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Albany State University NURS 2115
Respiratory Study Guide
1. Review A&P of lungs: - Bronchioles lead to alveoli - Alveoli lead to alveolar sacs - Alveoli: functional unit of the lungs o 35% of gas exchange occurs here o Surfactant formation occurs here - Alveolar sacs: last part of the airway o Surrounded by alveoli o 65% of gas exchange occurs here - Lungs: o Right lung: 3 lobes o Left lung: 2 lobes 2. In order to understand the more difficult content, you should have an understanding of the following basics: - Upper and lower airways: provide defense mechanisms. Patients lose their normal respiration defense mechanisms due to: o Disease/illness o Injury o Anesthesia o Corticosteroids o Smoking o Malnutrition o Uremia o Ethanol o Hypoxia o Artificial airways - Work of breathing: o Related to lung compliance and resistance of lungs and/or thorax o Factors affecting lung or chest wall compliance: ▪ Flail chest ▪ Atelectasis ▪ Pneumonia ▪ Pulmonary edema ▪ Pulmonary fibrosis ▪ Pleural effusion ▪ Pneumothorax - O2 :
o SpO2 saturation: measurement of the percent of oxygen the hemoglobin is saturated with- 95-100% ▪ Non-invasive ▪ Not indicative of the amount of oxygen being let go to perfuse the tissues
o Respiration rate o Tidal volume
- Effective respirations requires gas exchange in the lungs (external resp) and tissues (internal resp) and depends on the following to maintain oxygenation and acid-base balance: o Ventilation : gas distribution into and out of the pulmonary airways o Pulmonary perfusion : blood flow from the right side of the heart, through pulmonary circulation, and into the left side of the heart
o Diffusion : gas movement from areas or greater concentration to lesser concentration o Internal respirations : occurs only through diffusion when the RBCs release O2 and absorb CO o Variable effecting O2 transport: ▪ Cardiac output ▪ PaO ▪ Hemoglobin ▪ Metabolic demand o Variables affecting consumption of O2 by the cells: ▪ Increased work of breathing ▪ Hyperthermia ▪ Trauma ▪ Sepsis ▪ Anxiety ▪ Hyperthyroidism ▪ Seizures
- Ventilation and perfusion balance and imbalance: o Adequate gas exchange depends on adequate ventilation- perfusion ration (V/Q) o Normal V/Q ratio o Low V/Q ration: shunt o High V/Q ratio: dead space o Absence of ventilation and perfusion: silent unit **3. Review clinical manifestations, nursing assessment and interventions, and patient teaching for the following:
- ARDS:** sudden and progressive form of acute respiratory failure in which the capillary membrane is damaged and more permeable to intravascular fluid o Pathology: ▪ Noncardiac pulmonary edema ▪ Alveoli fill with fluid and the fluid blocks surfactant ▪ Phase 1: injury or exudative phase- inflammation ▪ Phase 2: reparative or proliferative phase- this phase is complete when the diseased lung is dense, fibrous tissue ▪ Phase 3: fibrotic can occur in 2-3 weeks, late or chronic phase- scarring, gas exchange is very limited ▪ Causes: ❖ Trauma ❖ Pulmonary infection/aspiration ❖ Prolonged cardiopulmonary bypass
❖ Capillaries leaking ▪ Early stages: ❖ Slight elevation of RR ❖ Tachypnea, tachycardia
