respiratory 1

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respiratory 1
2010-02-23 20:00:13

respiratory 1
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  1. What are some causes of respiratory acidosis?
    • asthma
    • atelectasis
    • brain trauma
    • bronchitis
    • bronchietasis
    • CNS depressants
    • emphysema
    • hypoventilation
    • pulmonary edema
    • pneumonia
    • PE
  2. What are some causes of respiratory alkalosis?
    • fever
    • hyperventilation
    • hypoxia
    • hysteria
    • overventilation by mechanical ventilator
    • pain
  3. What are some causes of metabolic acidosis?
    • DM or Diabetic Ketoacidosis
    • excessive ingestion of acetylsalicylic acid (aspirin)
    • high fat diet
    • insufficient metabolism of carbohydrates
    • malnutrition
    • renal insufficiency or renal failure
    • severe diarrhea
  4. What are some causes of metabolic alkalosis?
    • diuretics
    • excessive vomiting or gastrointestinal suctioning
    • hyperaldosteronism
    • ingestion of and/or infusion of excess sodium bicarbonate
    • massive transfusion of whole blood
  5. What are s/s of respiratory acidosis?
    • neuro-drowsiness, disorientation, dizziness, headache, coma
    • cardiovascualr-dec. BP, ventricular fibrillation r/t hyperkalemia from compensation, warm flushed skin r/t peripheral vasodilation
    • GI-no significant findings
    • respiratory-hypoventilation with hypooxia (lungs are unable to compensate when there is a respiratoy problem)
    • neuromuscular-seizures
  6. What are some s/s of respiratory acidosis?
    • neuro-drowsiness, confusion, headache, coma
    • cardiovascular-dec. BP, dysrhythmias r/t hyperkalemia from compensation, warm flushed skin r/t peripheral vasodilation
    • GI-N/V, diarrhea, abd pain
    • neuromuscular-no significant findings
    • respiratory-deep rapid respiraoty rate (compensatiing action by lungs)
  7. What are some s/s of respiratory alkalosis?
    • neuro-lethargy, light headedness, confusion
    • cardiovascular-tachycardia, dysrhythmias r/t hypokalemia from compensation
    • GI-N/V, epigastric pain
    • neuromuscular-tetany, numbness, tingling in the extremities, hyperreflexia, seizures
    • respiratory-hyperventilation (lungs are unable to compensate when there is a respiratory problem)
  8. What are some s/s of metabolic alkalosis?
    • neuro-drowsiness, dizziness, nervousness, confusion
    • cardiovascular-tachycardia, dysrhythmias r/t hypokalemia from compensation
    • GI-N/V, anorexia
    • neuromuscualr-tremors, hypertonic muscles, muscle cramps, tetany, tingling of fingers and toes, seizures
    • respiratory-hypoventilation (compensating action by lungs)
  9. respiratory acidosis
    • occurs when there is an excess buildup of CO2 in the blood
    • most common acid/base imbalance
  10. Common causes of respiratory acidosis
    • occurs secondary to problems that cause hypoventilation
    • CNS depression (head injury, sedatives, anesthesia)
    • increased reistance-aspiration, broncho and laryngospasm, prolonged narrowing of airway (asthma, airway edema)
    • loss of lung surface-atelectasis, COPD, pneumonia, pneumothorax, chronic pulmonary diseases
    • neuromuscular diseases-Guillain-Barre, myasthenia gravis
    • mechanical ventilation-inc retention on CO2
  11. s/s of respiratory acidosis
    • dyspnea, hypoventilation
    • hypoxia
    • restlessness progressing to lethargy
    • drowsiness, confusion, coma
    • trachycardia, tachypnea
    • dysrhythmias associated with hypoxia, hyperkalemia
    • seizures
    • diaphoresis-skin may appear flushed and feel warm
    • hypercapnia-inc. CO2, this will cause cerebral vasodilation and cause IICP
  12. respiratory acidosis
    • pH is less than 7.35
    • PCO2 is greater then 45
    • HCO3 may be normal or increased b/c of compensation
    • compensation from renal system is slow
    • urine pH is less than 6
  13. mgmt of respiratory acidosis
    • even though oxygen doesn't play a part in acid/base balance, acidosis will occur when the pt doesn't have adequate gas exchange.
    • respiratory depression from whatever cause will precipitate hypoxia (too little O2) and hypercapnia (too much CO2).
    • excess CO2 causes this
  14. medical mgmt of respiratory acidosis
    • bronchodilators
    • if on a ventilator the Dr. may order an inc. in tidal volume to facilitate maximum volume and gas exchage to inc. expiration of CO2
    • correct the precipitating cause of hypoxia or respiratory problem if possible
  15. nursing mgmt for repspiratory acidosis
    • Semi-Fowler's to facilitate ventilation
    • suction PRN to remove excess mucus
    • have artififcial airway available
    • assess patency of airway-resp. rate, breath sounds
    • assess for tachycardia, secondary to hypoxia
    • maintain calm reassuring attitude (pt is restless and anxious)
    • teach to use incentive spirometer
    • turn, cough, and deep breathe
    • monitor for bradypnea (less than 12 bpm)
    • initiate seizure precautions
    • assess medications (may need to dec. sedation)
    • encourage ambulation (assess response to activity, stop with increased SOB and tachycardia)
  16. respiratory alkalosis
    Due to low circulation CO2 levels in the bloodfrom hyperventilation secondary to hypoxia, PE, pain, anxiety, pregnancy, or alveolar hyperventilation as seen in clients with a ventilator with high tidal volume and increased respiratory rate

