The right lung because the right mainstem bronchus is shorter, wider, and straighter than the left mainstem bronchus.
What is the actual site where oxygen and carbon dioxide exchange occurs?
The respiratory bronchioles
The volume of air exhanged with each breath.
Tidal Volume (Vt)
Normal - 500 mL
What is the primary site of gas exchange within the lung?
alveoli (small sacs in the lung)
Deep breaths promote air movement through these pores and assist in moving mucus out of the respiratory bronchioles.
Bacteria can also move through these pores leading to the spread of infection to previously non-infected areas.
Pores of Kohn
A lipoprotein that lowers the surface tension in the alveoli. It reduces the amount of pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse.
Surfactant
The term for collapsed, airless alveoli. Occurs when not enough surfactant is present.
atelectasis
Provides the lungs with blood for gas exchange.
Pulmonary circulation.
Starts with the bronchial arteries, which arise from the thoracic aorta.
Provides oxygen to the bronchi and other pulmonary tissues.
Bronchial circulation.
The membrane that lines the chest cavity.
The parietal pleura
The membrane that lines the lungs.
The visceral pleura.
Normally contains 20-25mL of fluid.
Provides lubrication, allows the pleural layers to slide over each other during breathing.
Increases cohesion between the pleural laers, thereby facilitating expansion of the pleura and lung during inspiration
Intrapleural space
Purulent pleural fluid with bacterial infection
empyema
What type of injury would result in hemidiaphragm paralysis on the side of the injury?
Injury to the spine at C3 and C5 because the phrenic nerves arise from those locations and they control the hemidiaphragm.
What would be the result of a complete spinal cord injury above the level of C3?
Total diaphragm paralysis and dependence on a mechanical ventilator.
The tendency for the lungs to relax after being stretched or expanded.
Elastic recoil
Is the process of expiration active or passive?
Passive, unlike inspiration which is active.
A measure of the ease of expansion of the lungs.
Compliance (distensibility)
What causes a decrease in compliance?
Conditions that make the lungs more difficult to inflate such as conditions that increase fluid (pulmonary edema, ARDS, pneumonia), conditions that make lung tissue less elastic or distensible (pulmonary fibrosis), and conditions that restrict lung movement (pleural effusion).
What causes an increase in lung compliance?
Conditions in which there is destruction of alveolar walls and loss of tissue elasticity (COPD)
The amount of oxygen dissolved in the plasma.
PaO2
The amount of oxygen bound to hemoglobin in comparison with the amount of oxygen the hemoglobin can carry.
SaO2
At what level is the patient considered adequately oxygenated?
PaO2 greater than 60.
What does the upper flat portion of the oxygen-hemoglobin dissociation curve represent?
The conditions in the lungs.
What does the lower portion of the oxygen-hemoglobin dissociation curve represent?
Oxygen binding by hemoglobin at the level of peripheral tissues.
What is happening when the oxygen dissociation curve shifts to the left?
Blood picks up oxygen more readily in the lungs, but delivers it less readily to the tissues.
What conditions causes a shift to the left in the oxyhemoglobin dissociation curve?
Alkalosis, hypothermia, and a decrease in the partial pressure of carbon dioxide in arterial blood.
What is occuring when the oxyhemoglobin dissociation curve shifts to the right?
blood picks up oxygen less rapidly in the lungs but delivers oxygen more readily to the tissues.
When would a shift to the right occur?
Acidosis, hyperthermia, and when PaCO2 is increased
What two methods are used to assess the efficiency of gas transfer in the lungs of a stable patient who is not critically ill?
ABG's and oximetry.
What is the normal level of pH?
7.35-7.45
What is the normal level of PaO2?
80-100 mmHg
What is the normal level of SaO2?
>95%
What is the normal level of PaCO2?
32-48mmHg
What is the normal level of HCO3?
22-26mEq/L
What factors can contribute to a lower PaO2?
advancing age and higher altitude
What is blood that is drawn from a PA catheter called?
mixed venous blood gas because it consists of venous blood that has returned to the heart from all tissue beds and mixed in the right ventricle.
How is the SpO2 level obtained?
via a pulse oximetry
What would a decrease in SvO2 indicate?
Less oxygen is being delivered into the tissues or more oxygen is being consumed. It may be an early warning of a change in cardiac output or tissue oxygen delivery.