- My heart is racing and I can’t catch my breath ❖ Dyspnea ❖ PaO2 on room air is 90 mmHg and dropping ❖ Early respiratory alkalosis and hypoxemia - Hypoxemia determined by ABG ▪ Progresses to: ❖ Refractory hypoxemia despite high levels of FiO2 delivery - Shunting blood from right side to left without gas exchange ❖ Chest xray whited out (fluid in lungs) ❖ Breathing becomes labored: mechanically ventilate ❖ Reduced lung (pulmonary) compliance ❖ Retractions ❖ Fibrosis ❖ Acidotic - Could be metabolic depending on if RR is elevated o Nursing assessment: ▪ ABGs ▪ Chest xray: usually shows diffuse bilateral and rapidly progressing interstitial or alveolar infiltrates ❖ Whited out ▪ ECG o Nursing interventions: ▪ ET intubation, mechanical ventilation, PEEP ▪ Nutrition on vent: ❖ TPN vs enteral ❖ Increase protein ❖ Decrease carbs ❖ Increase calories ▪ Hemodynamic monitoring: provides precise measures for effectiveness of interventions ❖ Swans catheter: right atrium pressure, CO, mixed venous oxygen saturation ▪ Perfusion? Check urine output ▪ Vent: ❖ 100% FiO ❖ Increase levels of PEEP ❖ Sedation: calms patient and decreases demand for O - Fentanyl, propofol
❖ Paralytic agents: pavulon, norcuron, tracrium, zemuron
▪ Late sign: cyanosis ▪ Signs of deterioration: ❖ Tripod position ❖ Inability to speak ❖ Muscle retractions ❖ Use of refractory muscles ❖ Work of breathing ❖ Crackles/rhonchi ❖ Absent/diminished breath sounds o Nursing assessment: ▪ Cause related to inflammation, infarction ▪ Labs: ❖ ABGs: determines extent of hypoxemia and course of action ❖ Chest xray: determine cause ❖ CBC: potential cause
- Elevated WBC: infection ❖ CMP: electrolyte imbalances and kidney function ❖ Sputum/blood cultures: determine microorganism for antibiotic ❖ EKG: if client has any underlying cardiac issue o Nursing interventions: ▪ Maintain adequate oxygenation and ventilation ▪ O2 admin ▪ Mobilize pulmonary secretions: ❖ Effective coughing ❖ Adequate hydration and humidification ❖ Chest physical therapy - Postural drainage - Tracheal suctioning - Breathing exercises: purse lipped breathing, incentive spirometer ▪ Decrease anxiety: breathing techniques, calm voice ▪ Bronchodilators: reverse bronchospasms ▪ Corticosteroids: decrease inflammation ▪ Diuretics, nitroglycerin, opioids: decrease pulmonary congestion ❖ Heart failure ▪ Antibiotics: if infection is present ▪ Sedation and analgesics: decrease anxiety, agitation, and pain ▪ Mechanical ventilation: ❖ Invasive: ET intubation ❖ Noninvasive: BiPAP o Patient teaching: ▪ Use of incentive spirometer - Pulmonary embolism : collection of matter in venous circulation and
lodges in pulmonary vessels
❖ Small doses of morphine or sedatives for pain and anxiety ▪ General:
❖ Treat underlying cause and restore adequate gas exchange in lungs ❖ Oxygen for hypoxemia, relieve vasoconstriction and reduce pH ❖ Antiembolic stocking or intermittent pneumatic leg compression devices reduce hemostasis ❖ Elevate legs above level of heart ▪ Anticoagulants and thrombolytics: ❖ Patients with proven PE and hemodynamically stable:
- LMWH: enoxaparin (lovenox) - Unfractionated heparin - NOAC: dabigatran (Pradaxal) - Factor Xa inhibitor: fondaparinux (Arixtra), rivaroxaban (Xarelto) apixalban (Eliquis), or edoxaban (Savaysal) ❖ Long-term treatment: - Warfarin (coumadin) - NOACs ❖ Thrombolytic: - Recombination with tissue plasminogen activator (Activase) or others like kabikinase (Streptase) ▪ Surgical: ❖ Surgical embolectomy ❖ IVC filter may be inserted o Nursing interventions: ▪ Oxygen: ❖ Assess for signs of hypoxemia and pulse ox ❖ Deep breathing and incentive spirometry ▪ Assisting with intubation and maintaining mechanical ventilation ▪ Implement turning schedule, mouth care, skin, care, and ROM of extremities to prevent complications ▪ Prevent thrombus formation: ❖ Ambulation and active and passive leg exercises ❖ IPC devices ▪ Monitor thrombolytic therapy: ❖ Vitals every 2 hours ❖ Invasive procedures avoided ❖ INR and PTT 3-4 hrs after infusion is started ▪ Managing pain: ❖ Semi-fowlers position ❖ Turn patient frequently and reposition to improve
