount of air that can be exhaled in first second of expiration
Normal or increased with restrictive lung disease
Reduced with obstructive disease or age
FVC/FEV1= ratio that indicates obstruction to airflow
Thoracentesis
Needle aspiration of pleural fluid or air from the pleural space
Can be done at bedside or IR with assist of CT or U/S
Complications: SQ emphysema, infection, pneumothorax
Phlebotomy: arterial blood sample
ABG analysis assess:
Gas exchange Perfusion (PaO2) Alveolar ventilation (PaCO2)
Allen’s test (remember 5-15 seconds!)
Normal (positive): hand quickly becomes warm and returns to normal color after in-occluding the radial and ulnar arteries. This means one artery alone will be enough to supply blood to your hands and fingers
Abnormal (negative): hand remains cold and pale after in-occluding the arteries. This means that one artery is not enough to supply blood to your hand and fingers. Blood will not be collected from an artery in this hand
Respiratory Nursing Interventions: airway management
Positioning to improve ventilation and relieve dyspnea
Chest PT
DB&C (instruct and encourage)
Auscultation
Administer bronchodilators
Suctioning
Fluid intake
Respiratory Nursing Interventions: cough Enhancement
Assist pt to sitting position with head slightly flexed, shoulders relaxed, & knees flexed
Encourage pt to take several deep breaths
Encourage pt to take a deep breath, hold in for 2 seconds, & cough 2-3x in succession
Instruct pt to inhale deeply, bend forward slightly & perform 3-4 huffs (against an open glottis)
Instruct pt to inhale deeply several times, to exhale slowly, & to cough at the end of exhalation
Respiratory Nursing Interventions: Oxygen Therapy
Restrict smoking
Maintain airway patency
Administer O2 via humidified system
Monitor liter flow
Monitor effectiveness
Monitor skin breakdown
Educate
Upper airway problems
Rhinitis
Sinusitis
Acute pharyngitis
Acute follicular tonsillitis
Acute laryngitis
Laryngeal paralysis
Laryngeal edema
Pertussis
Bacterial infection
Bordetella pertussis
Highly contagious
Most dangerous for infants <1 year: 1 in 4 will get pneumonia; 1 in 2 will have a febrile seizure; 2 in 3 will have apnea
Pertussis disease progression
Stage 1: Catarrheal Stage (1-2 weeks): runny nose, low-grade fever, mild occasional cough; highly contagious
Stage 2: paroxysmal stage (1-6 weeks; may extend to 10): fits of numerous rapid coughs followed by “whoop” sound; vomiting and exhaustion after coughing fits (called paroxymsms)
Stage 3: convalescent stage (lasts 2-3 weeks; susceptible to many other respiratory infections): recovery is gradual; cough lessens but fits of coughing may return
Lower airway problems
Acute bronchitis
Pneumonia
COPD
Acute bronchitis
Inflammation of the bronchi and usually trachea (tracheobronchitis)
Occurs most often with persons with CLD
Extension of URI
Typically viral but can be bacterial or irritant
Treat symptomatically
Pneumonia patho
Colonization- growth of organisms other than normal flora without signs of infection
Oropharyngeal colonization: Normal- gram(+) and anaerobic Abnormal- gram (-) Available for aspiration Higher in hospitalized
Importance of oral care
Pneumonia continued
Acute inflammation of the lung tissue
Caused: infection, atelectasis, noxious inhalation, radiation
Patho: normal pulmonary defense mechanisms are impaired or overwhelmed, allowing microorganisms to multiply rapidly
Entry routes: aspiration (primary route), inhalation, hematogenous spread (proximity of pulmonary blood supply)
Pneumonia patho continued
Gastric colonization: Normally sterile ⬆️pH= ⬆️colonization ⬆️risk for oropharyngeal colonization Risk factors: enteral feedings, H2 blockers, antacids, aged
Contaminated Aerosols:
Respiratory & anesthesia equipment
⬇️ frequency of changing vent circuits
Lobar pneumonia
Consolidation in a segment or entire lobe of the lung
Bronchopneumonia
Diffusely scattered patches around the bronchi
Community Acquired Pneumonia (CAP)
Organisms: streptococcus pneumoniae; hemophilus influenza
Risk factors: Older adult No pneumococcal vaccination Exposure to respiratory viral or influenza infection Tobacco or alcohol use
Healthcare Acquired Pneumonia
Organisms: staph aureus, pseudomonas
Risk factors: Older adult CLD Gram (-) colonization of mouth, throat, stomach Altered LOC Aspiration Presence of ett, teach, or OG/NG Mechanical ventilator Poor nutritional status Reduced immunity Medications that increase gastric pH or alkaline TF
Pneumonia diagnosis
Symptoms
Assessment
Tests: CXR, ABG, pulse ox, CBC, blood culture
Fever, rigors, sweats, new cough with or without sputum, change sputum color, chest discomfort, onset of dyspnea
Pneumonia interventions
Preventative: hand hygiene, annual flu vaccine, pneumococcal vaccination (at 65 yo or chronic illness), no smoking, healthy diet, adequate hydration (3L water), avoid crowds, increase mobility, DB&C exercises, clean any respiratory equipment, avoid pollutants, adequate rest/sleep
Acute
Pneumonia prognosis
Prediction model
Demographic factors: age, gender, nursing home
Comorbid illnesses: neoplasm, liver, CHF, cerebral, renal disease
Physical finds: LOC, RR, ⬇️BP, high or low temp, ⬆️pulse
Lab finds: ⬇️pH, ⬆️BUN, ⬇️HGB, ⬆️glucose
Pneumonia complications
Respiratory failure
Lung damage
Sepsis
Pneumonia nursing care: ineffective airway clearance
NICs: airway management, cough enhancement (hydration, nebulizer, bronchi-active meds), positioning, respiratory monitoring
Pneumonia nursing care: impaired gas exchange
NICs: airway management, oxygen therapy, respiratory monitoring
Pneumonia nursing care: activity intolerance
NICs: energy management, self-care assistance
Pneumonia nursing care: imbalanced nutrition
Pneumonia Nursing Care NOCs
Activity tolerance
Nutrition status: energy, food and fluid intake
Respiratory status: gas exchange, ventilation, vital signs
Preventing hospital acquired pneumonia
DB&C, spirometer, ⬆️activity
Prevention of ventilator associated pneumonia (VAP)= “vent bundle”: HOB ⬆️30 degrees Oral hygiene Glucose control Gastric ulcer prophylaxis (thoughtful) Sub-glottic suctioning DVT prophylaxis Early mobilization Delirium assessment and prevention
Chest tube chambers
Chamber I: collects fluid draining from pt
Chamber II: water seal prevents air re-entry
Chamber III: suction control of system
