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What is included in the respiratory system and why is it important?
The upper airway, lungs, lower airway and alveolar sacs.
It is important in helping the body meet the need for oxygenation and tissue perfusion because the source of the oxygen for all body cells is the air we breathe.
Functions on the respiratory system
Ventilation- movement of air in and out of lungs.
Oxygen affinity is related to what?
How much do you breathe in and out of your lungs every minute?
6 liters of air.
What is the process in the oxygenation of blood?
1. Deoxygenated blood goes to the right side of the heart to the lungs.
2. The lungs oxygenate blood.
3. Oxygenated blood goes to the left side of the heart.
4. Oxygenated blood is them pumped to the tissue in the body.
What are the three steps of oxygenation?
-All organs, nerves, and muscles of the respiratory tract must be intact.
What are the interfering factors with oxygenation?
Coronary artery disease, blood volume depletion, inadequate blood flow, disease of the lungs, anemia, toxic inhalants, airway obstruction, fever, decreased chest wall motion.
What does the upper airway consist of?
The nose, sinuses, pharynx (throat) and the larynx (voice box).
What does the lower airway consist of?
Trachea, lungs, bronchi, alveoli, pleura
Excessive ventilation (fever)
Inadequate alveolar ventilation (atelectasis)
Inadequate tissue oxygenation (anemia)
a life threatening condition
decreased hemoglobin levels
diminished inpired oxygen
Poor tissue perfusion
S/S of hypoxia
- restlessness, apprehension, anxiety
- decreased ability to concentrate
- decreased LOC
- Increased fatigue
S/S of altered respiration
- behavioral changes
- Increased pulse rate
- Elevated blood pressure
- Increased respiration rate and depth
- Cardia Dysrrhythmias
- pallor. cyanosis
LIfe style changes for altered respiration
- reduce exposure to factors causing pulmonary disease
- Maintain ideal body weight
- Eat low fat, salt and calorie appropriate diet
- Engage in regular exercises
- Be smoke free
- monitor BP
- control cholesterol/triglyceride levels
- reduce stress and exposure to infection
How do you maintain respiration?
- Cough, turn, and deep breathe with early ambulation
- Cutaneous oxmetry
- Positioning q 2 hours
- adequate systemic hydration
breathing sounds that are musical in nature.
- bronchial and vesicular breathing
- high or low pitched
indicates that the airway is narrowed by a solid mass, mucus plug, bronchospasm or bronchial swelling. Narrowing may be more prominent upon expiration.
What do high and low pitched wheezing indicate?
High pitched- pathology within the smaller airways like the bronchioles
Low pitched- pathology within the larger airways like the main bronchi.
What are the most common causes for wheezing?
Asthma and COPD. (emphysema or chronic bronchitis) They result in episodes of wheezing with sounds of varying pitch and vlume. Causes of wheezing like lung cancer usually results in a wheee that is continuous and does not differ significantly in pitch since the obstruction is fixed.
What are the methods of oxygen delivery?
Venturi mask with reservoir bag
What are the benefits of oxygen?
Maintain a patent airway
keep a healthy level of tissue oxygenation
What will you hear with auscultation of lungs? Normal sounds
Bronchial(tracheal)- high pitch- harsh hollow sounds heard over the trachea and mainstem bronchi
bronchovesicular- moderate pitch- heard over the branching bronchi
vesicular- low, soft rustling sound heard in the periphery over small bronchioles.
What are 3 abnormal breath sounds?
Crackles- fine, coarse
Pleural friction rub
Wheeze (rhonchi)- high-pitch, low-pitch
occurs when a chronic hypoxia is present
normal nail bed angle= 160 degrees
As the client inhales, the hands move up and out symmetrically
abnormal- hands move asymmetrical
Palpation as the client says words that produce vibrations
Understand the care of a patient having a thorancetesis
- Withdrawal of fluid from pleural cavity.