A receptor that responds to a change in the chemical composition (PaCO2 and pH) of the fluid around it.
chemoreceptor
How does the medulla respond to an increase in the H+ concentration?
Acidosis is occurring and the medulla responds by increasing the respiratory rate and tidal volume.
How does the medulla respond to a decrease in the H+ concentration?
Alkalosis is occurring and the medulla responds by decreasing the respiratory rate and tidal volume.
What happens when the PaCO2 level is increased?
More CO2 is available to combine with H2O and form carbonic acid which lowers the cerebrospinal fluid pH and therefore stimulates and increase in the respiratory rate.
What happens when the PaCO2 level is decreased?
The pH level in the cerebrospinal fluid is increased and the respiratory rate is decreased.
As the lungs inflate, pulmonary stretch receptors activate the inspiratory center to inhibit further expansion. What is reflex called that prevents overdistention of the lungs?
The Hering-Breuer reflex
What receptors are stimulated by fluid entering the pulmonary interstitial space?
J receptors (juxta-capillary)
What factors impair ciliary action?
dehydration, smoking, inhalation of high oxygen concenrations, infection, and ingestion of drugs such as atropine, anesthetics, alcohol, or cocaine.
At what level is the cough reflex no longer effective?
below the subsegmental level secretions must be moved upward by the mucociliary mechanism before they can be removed by coughing.
How might the body respond to the inhalation of large amounts of irritating substances?
reflex bronchoconstriction
What is the primary defense mechanism at the alveolar level?
alveolar macrophages rapidly phagocytize inhaled foreign particles such as bacteria, and they are moved to the level of the bronchioles for removal by the cilia or the lymphatic system.
What might impair the body's alveolar macrophage activity and put the pt at higher risk for lung disease?
Smoking.
The patient has blood tinged sputum at the bedside, and states that he coughed it up. Upon testing, it was determined that the pH was acidic. Is it hematemesis or hemoptysis?
Hematemesis has an acidic pH, therefore the sputum was thrown up, not coughed up.
Rapid, deep breathing
Kussmaul respirations
abnormal pattern of respiration characterized by alternating periods of apnea and deep, rapid breathing
Cheyne-Stokes
Irregular breathing with apnea every 4 -5 cycles
Biot's respirations
If a tension pneumothorax or neck mass was present, to which side would the trachea deviate?
Away from the side of the occurence
If a pneumonectomy or lobar atelectasis was present, to which side would the trachea deviate?
Toward the side of occurrence.
low-pitched sound heard over normal lungs
resonance
loud, lower-pitched sound than normal resonance heard over hyperinflated lungs, such as in chronic obstructive lung disease and acute asthma.
hyperresonance
sound with drumlike, loud, empty quality heard over gas-filled stomach or intestine, or pneumothorax
tympany
sound with medium-intensity pitch and duration heard over areas of "mixed" solid and lung tissue, such as over top area of liver, partially consolidated lung tissue (pneumonia) or fluid-filled pleural space
dull
soft, high pitched sound of short duration heard over very dense tissue where air is not present, such as posterior chest below level of diaphragm
flat
Pt presents with barrel chest, cyanosis, use of accessory muscles, hyperresonant sound upon percussion, crackles, rhonchi, or wheezes are heard upon auscultation. What might they have?
COPD
Pt presents with prolonged expiration, they are sitting in the tripod position, and they are breathing through pursed lips. Hyperresonance is heard when the chest is percussed. Wheezes and decreased breath sounds are heard.
Exacerbation of asthma.
Pt presents with tachypnea, they are cyanotic and appear dusky, and they are using their accessory muscles to assist with breathing. Fremitus is increased. Dullness is heard upon percussion. Upon admission bronchial sounds were heard, a few days later crackles and rhonchi were apparent as well was egophony and bronchophony. What might they have?
Pneumonia
A dullness is heard upon percussion, crackles are heard upon auscultation, but disappear with deep breaths. What might this pt be experiencing?
Atelectasis
Pt presents with tachypnea and labored respirations. They are cyanotic, a dullness can be heard upon percussion, and fine or coarse crackles were initially at the bases of the lungs but have progressed upward. What might this be a sign of?