    • causes:
    • hyperventilation (anxiety, hysteria)
    • hyperventilation cuased by:
    • -fever
    • -hypoxia
    • -pain
    • -pulmonary d/os
    • CNS problems
  17. s/s of respiratory alkalosis
    • hallmark sign is hyperventilation (hypernea)
    • client may say that they feel light-headed
    • arrythmias-tachycardia (potassium may be low)
    • anxiety
    • epigastric pain, nausea
    • tetany, seizures, parasthesias in toes and fingers
  18. respiratory alkalosis
    • pH is greater than 7.45
    • PCO2 is less than 35
    • HCO3 may be normal or less than 20 if compensating
    • pH urine is greater than 6
  19. medical mgmt for respiratory alkalosis
    • may need antianxiety like Ativan
    • Dr. may order a dec. in rate of tidal volume if client is on a ventilator
  20. nursing mgmt for respiratory alkalosis
    • identify and correct the precipitating cause
    • monitor ABGs
    • check for presence of dec. potassium, monitor for dysrhythmias
    • try to relax/calm pt relaxation techniques and guided imagery
    • breathing in a sac or rebreathing mask to increase retention of CO2
    • reduce environmental noise/stimuli
    • encourage pt to slow their breathing
    • if having pain, treat with analgesics
    • if fever, treat with antipyretics
  21. metabolic acidosis
    • result of excess acid production in body or rapid excreation of bicarbonate from the body
    • metabolic system is the primary problem, respiraoty system compensates
    • causes:
    • lactic acidosis (shock, respiratory, or cardiac arrest)
    • renal failure
    • liver failure
    • severe diarrhea
    • vomiting
    • salycilate toxicity
    • starvation
    • GI fistulas
  22. s/s of metabolic acidosis
    • Kussmal respirations (deep rapid respirations)
    • confusion, disorientation progressing to coma
    • headach, lethargy
    • hypotension
    • arrythmia changes secondary to hyperkalemia associated with diabetic ketoacidosis
    • warm to hot, flushed skin
    • abd pain
  23. metabolic acidosis
    • pH less then 7.35
    • HCO3 less than 22
    • PCO2 may be normal or resp. compensation may occur causing a dec. in PCO2 level
    • urine pH is less than 6
  24. medical mgmt of metabolic acidosis
    • IV bicarb if arterial level is less than 21 or plasma venous bicarb is less than 20
    • check ABGs frequently
    • correct precipitating cause of acidosis
  25. nursing mgmt for metabolic acidosis
    • fluid replacement 0.9% or 0.45% NaCl given for hydration therapy
    • antidiarrheals if having excessive diarrhea
    • assess skin turgor, urine, and weight for hydration status
  26. nursing mgmt for metabolic acidosis
    • identify and tx cause
    • determine hx of precipitaing cause (DM, ETOH, renal disease, excessive GI fluid loss, lactic acidosis)
    • assess BUN, CRT for renal function
    • AST and ALT for liver function
    • E-Lytes (K+ many inc., can fluctuate with tx)
    • blood sugar
    • ABGs check pH if less than 7.35 and HCO3 less than 22
    • VS including temp and wt
    • if a result of DKA-give insulin, watch for hypokalemia during administration b/c it moves K+ into the cells
    • antiemetics for vomiting
  27. metabolic alkalosis
    • occurs as a result of a loss of acid or a dec. in bicarb
    • the lings compensate by an inc. in respirations to inc. CO2 by taking fewer and longer breaths
    • kidneys also compensate by excreating bicarb
    • causes:
    • loss of stomach acid through suctioning or vomiting
    • excess alkali intake-antacids, bicarbonate
    • GI fistulas
    • adrenal disease-Cushing's, aldosteronism
    • diuretic therapy (especially Diamox)
  28. s/s of metabolic alkalosis
    • nervousness, dizziness
    • cardiac irritability- dec. K+, ventricular dysrhythmias, tachycardia
    • N/V
    • parasthesias in fingers and toes
    • tetany, muscle cramps-late signs
    • hypoventilation
    • assess hydration status-tend to be dehydrated
  29. metabolic alkalosis
    • pH greater than 7.45
    • PCO2 normal or may be inc. b/c of compensating
    • HCO3 greater than 26
    • urine PH greater than 6
  30. medical mgmt for metabolic alkalosis
    • administer Diamox to inc. excretion of bicarbonate
    • inatke of bicarb should be stopped
    • replacement of balanced fluids for pts with GI suctioning, intestinal fistulas, or both
  31. nursing mgmt of metabolic alkalosis
    • determine underlying cause
    • assess for hx of precipitaing cause-GI fistulas, suctioning, vomiting
    • moniotr ABGs
    • monitor K+ values (hypokalemia usually occurs, but levels will increase with tx of alkalosis)
    • assess for dysrhythmias-tachycardia and dysrhythmias r/t dec. K+
    • monitor respirations-may see bradypnea
    • if taking Digoxin, monitor labs, toxicity occurs when serum level is greater than 2.4 ng/ml
    • give antiemetics to control n/v
    • assess for parasthesias of toes and fingers
  32. midline values
    • pH=7.4
    • PaCO2=40
    • HCO3=24