- diagnostic and therapeutic reasons
- Needle in pleural space and extract air/fluid.
- Assess for hypovolemic shock, pain, nausea, pallor, diaphoresis, cyanosis, tachypnea, dyspnea.
- A chest x-ray is performed to rule out pneumothorax and medialstinal shift.
- Monitor VS and auscultate breath sounds.
- Check puncture site and dressing for leakage or bleeding.
- Urge pt to breathe deeply to promote expansion.
- Watch for emphysema.
- Subcutaneous emphysema- air in the subque layer that feels like rice crispies.
Assessing a patient after a bronchoscopy procedure.
- Provides a direct visualization. It is a tube looking at the bronchioles.
- Client is NPO for 6 hours prior
- Preop med is given and airway is anesthetized topically
- After the exam, evaluate for return of gag reflex and monitor to make sure sedation has resolved.
- Water for bleeding, infection and hypoxemia.
- Observe for complications like possible pneumothorax.
- Monitor VS including saturation and breath sounds every 15 minutes for the first 2 hours.
Prioritization and care of patient's having depressed respirations.
Lift the head of the bed up and give them oxygen.
Listen to lung sounds.
Give pulse ox to check oxygenation
Care of elderly with poor oxygenation.
- Expectations of the respiratory rate will be lower.
- Elevate HOB.
- Bipap- can wear when they are awake.
Assess pt with COPD and what type of questions to ask during history and physical?
- What caused it?
- Ask occupation.
- What makes is better/worse?
- Do they smoke?
- Assess lung sounds.
- a result of air trapped in the lungs causing a loss of lung elasticity and hyperinflation of the lung.
- inhalation starts before exhalation is complete.
- S/S dyspnea, increased respiratory rate and accessory muscles are used to breathe.
- Respiratory acidosis
Abnormal distention of the lower airways: bronchioles and alveoli
Tiny air sacs (alveoli) at the end of the bronchial tubes are damages, trapping air in the lungs. Leads to SOB and main symptom of emphysema
- Age 50-75
- Cachectic appearance
- pink skin color
inflammation of the bronchi caused by chronic exposure by irritants, especially tobacco smoke.
Increase in the size of mucous glands.
Bronchial walls thicken and impair airflow.
Main symptom is a cough that brings up mucous (sputum)
Hinders airflow and gas exchange because of mucous plugs and infection narrowing the airways.
PaO2 decreases (hypoxemia) and arterial blood carbon dioxide (PaCo2) increases causing respiratory acidosis.
- Age 40-50
- stocky build with no history of weight loss
- barrel chest
- increased secretions
- thickened bronchial walls
Complications of COPD
- oxygenation and tissue perfusion
- hypoxemia and acidosis- less able to exchange gas.
- respiratory infection- from increased mucous and poor oxygenation.
- Cardiac failure-cor pulmonale (right sided heart failure)
- Cardiac dysrhythmias-result of hypoxemia.
- decreased tissue oxygenation
- occurs from hypoxemia
low levels of oxygen in the blood.
assessment and S/S of COPD
- age, gender, occupation
- smoking history
- any breathing problems- difficulty breathing when talking.
- Assess cough pattern. Any sputum.
- Relationship between activity intolerance and dyspnea.
- Weigh the patient.
- Skin color
- changes in chest size/ fatigue
- slow moving/ slightly stooped
- rapid, shallow respirations
- respiratory movement is jerky and uncoordinated.
- barrel chest
- cyanotic, dusky appearance
- dependent adema in feet and ankles
Peak flow meter values
- Measures peak expiratory flow volume
- Normal is 300-7-- L/min
- Obtain base values for comparison
- is for asthma patients
- 60% and under is red. - go to the ER
- 60-80% is yellow. - need to rest
- 80% and up is green.- are fine.
Suctioning pts in clinical setting
- Hyperoxygenation before and after you suction.
- Dont suction for longer than 10 seconds.