Pulmonary edema
Pt presents with tachypnea. They are using their accessory muscles to breath, dullness is heard when the chest is percussed, and lung sounds are diminished. What is this pt exhibiting signs of?
pleural effusion
Pt presents with tachypnea. Decreased movement is felt upon palpation of the chest, and crackles sounding like velco being pulled apart are heard. What might this pt have?
pulmonary fibrosis
If a patient is unable to expectorate spontaneously for a sputum sample, how might you assist them?
Sputum induction. Inhalation of an irritating aerosol, usually hypertonic saline.
How long before obtaining ABG's is it safe to suction the patient?
20 minutes. All changes in oxygen therapy or interventions should be avoided for 20 min before obtaining a sample.
What type of syringe should be used to collect blood in when obtaining an ABG sample?
heparinized syringe
After obtaining an ABG sample, you notice there are bubbles in the sample. Should you expel them?
Yes. expel all air bubbles and place the sample in ice to ensure accurate results.
After a sample is obtained for ABG analysis, what important intervention is necessary?
apply pressure to the artery for 5 minutes after the specimen is obtained.
How long does it take for the results of a culture and sensitivity to be obtained?
48-72 hours
What is the best time of day to obtain sputum samples for gram staining?
early in the morning after mouth care because secretions settle during the night.
When assessing sputum for acid-fast bacilli using an acid-fast smear and culture, how many samples are needed?
A series of 3 early-morning specimens are used.
When a sputum sample is obtained for cytology to determine the presence of abnormal cells that may contain a malignant condition, how many samples are needed?
a single sputum specimen is collected in a special container with a fixative solution.
Your patient is going to have a CT scan done. When discussing the procedure with the patient you ask them if they are allergic to shellfish, check their BUN and creatinine levels, inform them that they might experience a warming sensation, and instruct them to stay well hydrated before and after the procedure. Are you preparing them for a spiral CT scan or a high-resolution CT scan?
Contrast media is usually used for a helical or spiral CT scan.
Your patient is sent to have an MRI done to distinguish vascular from non-vascular structures. You discussed with them the warm sensation they might experience, and the need to stay hydrated, but you forgot to ask if they are allergic to shellfish. Should you call and have the radiology tech do it?
No, the contrast medium used is not iodine based.
Your patient has had a (V/Q) ventilation - perfusion done in which they inhaled radioactive gas to outline the alveoli. What precautions are needed afterward.
None, the gas and isotope only transmit radioactivity for a brief interval.
Your patient is going to have a pulmonary angiogram done. You ask them if they are allergic to shellfish, and afterward you encourage them to drink water to flush the contrast medium out, but what else should you do?
Check the pressure dressing site after and monitor their BP, pulse, and circulation distal to the injection site.
During a PET scan, an IV radioactive glucose preparation is used. In what type of cells is an increased uptake of the glucose seen?
malignant
After a PET scan, what nursing interventions are needed?
No precautions are needed because the isotope only transmits radioactivity for a brief interval, but you should encourage fluids to flush the substance.
Your patient is ordered to have a bronchoscopy done, what should you implement first?
NPO status! the patient must be NPO for 6-12 hours before the test.
After a bronchoscopy your patient complains of blood tinged mucus, should you give them water to help them flush the taste from their mouth before calling the doctor?
No, blood tinged mucus is not abnormal. The patient should remain NPO until the gag reflex returns, and they should be monitored for laryngeal edema. If a biopsy was done, monitor for hemorrhage and pneumothorax.
Your patient just had a TTNA done under CT guidance in radiology, what should you monitor?
Check breath sounds q4hr for 24 hr and report any distress. Also, check the incision site for bleeding.
After a TTNA is done, what should be done to assess for pneumothorax?
A chest x-ray.
After a VATs procedure, what might be done until the lung has re-expanded?
chest tube insertion. encourage deep breathing for lung reinflation and monitor breath sounds.
What should always be done after a thoracentesis?
Chest x-ray to check for pneumothorax.
What should you instruct your patient to do when preparing for a thoracentesis?
sit upright with their elbows on an overbed table and feet supported and not to talk or cough
xylocaine is instilled subcutaneously
What should you do after your patient returns from a thoracentesis?
observe for signs of hypoxia and pneumothorax, verify breath sounds in all fields, and encourage deep breaths to expand lungs.
When should you not schedule for pulmonary function tests to be done?