▪ Do not cross legs ▪ Do not wear restrictive clothing ▪ Lifestyle change necessary to restore health ▪ Name, dose, side effects, frequency and schedule for meds ▪ Avoid and prevent bleeding: ❖ No sharp objects ❖ Toothbrush with soft bristle ❖ Avoid laxatives ❖ Report black, tarry stool ❖ Wear ID bracelet ▪ Drink fluids, especially traveling and in warm weather ▪ Tell s/sp of lower circulatory compromise: ❖ Calf/leg pain, swelling, pedal edemal ▪ Tell s/sp of pe: ❖ Dyspnea, chest pain, anxiety, fever, tachycardia, apprehension, cough, diaphoresis, syncope, hemoptysis
- Pneumothorax/hemothorax: partial/complete collapse of lung due to accumulation of air/fluid in pleural space o Types : ▪ Spontaneous pneumo: ruptured blebs (COPD, emphysema, asthma) ▪ Open pneumo ▪ Tension pneumo ▪ Hemothorax o Causes : ▪ Thoracentesis ▪ Trauma ▪ Secondary infection o Clinical manifestations: ▪ Sudden sharp pain ▪ Dyspnea ▪ Diminished/absent breath sound ▪ Decreased respiratory excursion ▪ Hyperresonance: sounds hollow ❖ pneumo ▪ Decreased vocal fremitus ▪ Dullness ❖ Hemothorax ▪ Unequal chest expansion ▪ Tracheal shift to opposite side: ❖ Tension pneumo ▪ Weak rapid pulse ▪ Anxiety o Nursing assessment: ▪ Chest xray
▪ PCO2 elevated ▪ PO2 and pH decreased o Nursing interventions: ▪ ETT ▪ Suctioning ▪ Monitor mechanical vent ▪ Restore function: ❖ Thoracentesis: ❖ Insertion of chest tube: ❖ Provide pain relief ❖ Position in high fowler’s o Patient teaching:
- Pulmonary contusion: o Clinical manifestations: o Nursing assessment: o Nursing interventions: o Patient teaching: - Oxygen toxicity : O2 concentrations of > 50% for extended periods of time (> 48 hours but can occur in hours) can lead to overproduction of free radicals which can severely damage cells leading to pulmonary edema and progressing to cell death o Clinical manifestations: ▪ Substernal discomfort ▪ Paresthesia ▪ Dyspnea ▪ Restlessness ▪ Fatigue ▪ Malaise ▪ Progressive respiratory difficulty ▪ Refractory hypoxemia ▪ Alveolar atelectasis ▪ Alveolar infiltrates on chest x-rays o Nursing assessment: o Nursing interventions: ▪ Using lowest amount of O2 to maintain an acceptable PaO2 level and treating the underlying condition aids in prevention of O2 toxicity ▪ PEEP applied to the end of expiration of ventilator breaths or CPAP reverses or prevents o Patient teaching: - Chest tubes: catheter placed into the intrapleural space to drain air and/or fluid o Cath is connected to a 3 chamber drainage system consisting of a drainage,
▪ Establishes negative pressure ▪ Chest expansion o Nursing assessment: ▪ Tidaling: movement with respiration- rise with inspiration and fall with exhalation ❖ Normal ❖ No tidaling: re-expansion or obstruction ▪ Drainage output every hr ❖ Report >100 ml to provider ▪ Water seal: air exits, can’t enter ❖ Level should be at 2 cm ALWAYS ❖ Sterile water or saline ❖ There should never be any bubbling in the water seal chamber: indicates air leak o Nursing interventions: ▪ Place upright and below the chest ❖ Usually on floor by end of bed ▪ Coil tubing in bed ▪ NEVER clamp the tube ▪ NEVER milk the tube: can create high negative pressure ▪ Keep at bedside: ❖ 2 hemostats ❖ Sterile water ❖ Sterile occlusive dressings ▪ Frequent respiratory assessments ▪ Suction control chamber: ❖ Dry suction: know it’s on when orange thing at top is blown up ❖ Wet unit: add sterile water/saline
- Bubbles should occur when connected to suctioning ❖ Constant suction: usually 20 units of pressure o Patient teaching: ▪ Instruct on coughing and deep breathing - Flail Chest : 3 or more ribs are fractured at 2 or more sites, resulting in free-floating rib segments o Clinical manifestations: ▪ Hypoxia ▪ Hypercarbia ▪ Increased retention of secretions o Nursing assessment: o Nursing interventions: ▪ Humidified O ▪ Pain management ▪ Deep breathing
▪ Mechanical ventilation