- Give extra oxygen to prevent worse issues.
- Suctioning doesnt start until full insertion
- A minute between suctions
Nursing intervention for thick secretions
- Give water.
- Deep breathing and coughing
- Encourage deep breathing and IS
Know tips to teach pt for bronchodilators
- Inhalers. Take a minute apart. Brush your teeth after use of dry powder and steroids to prevent thrushing (mouth has white spots)
- Check expiration date
- Shake up
- hold it an inch or two away from mouth
- deep breath out. breathe in, press, keep breathing, hold for 10 seconds.
number of packs smoked per day multiplied by number of years patient has smoked.
SOB lying down but relieved by sitting up.
- blood in the sputum
- Often seen in lung cancer and chronic bronchitis
Lab tests uselful in assessing respiratory problems
- RBC count-transport of oxygen
- Arterial Blood gas- ABG- pH, bicarb and PaCO2.
- pH < 7.35 and PaCO2 > 45
- accumulation of CO2 which combines with water in the body to produce carbonic acid, which lowers the pH of the blood.
- Caused by any condition that results in hypoventilation : CNS depression from head injury or meds like narcotics, anesthesia, atelectasis, pneumoniz, pulmonary embolus, pneumothorax
- pH > 7.45 and PaCO2 < 35
- any condition that causes hyperventilation like anxiety, fear, pain, fever, sepsis, pregnancy, meds like respiratory stimulants, CNS lesions
Bicarb levels <22 and pH < 7.35.
Caused by a deficit of base in the bloodstream or an excess of acids, other than CO2.
Diarrhea and intestinal fistulas may cause decreased levels of a base.
Increased acids include:renal failure, diabetic ketoacidosis, anaerobic metabolism, starvation, salicylate intoxication
- Bicarb > 26 and pH > 7.45
- from an excess of base or a loss of acid within the body.
- Excess base occurs from ingestion of antacids, excess use of bicarb, or use lactate in dialysis.
Loss of acids can occur secondary to protracted vomiting, gastric suction, hypochloremia, excess admin of diuretics or high levels of aldosterone.
- Symptoms are neurological and musculoskeletal. Dizziness, disorientation, seizures, coma
- Weakness, muscle twitching, cramps and tetany.
- N/V, respiratory depression.
- Most difficult to treat
- Surgical opening into trachea
- Maintain airway over extended pd of time
- establish a method of communication
- maintain safety
- assess breathing
- maintain cuff pressure
- airways overreact to a stimulus which causes bronchospasm, edematous swelling of mucous membrane, alot of thick mucous.
- Notify physician if: anxiety, increased effort of respirations, continuous cough, respiratory distress- nasal flaring, accessory muscles, pursed lip breathing, cyanosis
- Chronic obstructive pulmonary disorder.
- group of long term, irreversible diseases that make is difficult to breath because air does not flow easily out of the ungs.
- Over time, it can worsen and lead to severe SOB, heart problems and death.
2 diseases generally associated are emphysems and chronic bronchitis. caused by smoking tobacco.
- Cannot be ccured. Only reliable way to slow disease is stop smoking.
- Meds and lifestyle changes reduce or relieve symptoms
- COPD exacerbation is a sudden increase in SOB and wheezing and possible an increased cough with out without mucous. Can be life threatening.