Immediately after mealtime or within 6 hrs of administration of a bronchodilator. (do not administer an inhaled bronchodilator for 6hr before the procedure)
Skin tests involve interdermal injection of what?
an antigen
In an HIV infected person, what size induration would be considered positive after a skin test?
> or = to 5 mm
In a low risk person, what size induration would be considered positive after a TB skin test?
> or = 15mm
A technique in which about 30mL of saline is injected through a scope and withdrawn to examine for cells.
BAL bronchoalveolar lavage
Can bronchoscopy be done on a mechanically ventilated patient?
Yes, through the endotracheal tube.
What 2 techniques are used to differentiate between infection and rejection in lung transplant patients?
a combination of transbronchial lung biopsy and BAL
What is the less invasive, procedure of choice for a lung biopsy?
VATS
A spirometry is ordered before and after the administration of a bronchodilator to determine the degree of response. What is considered a positive response?
an increase greater than 200mL or 12% between preadministration and postadministration.
During what situation can PFT's not be interpreted.
isolation. the entire clinical presentation must be considered.
What is the difference between a modified desaturation tst and a complete exercise test?
only SpO2 is monitored in a desaturation test
The mechanism that stimulates the release of surfactant is
a. fluid accumulation in the alveoli
b. alveolar collapse from atelectasis
c. alveolar stretch from deep breathing
d. air movement through the alveolar pore of Kohn
C
Rationale: Surfactant is a lipoprotein that
lowers the surface tension in the alveoli. It reduces the amount of pressure
needed to inflate the alveoli and decreases the tendency of the alveoli to
collapse. Deep breaths stretch the alveoli and promote surfactant secretion.
During inspiration, air enters the thoracic cavity as a result of:
a. contraction of the accessory abdominal muscles
b. increased carbon dioxide and decreased oxygen in the blood
c. stimulation of the respiratory muscles by the chemoreceptors
d. decreased intrathoracic pressure relative to pressure at the airway
D
During inspiration, the diaphragm contracts, increasing
intrathoracic volume and pushing the abdominal contents downward. At the same
time, the external intercostal muscles and scalene muscles contract, increasing
the lateral and anteroposterior dimension of the chest. This causes the size of
the thoracic cavity to increase and intrathoracic pressure to decrease, which
causes air to enter the lungs.
The ability of the lungs to adequately oxygenate the arterial blood is best determined by examination of the
a. heart rate
b. hemoglobin level
c. arterial oxygen tension
d. arterial carbon dioxide tension
C
The ability of the lungs to
oxygenate arterial blood adequately is determined by examination of the partial
pressure of oxygen in arterial blood (PaO2) and arterial oxygen
saturation (SaO2).
The most important respiratory defense mechanism distal to the respiratory bronchioles is the
a. alveolar macrophage
b. impaction of particles
c. reflex bronchoconstriction
d. mucociliary clearance mechanism
A
Respiratory defense mechanisms are efficient in protecting
the lungs from inhaled particles, microorganisms, and toxic gases. The defense
mechanisms include filtration of air, the mucociliary clearance system, the
cough reflex, reflex bronchoconstriction, and alveolar macrophages.
A rightward shift of the oxygen-hemoglobin dissociation curve
a. is caused by metabolic alkalosis
b. is seen in postoperative hypothermia
c. facilitates release of oxygen at the tissue level
d. causes blood to pick up more oxygen in the lungs
C
When the curve shifts to the right, blood picks up oxygen less rapidly in the
lungs but delivers oxygen more readily to the tissues. This shift is seen in
cases of acidosis and hyperthermia and when the PaCO2 is increased
Very early signs or symptoms of inadequate oxygenation include
a. dyspnea and hypotension
b. apprehension and restlessness
c. cyanosis and cool, clammy skin
d. increased urine output and diaphoresis
B
Early symptoms of inadequate
oxygenation include unexplained restlessness and irritability.
During the respiratory assessment of the older adult, the nurse would expect to find (select all)
a. a vigorous cough
b. increased chest expansion
c. increased residual volume
d. increased breath sounds in the lung apices
e. increased anterior-posterior chest diameter
C,E
The anterior-posterior diameter of the thoracic cage and the
residual volume increase in older adults. An elderly patient has a less
forceful cough. The costal cartilages calcify with aging and interfere with
chest expansion. Small airways in the lung bases close earlier during expiration.