    • note:
    • pH greater than 7.4=alkalosis
    • pH less than 7.4=acidosis
    • pH of 7.4=normal
  33. if HCO3 is less than 24, the primary disturbance is...
    metabolic acidosis

    body's bicarb level drops from direct bicarb loss or gains of acids like lactic or ketones
  34. if HCO3 is greater than 24, the primary disturbance is..
    metabolic alkalosis

    occurs when the body gains too much bicarb
  35. id PaCO2 is greater than 40, the primary disturbance is...
    respiratory acidosis

    occurs when the pt hypoventilates and retains too much CO2
  36. if PaCO2 is less than 40, the primary diaturbance is...
    respiratory alkalosis

    occurs when pt hyperventilates and "blows off" too much CO2
  37. HCO3 is increased or normal
    resp. acidosis
  38. HCO3 is dec. or normal
    resp. alkalosis
  39. PaCO2 is dec. or normal
    met. acidosis
  40. PaCO2 is inc. or normal
    met. alkalosis
  41. increases renal acid excretion and increases HCO3 to compensate
    resp. acidosis
  42. decreases renal acid excretion and decreases HCO3
    resp. alkalosis
  43. hypoventilates resulting in inc. PaCO2 to compensate
    met. alkalosis
  44. purpose of chest tubes
    • to relaease normal negative pressure in the pleaural space by removing
    • -air (pneumothorax)
    • -blood (hemothorax)
    • -air and blood (hemopneumothroax)

    promotes and facilitates lung re-expansion
  45. uses a dial to set suction control
    dry suction
  46. pneumothorax
    • air in the pleaural cavity resulting in lung collapse
    • causes:
    • ruptured bleb (COPD)
    • thoracentesis>>trauma>>secondary infection

    • dx:
    • CRX
    • ABGs

    • tx:
    • chest tube
  47. s/s of pneumothorax
    • dyspnea
    • anxirty
    • tachycardia
    • pleural pain
    • assymetrical chest wall expansion
    • * dec. breath sounds
  48. spontaneous/closed pneumothorax
    • ruptured bleb, idiopathic
    • sudden onset of air in pleural space and lung deflation