- Prevention of infections
- Low flow oxygen
- Balance of activities
- teach self care
Obstruction of a pulmonary artery caused by air, fat, or emboli
Treat: bed rest, oxygen, ventilator, anticoagulants
- Collapse of lung tissue
- develop when interference of lungs expanding
- Pleural effusion, tumor, pneumothorax
- chest wall disorder
- airway obstruction
- insufficient pulmonary surfactant
- increased elastic recoid
- Viral infection of respiratory tract
- Spread by droplet
- Sudden onset
- Causes fever, muscle aches and cough
Lobar pneumonia- consolidation in one lobe of one lung
Lobular or bronchopneumonia-patchy consolidation throughout lobes of one or both lungs
Treatment for communit- acquired pneumonia
- Outpatient or inpatient
- obtain culture specimen
- appropriate antibiotics
Assessment of pneumonia
- Pneumonococcal- sudden onset, chill, fever, chest pain, cough
- Staphylococcal- sudden onset, fever, chills, pain, cough
- Influenzal- cough, green sputum
- Gram-negative- sudden onset, high fever, chills, pain, dyspnea
- Anaerobic bacterial- low grade fever, dyspnea, crackles, cyanosis
- Legionnaires- fever, headache 48 hours, high fever, dyspnea
- Mycoplasma- slowly rising fever, headache, cough
- Viral- headache, myalgia followed by high fever, dyspnea, cough
- Fungal- usually asymptomatic, resembles influenza
- Parasitic- immunocompromised client, cough, dyspnea, chest pain, fever, crackles, night sweats
- Pus within the lung tissue
- Bad odor
- Sputum will have a foul taste
Treatment of tuberculosis
- 2 months of daily doses of isonaizid and refampin
- plus 1 or 2 additional drugs
Medications of tuberculosis
- First line drugs:
- Second line drugs:
TB skin testing
- 0-4 mm induraton is not significant
- 5mm or greater may be
- 10 mm or greater is significant
dysfunction precipitated by an obstruction of the exocrine gland ducts, causing thick mucous secretions
Pleural Effusion. what is it and causes
- Accumulation of fluid in the pleural space
- Causes: heart failure, liver or renal failure, infections or trauma, impaired lymphatic system
Collection of thick purulent fluid in the pleural space
procedure performed if the purulent fluid becomes solidified (fibrothorax), requires surgical removal
presence of air in the pleural space
Sucking chest wound
- Occurs when two or more adjacent ribs are fractured at two or more sites.
- During inspiration, the detached part of the rib segment moves in a paradoxical manner (pulled inward)
- On expiration, the segment will be bulging outward
- Mediastinum shifts.
RSV- Respiratory Syncytial Virus
- Inflammation of the bronchioles
- Transmitted by direct contact
- Treated with rest, fluids, high humidity and oxygen
Surgical management for respiratory disorders
- 1- Segmental resection- a lung resection
- 2- Wedge resection- removal of peripheral portion of small localized area of disease.
- Pneumonectomy- removal of the lung.
- the tip of the tube used to drain air is placed near the front of the lung apex.
- It drains liquid. Placed on the side near the base of the lung
- Covered with airtight dressing
Care of chest tubes
- Do not strip the chest tube
- keep drainage system lower than pt chest
- Keep tube straight as possible to avoid kinds and dependent loops
- Ensure tube is secured to connector
- Assess for bubbling in the water seal chamber. Should be gentle bubbling on patients exhalation
- Forceful cough position changes
Collaborative nursing diagnosis for respiratory
Potential for pneumonia or other respiratory infection
Best test for dehydration in older adult
sudden onset of confusion
used for acute heart failure.
given by IV push
In doses of 20-40 mg IV and decreased by 20 mg every 2 hours.
Na level below 136 mEq/L.
Sodium imbalances often occur with fluid volume imbalances because the same hormones regulate both sodium and water balance.
Problems caused by hyponatremia
Excitable Cell Membrane Depolarization- depends on high ECF levels of sodium being available to cross cell membranes and move into cells in response to a stimulus. It makes depolarization slower so that excitable membranes are less excitable.
Osmolarity of the ECF is lower than the ICF. Water moves into the cell, causing swelling. Large amounts of swelling can make the cell burst and die. (lysis)
What does ECF consist of?
- Blood, lymph, connective tissue, water, bone.
- 1/3 of body water weight
What does ICF consist of?
- 2/3 of body water weight.