As a consequence, more inspired air is distributed to the lung apices, and
ventilation is less well matched to perfusion, lowering the PaO2.
When assessing activity-exercise patterns related to respiratory health, the nurse inquires about
a. dyspnea during rest or exercise
b. recent weight loss or weight gain
c. willingness to wear oxygen equipment in public
d. ability to sleep through an entire night
A
Determine whether the
patient’s activity is limited by dyspnea at rest or during exercise.
When auscultating the chest of an elderly patient in respiratory distress it is best to
a. begin listening at the apices
b. begin listening at the lung bases
c. begin listening on the anterior chest
d. ask the patient to breathe through the nose with the mouth closed
B
Auscultation should proceed
from the lung apices to the bases, comparing opposite areas of the chest,
unless it is possible the patient will tire; if so, start at the bases.
Which of the following is an abnormal assessment finding of the respiratory system?
a. inspiratory chest expansion of 1 inch
b. percussion resonance over the lung bases
c. symmetric chest expansion and contraction
d. bronchial breath sounds in the lower lung fields
D
The term abnormal breath sounds is used to describe
bronchial or bronchovesicular sounds heard in the peripheral lung fields.
A diagnostic procedure done to remove pleural fluid for analysis is
a. thoracentesis
b. bronchoscopy
c. pulmonary angiography
d. sputum culture and sensitivity
A
Thoracentesis is the insertion of a large-bore
needle through the chest wall into the pleural space to obtain specimens for
diagnostic evaluation, remove pleural fluid, or instill medication into the
pleural space.
Amount of air remaining in lungs after forced expiration
residual volume (RV)
maximum amount of air lungs can contain
total lung capacity (TLC)
maximum amount of air that can be exhaled after maximum inhalation
vital capacity (VC)
amount of air that can be quickly and forcefully exhaled after maximum inspiration
forced vital capacity (FVC)
maximum rate of airflow during forced expiration
peak expiratory flow rate (PEFR)
amount of air exhaled in first second of forced vital capacity
forced expiratory volume in 1 second (FEV1)
volume of air in lungs after normal exhalation
functional residual capacity (FRC)
Arterial blood gas analysis includes measurement of:
PaO2, PaCO2, pH, HCO3, and SaO2
When assessing a patient’s sleep-rest pattern related to respiratory health, the nurse would ask if the patient (select all that apply)A) Has trouble falling asleep.B) Needs to urinate during the night.C) Awakens abruptly during the night.D) Sleeps more than 8 hours per night.E) Has to sleep with the head elevated.
A, C, E
The patient with sleep apnea may have insomnia and/or abrupt awakenings. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night or needing to urinate during the night is not indicative of impaired respiratory health.
The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by inspecting
D)
Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.
The nurse is caring for a patient with COPD and pneumonia who has an order for arterial blood gases to be drawn. Which of the following is the minimum length of time the nurse should plan to hold pressure on the puncture site?
B)
After obtaining an arterial blood gas, the nurse should hold pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic vessel under much higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient.
A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of nodules. In an effort to determine whether the nodules are malignant or benign, the primary care provider is likely to order a
B)
PET is used to distinguish benign and malignant pulmonary nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan, which uses an IV radioactive glucose preparation, can demonstrate increased uptake of glucose in malignant lung cells. This differentiation cannot be made using CT, a pulmonary angiogram, or thoracentesis.
A patient with recurrent shortness of breath has just had a bronchoscopy. Which of the following is a priority nursing action immediately following the procedure?
A)
Priorities for assessment are the patient’s airway and breathing, both of which may be compromised after bronchoscopy by laryngeal edema. These assessment parameters supersede the importance of loss of consciousness (LOC), pain, heart rate, and blood pressure, although the nurse should also be assessing these.
After assisting at the bedside with thoracentesis, the nurse should continue to assess the patient for signs and symptoms ofA) Pneumothorax.B) Bronchospasm.C) Pulmonary edema.D) Respiratory acidosis.
A
Because thoracentesis involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax. Thoracentesis does not carry a significant potential for causing pulmonary edema, respiratory acidosis, or bronchospasm.
Which type of lung cancer is most likely to be confused with a lung abscess?
Large cell carcinoma of the lungs is most likely to be confused with a lung abscess because it can appear as a cavitated lesion on chest x-ray