    • s/s:
    • chest discomfort, diminished/absent breath sounds

    • intervention:
    • less than 15% monitor, more than 15% chest tube, deep breathing, incentive spirometry
  49. tension pneumothorax
    • blunt or penetrating trauma
    • air enters on inspiration and cannot escape
    • wound creates a one-way valve

    • s/s:
    • severe pain with breathing, cyanosis, dyspnea, air hunger, restlessness, diminished breath sounds, assymmetry with breathing, hypotension, tachycardia, tracheal deviation, mediastinal shift, JVD

    • intervention:
    • chest tube or thoracentesis to release trapped air, check PMI for mediastinal shift
  50. traumatic/open sucking pneumothorax
    • penetrating chest trauma
    • open pathway, air passes freely in and out of cavity
    • partial or total liunf collapse

    • s/s:
    • mediastinal shift possible
    • dyspnea, sucking/hissing sound of wound
    • tachycardia
    • hypotension
    • cyanosis
    • dec. breath sounds
    • airhunger
    • JVD
    • crepitus

    • intervention:
    • cover wound with a taped 3 sided vasoline gauze, bear down/valsalva maneuver, w/o chest tube a tension pneumothorax could occur, turn on affected side to splint
  51. hemothorax
    • blunt or penetrating trauma in pleural cavity
    • partial or total lung collapse
    • mediastinal shift possible

    • s/s:
    • dyspnea, chest tightness, diminished breath sounds, hemoptosis, bruising on chest (eccymosis)

    • intervention:
    • thoracentsis, chest tube, monitor fluid status, replace fluids, blood
  52. flail chest
    • blunt chest trauma
    • ribs broken in 2 or more places-side/close to sternum
    • chest stability is los-paradoxical chest movement

    • s/s:
    • diminished breath sounds, hypotension, tachycardia, cyanosis, crepitus, paradoxical chest movement

    • intervention:
    • stabilize ribs, turn on affected side, be careful of spinal injuries/car accidents
  53. what happens when a mediastinal shift occurs and how do you assess?
    compression of aorta, dec. CO, dec. BP, misplaced trachea

    • interventions:
    • check apical pulse-PMI, moves mark on chest to monitor changes/movement
  54. pre-insertion of chest tube
    • oxygen-suction available
    • premedicate-local anesthetic
    • positioning
  55. chest tube post-insertion
    • position-semi-fowler's to high fowler's for air, high-fowler's for blood
    • encourage CDD to help push things out and expand lung drainage
    • incentive spirometry
    • monitor drainage-use date and time as a marker
    • *over 100 ml/hr is excessive
    • anterior-little to no drainage (air)
    • posterior-100-300 ml during 1st 2 hrs post-op thoracotomy, then dec., 500-1000 ml in 1st 24 hrs
    • check for crepitus/sq empysema
    • check for tubing kinks
  56. chest tube post insertion cont.
    • check chest tube drainage system connections
    • observe for fluctuation in water seal chamber (intermittent tidaling) should happen with respirations
    • observe for air leak (constant bubbling)
    • dry suction-the higher the # in air leak. the greater the leak
    • check CT dressing-vasoline gauze and 4 X 4s/ABD air occlusive dressing
    • removing chest tube:
    • medicate prior to removal
    • positon on side/sitting up
    • ask pt to hold breath or exhale while removed
    • apply air occlusive drsg (vasoline gauze 4x4s)
  57. when to call Dr.
    • over 100 ml drainage
    • rapid, shallow respiration
    • cyanosis
    • chest tube comes out
    • drastic change in VS
    • constant bubbling
  58. sites for chest tube placement
    • high apical and anterior-air
    • low posterior or lateral-blood
    • mediastinal (below sternum)-blood or air used in cardiac surgery
  59. water seal chamber
    • allows air to escape with expiration
    • prevents air from coming into lungs with inspiration

    use sterile water or normal saline
  60. suction chamber
    • wet suction
    • -if suction is applied, fill chamber to the 20 cm level