- fluid within the cells
- serum sodium level > 145 mEq/L.
- Can be caused by or can cause changes in fluid volume. As sodium level rises, there is a larger difference between ECF and ICF.
More sodium is present to move rapidly across cell membranes during depolarization, making excitable tissues more easily excited. This is called irritability.
Water moves from the cell into the ECF to dilute the hyperosmolar ECF.
When serum sodium levels are high, severe cellular dehydration occurs.
- Major cation of ICF.
- Regulate protein synthesis and glucose use and storage.
- has some control over intracelular osmolarity and volume.
- Highest in meat, fish, veggies and fruit. Lowest in eggs, bread and cereal grains.
- 2-20 g/day.
- Occurs through kidney function. 80% of potassium is moved thorugh the body with the kidneys. It is enhanced by aldosterone.
- Is the main controller of ECF potassium level.
- The pump moves extra sodium ions from the ICF and moves extra potassium ions from the ECF back into the cell.
- The serum potassium level remains low and the cellular potassium level remains high. This also keeps the serum sodium level high and cellular sodium level low.
Causes of hyponatremia
diaphoresis, loop diuretics, NPO
S/S of hyponatremia
Weakness, low DTR, confusion
N & D, seizures when below 120
FVE: bounding pulses, possible pulmonary edema
may need osmotic diuretic FVD: weak pulse
Nursing Implications for Hyponatremia
monitor labs, IV fluids, I&O, V/S, neuro checks, hypertonic fluids
Causes for hypokalemia
- cushings (increased aldosterone)
- renal disease
- movement to ICF
S/S for hypokalemia
- rapid, irregular, thready and weak pulse
- orthostatic hypotension
- EKG changes
- shallow respirations
- flaccid paralysis
- abd distension
Nursing implications for hypokalemia
- Monitor respirations
- hold digitalis, diuretics or steroids
- NEVER GIVE K BY IV PUSH
- must be on pump and telemetry ( never exceed 20 mEq/Hr
- check labs
- assist with constipation
Causes for hypocalcemia
- renal failyre
- malabsorption syndrome
- low intake
- lack of sun
- meds like mithramycin, cisplatinum, dilantin
S/S for hypocalcemia
- Charley horses
- Muscular tremors
- hyperactive DTR
- tetany to seizures
- laryngeal spasm
Nursing Implications for hypocalcemia
Vitamin D, calcium supplements, maybe low magnesium, seizure precautions, monitor VS, tetany, labs (P, Ca, Mg, albumin)
Causes for hypophospatemia
Calcium high, malnutrition, low intake, prolonged vomiting, diuretic use, alcoholism and witdrawl, hyperparathyroidism, aldosteronism, pancreatitis, renal disease
Nursing implications for hypophosphatemia
Monitor for curcumoral parathesia, safety precuations for LOC, watch for high calcium, infection
S/S for hypophosphatemia
muscle weakness with pain and tenderness, anorexia, malaise, rapid shallow respirations, respiratory depression, CHF, seizures, increased bleeding, immunospasm
Causes of hypomagnesemia
GI fluid loss, malnutrition, malabsorption problems, alcoholism, meds like diuretics, antibiotics, antineoplastics, hyperglycemia, insulin, sepsis, alkalosis
S/S of hypomagnesemia
EKG change, dysrthmias, hypertension, shallow respiratoins, seizures, neuro symptoms like twitching, parathesias, hyperrefexia, tetany
Nursing implications for hypomagnesemia
Hold meds, supply IV magnesium sulfate, monitor EKG and respirations
Sodium - ICF or ECF- and why
- maintaining fluid and acid/base balance
Potassium - ICF or ECF- and why
- fluid balance, protein synthesis and regulate muscle contraction. 80% is lost in daily urine. (intake is important)
Calcium - ICF or ECF- and why
- in bone and teeth, coagulation, nerve impulses, muscle contraction, need Vitamin D to be absorbed, inverse relation to P.
