Adult 2

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Adult 2
2011-10-22 22:59:14
nursing test

Module 1 exam questions
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  1. 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.
  2. Functions on the respiratory system
    Ventilation- movement of air in and out of lungs.


    Surface tension

    Musclular Effort

  3. Oxygen affinity is related to what?


    Body Temperature
  4. How much do you breathe in and out of your lungs every minute?
    6 liters of air.
  5. 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.
  6. What are the three steps of oxygenation?
    • Ventilation
    • Perfusion
    • Diffusion

    -All organs, nerves, and muscles of the respiratory tract must be intact.
  7. 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.
  8. What does the upper airway consist of?
    The nose, sinuses, pharynx (throat) and the larynx (voice box).
  9. What does the lower airway consist of?
    Trachea, lungs, bronchi, alveoli, pleura
  10. Hyperventilation
    Excessive ventilation (fever)
  11. Hypoventilation
    Inadequate alveolar ventilation (atelectasis)
  12. Hypoxia
    Inadequate tissue oxygenation (anemia)

    a life threatening condition

    decreased hemoglobin levels

    diminished inpired oxygen

    Poor tissue perfusion

    Impaired ventilation
  13. S/S of hypoxia
    • restlessness, apprehension, anxiety
    • disorientation
    • decreased ability to concentrate
    • decreased LOC
    • Increased fatigue
    • Dizziness
  14. S/S of altered respiration
    • behavioral changes
    • Increased pulse rate
    • Elevated blood pressure
    • Increased respiration rate and depth
    • Cardia Dysrrhythmias
    • pallor. cyanosis
    • dyspnea
  15. 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
  16. How do you maintain respiration?
    • Cough, turn, and deep breathe with early ambulation
    • IS
    • Cutaneous oxmetry
    • Positioning q 2 hours
    • adequate systemic hydration
    • humidification
  17. Wheezing
    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.
  18. 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.
  19. 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.
  20. What are the methods of oxygen delivery?
    Nasal cannula

    Simple mask

    Venturi mask with reservoir bag
  21. What are the benefits of oxygen?
    Expand lungs

    Mobilize secretions

    Maintain a patent airway

    keep a healthy level of tissue oxygenation
  22. 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.
  23. What are 3 abnormal breath sounds?
    Crackles- fine, coarse

    Pleural friction rub

    Wheeze (rhonchi)- high-pitch, low-pitch
  24. Clubbing
    occurs when a chronic hypoxia is present

    normal nail bed angle= 160 degrees
  25. Thoracic Excursion
    As the client inhales, the hands move up and out symmetrically

    abnormal- hands move asymmetrical
  26. Tactile Fremitus
    Palpation as the client says words that produce vibrations
  27. 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.
  28. 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.
  29. 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

    Check airway
  30. Care of elderly with poor oxygenation.
    • Expectations of the respiratory rate will be lower.
    • Elevate HOB.
    • IS.
    • Bipap- can wear when they are awake.
  31. Assess pt with COPD and what type of questions to ask during history and physical?

    • What caused it?
    • Onset/duration
    • Ask occupation.
    • What makes is better/worse?
    • Do they smoke?
    • Assess lung sounds.
    • Percussion
  32. Pulmonary Emphysema
    • 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
    • Tachypnea
    • pink skin color
  33. Chronic Bronchitis
    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
    • cyanotic
    • increased secretions
    • edema
    • bronchospasm
    • thickened bronchial walls
  34. 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.
  35. Hypoxia
    • decreased tissue oxygenation
    • occurs from hypoxemia
  36. hypoxemia
    low levels of oxygen in the blood.
  37. 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
    • clubbing
    • 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
  38. 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.
  39. 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
  40. Nursing intervention for thick secretions
    • Give water.
    • Deep breathing and coughing
    • Encourage deep breathing and IS
    • Mucolytics
  41. 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.
  42. Pack-years
    number of packs smoked per day multiplied by number of years patient has smoked.
  43. orthopenia
    SOB lying down but relieved by sitting up.
  44. Hemoptysis
    • blood in the sputum
    • Often seen in lung cancer and chronic bronchitis
  45. Lab tests uselful in assessing respiratory problems
    • RBC count-transport of oxygen
    • Arterial Blood gas- ABG- pH, bicarb and PaCO2.
  46. Respiratory Acidosis
    • 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
  47. RespiratoryAlkalosis
    • pH > 7.45 and PaCO2 < 35
    • any condition that causes hyperventilation like anxiety, fear, pain, fever, sepsis, pregnancy, meds like respiratory stimulants, CNS lesions
  48. Metabolic Acidosis
    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
  49. Metabolic Alkalosis
    • 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
  50. Tracheostomy
    • Surgical opening into trachea
    • Maintain airway over extended pd of time
    • establish a method of communication
    • maintain safety
    • assess breathing
    • maintain cuff pressure
  51. Asthma
    • 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
  52. COPD
    • 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.
  53. COPD treatment
    • Prevention of infections
    • Bronchodilators
    • Low flow oxygen
    • Corticosteroids
    • Balance of activities
    • teach self care
  54. Pulmonary Embolus
    Obstruction of a pulmonary artery caused by air, fat, or emboli

    Treat: bed rest, oxygen, ventilator, anticoagulants
  55. Atelectasis
    • Collapse of lung tissue
    • Cause:
    • develop when interference of lungs expanding
    • Pleural effusion, tumor, pneumothorax
    • chest wall disorder
    • airway obstruction
    • insufficient pulmonary surfactant
    • increased elastic recoid
  56. Influenza
    • Viral infection of respiratory tract
    • Spread by droplet
    • Sudden onset
    • Causes fever, muscle aches and cough
  57. Pneumonia
    Lobar pneumonia- consolidation in one lobe of one lung
  58. Lobular or bronchopneumonia-patchy consolidation throughout lobes of one or both lungs
  59. Treatment for communit- acquired pneumonia
    • Outpatient or inpatient
    • obtain culture specimen
    • appropriate antibiotics
  60. 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
  61. Lung Abscess
    • Pus within the lung tissue
    • Bad odor
    • Sputum will have a foul taste
  62. Treatment of tuberculosis
    • 2 months of daily doses of isonaizid and refampin
    • plus 1 or 2 additional drugs
  63. Medications of tuberculosis
    • First line drugs:
    • Isoniazid
    • Rifampin
    • Rifapentine
    • Second line drugs:
    • Capreomycin
    • Ethionamide
  64. TB skin testing
    • 0-4 mm induraton is not significant
    • 5mm or greater may be
    • 10 mm or greater is significant
  65. Cystic Fibrosis
    dysfunction precipitated by an obstruction of the exocrine gland ducts, causing thick mucous secretions
  66. 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
  67. Empyema
    Collection of thick purulent fluid in the pleural space
  68. Decorticaton
    procedure performed if the purulent fluid becomes solidified (fibrothorax), requires surgical removal
  69. Closed pneumothorax
    presence of air in the pleural space
  70. Open pnemothorax
    Sucking chest wound
  71. Flail chest
    • 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.
  72. RSV- Respiratory Syncytial Virus
    • Inflammation of the bronchioles
    • Transmitted by direct contact
    • Treated with rest, fluids, high humidity and oxygen
  73. 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.
  74. Chest tube
    • 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
  75. 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
  76. Collaborative nursing diagnosis for respiratory
    Potential for pneumonia or other respiratory infection