    • dry suction
    • -uses a dial to set the suction control (20 cm mark)
    • no fluid, quieter, connections must stay together, tape, clamp, ect.
    • Pleur-evac systems-water seal and suction control chamber will turn blue when filled
  61. suction chamber
    • tape all connections
    • position chest tube system below pts chest
    • dependant loops in tubung inc. resistance to drainage
    • extra tubing should be coiled in bed and draped along side of bed
  62. if fluid fluctuation the water seal chaber stops..
    • look for:
    • kinks
    • leaks in tube
    • lung could be re-expanded
    • is suction working?
  63. how you know if there is an air leak
    • constant bubbling in the water seal chamner
    • dry-air leak indicator (bubbling)
  64. how to identify the source of the leak
    • systemic brief clamping of drainage tube with padded clamp (hemostats)
    • clamp close to occlusive dressing
    • if bubbling stops-leak is btwn pt and clamp
    • tx-change dressing
    • if bubbling doesn't stop-leak is btwn clamp and drainage collector
    • tx-change tubing
  65. what to do if you knock over the collection system
    • stand it back up
    • have the pt couph and deep breathe
  66. what to do if water seal breaks
    • change system-RUN
    • place tubing in sterile water
  67. if the water seal level is low...
    • in suction control chamber-refill
    • in water seal chamber-refill
  68. milking the chest tube
    • controversial
    • milking prevents tube from being plugged with clots/fibrin, but it increases intrapleural pressure which can cause trauma

    new tubes are defibrinogenated so it's unlikely to clot and have a coating that makes them nonthrombogenic
  69. why are ABGS ordered and what do they monitor?
    • acid/base
    • oxygen-O2 sat
    • ventilation
  70. what factors influence ABG results?
    • 02 level
    • HGB
    • BP-if decreased not perfusing
  71. what effect does deep breathing (hyperventilation) have on the resp. system?
    lose CO2, so it causes resp. alkalosis
  72. what effect does shallow respirations have on the respiratory system?
    retain CO2 so it causes acidosis
  73. irregular respirations
    Biots respirations
  74. rapid respirations with periods of apnea
    near death breathing
    Cheyne-Stokes respirations
  75. deep labored breathing-shallow, rapid, gasping
    indicative of metabolic acidosis
    common in DM-renal failure
    fruity acetone breath
    Kussmal respirations
  76. how long after an oxygen change should ABGs be drawn?
    15-20 min

    e.g. suctioning

    safety:hold pressure
  77. 7-35-7.45
  78. 35-45
  79. 80-100
  80. 22-26
  81. 95-100
    O2 sat
  82. slow breathing, less than 12
  83. fast breathing, greater than 20
  84. amount of oxygen combined with HGB
    Rm Air O2 sat should be 95%
  85. what does HGB show about pt's resp. status?
    • oxygen in blood
    • shows is pt is getting adequate oxygentation
  86. what does Hct show about pt's resp. status?
    • ratio of PRBC in blood volume
    • 3X's Hgb
  87. polycythemia
    • too many rbc's
    • can occur from COPD-chronic hypoxemia
    • slows blood flow
    • pt is red
  88. what information does pulse ox give about resp. system?
    • O2 sat-how well you're perfusing
    • amount of O2 in blood
    • normal range is 95-100%
  89. quick to compensate
  90. slow to compensate
    kidneys-3-5 days
  91. c
  92. compensation of resp. alkalosis
    involves renal excretion of HCO3
  93. a pt with severe anemia will have..
    less oxygen delivered to tissues
  94. an increase in PC02...
    can be caused by hypoventilation (retaining CO2)
  95. to aspirate fluid from pleural space
    purpose of thoracentesis
  96. nursing care before and during a thoracentesis
    • obtain CRX
    • sit ip
    • comfort pt
    • may sedate
  97. assessment data after a thoracentesis
    • watch resp.
    • pain
    • vertigo
    • tightness
    • uncontrollable pulse
    • *lung sounds
    • assymetry of chest
    • diminished so after they should have relaxed breathing and can take a deep breath
  98. complications after thoracentesis
    • pneumothorax
    • infection
    • sq emphysema
    • cardiac distress
  99. expected assessment findings of a pt with labored breathing
    • agitation
    • rapid respirations
    • pallor
    • anxiety
    • sitting on bedside table
    • cyanosis
    • difficultly speaking

    • know if it's worsening
    • assess right away