Phosphorus - ICF or ECF- and why
- ATP, cell membrane integrity, absorbed in jejunum, excreated by kidneys, Carb, protein, lipid metabolism. when calcium is up, phosphorus is down.
Magnesium - ICF or ECF- and why
- 2nd most important
- protein synthesis
- neuromusclular process
Chlorine - ICF or ECF- and why
- Acid/base balance
- combines with ydrogen to form hydrochloric acid.
Causes for hypernatremia
- low H2O, hypertonic fluids or tube feedings
- severe dehydration
- long lasting high fever
- diabetes insipdus
S/S for hypernatremia
- low fever
- dry, sticky tongue and oral mucosa
- hypoactive or absent DTR
Nursing Implications for hypernatremia
- I&O, V/S, DW, neurochecks
- oral care every 2 hours
- skin assess
- monitor labs
- hypotonic solutions
Meds to treat hypernatremia
Hypotonic IV 0.225% or 0.15% sodium chloride
Causes for hyperkalemia
- renal failure, addisons adrenalectomy
- high potassium in the diet
- acidosis ( K shifts out of call and hydrogen goes in . try to buffer the low pH)
S/S for hyperkalemia
- irregulat, slow pulse
- EKG change
- muscle twitches and cramps
- hyperactive BS
- spastic colon
Nursing implications for Hyperkalemia
- emergency dialysis
- monitor EKG
- hold all K meds and inform MD
- diet restriction
Meds to treat hyperkalemia
- loop diuretics
- Dextrose (10 or 50%)
- IVP with regular insulin 10-25 units
- Na bicarb IVP
- Ca Gluconate for cardiac symptoms
Causes for hypercalcemia
- excessive intake
- renal failure
- adrenal insufficiency
- immobility and dehydration
- thiazide diuretic use
S/S for hypercalcemia
- increased BP
- pulses and bounding if caught early
- bradycardia and cardiac arrest if caught late
- diminished DTR
- high urine output with calculi
- decreased clotting time
- bone pain
Nursing implications for hypercalemia
- Monitor for pulmonary edema
- toxic dig level
- hydrate pt
- strain urine
- assess for flank pain
Meds to treat hypercalcemia
- Rocaltrol or Calcijex (calcifediol)
- PO4 binders
- IV calcium chloride or calcium gluconate
- Ca chlorids is 3x the doase of Ca gluconate. dilute in D5W
Causes of hyperohosphatemia
- Renal failure
- extra intake of PO4
- tumor lysis during chemo
S/S of hyperphosphatemia
- circumoral parathsia
- muscle spasms
Nursing implication for hyperphosphatemia
- seizure precautions
- Notify MD is S/S increase
- phosphate binders
- Ca supplement
Causes of hypermagnesemia
- high Mg intake
- decreased renal excretion
S/S of hypermagnesemia
- peripheral vasodilation
- EKG changes
- at risk for cardiac arrest
- reduced or absent DTR
- weakness of muscles
Meds to treat hypermagnesemia
IV magnesium sulfate or calcium
Fluid Volume Deficit
- decreased skin turgor
- dry membranes
- weight loss
- labs look normal
- poor urine output
Greater electrolytes lost
- diluted electrolytes
- increased labs
- neurological changes because of swelling
Greater H2O loss
- pittin gedema
- increase sensation of thirst
- hyperactive DTR
- Bun Creatinine and Albumin levels are increased
Fluid Volume Deficit
- neck and hand vein distension
- crackles in lungs
- pale and cool skin
- full and bounding pulse
- weight gain
- labs look normal
- 3-5 lbs daily is cause for concern
- risks for CHF and pulmonary edema (life threatening)
- water intoxication
- neuro changes
- Cells shrink
- cause by high sodium intake
- has pitting edema
Urine Specific Gravity
- 0.6-1.5 mg/dL
- better for renal function than BUN