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102 Cards in this Set
- Front
- Back
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What are the purposes of intubation?
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-maintain airway
- oxygenate - pulmonary hygiene - prevent aspiration |
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A stoma resultingfrom a tracheotomy is called a:
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tracheostomy
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When should you suction ETT or trach tubes?
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only when secretions present
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How often should you provide thrach care?
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q shift (q8h)
or according to institutional P&P |
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How often should you change the disposable inner cannula?
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q24h
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Stop suctioning the artificial airway if the HR decreases by ___ BPM or if it increases by ____ BPM, or if oxygen saturation drops below ___ %
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20
40 90 |
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distressful sensation of uncomfortable breathing. the most common complaint of respiratory problems. Is subjective.
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SOB
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may or may not be heard by patient, and may be described as chest tightness
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wheezing
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a continuum from discomfort during inspiration to intense, sharp pain at the end of inspiration.
pain is aggravated by deep breathing and coughing. pain that is localized (vs diffuse) |
pleuritic chest pain
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material coughed up from lungs that may containt mucus, cellular debris, blood, pus, or microorganisms.
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sputum
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coughing up of blood
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hemoptysis
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Abnormality of upper airway indicated by haorseness, stridor (whistling during inspiration), muffling, or barking cough; can be in fombination with vocal cord dysfunction or GERD
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voice change
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sense of overwhelming tiredness not completely relieved by sleep or rest
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fatigue
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Low-pitched sound on percussion heard over normal lungs
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resonance
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loud, lower-pitched sound on percussion heard over hyperinflated lungs, such as COPD/asthma
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hyperresonance
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sound on percussion with drumlike, loud, empty quality heard over gas-filled stomach or intestine, or pneumothorax
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tympany
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sound on percussion 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.
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dull
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Sound on percussion that is soft, high-pitched, of short duration heard over very dense tissue where air is not present, such as posterior chest below level of diaphragm
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flat
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Exhalation through the mouth with lips pursed together to slow exhalation
taught to slow expiration in COPD and asthma. |
pursed-lip breathing
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what does a patient in the tripod position/who is unable to lie flat indicate?
(leaning forward with arms and elbows supported on overbead table). |
indicates moderate to severe respiratory distress or hypoxemia in COPD, asthma, pulmonary edema.
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What does accessory muscle use/ intercostal retractions indicate?
(neck and shoulder muscles used to assist in breathing. muscles between ribs pull in during inspiration) |
Indicates severe respiratory distress/hypoxemia in COPD, asthma, secretion retention.
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voluntary decrease in tidal volume to decrease pain on chest expansion.
What does this indicate? |
splinting
*Due to thoracic or abdominal incision, chest trauma, or pleurisy |
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What does increased AP diameter indicate?
(AP chest diameter equal to lateral. Slope of ribs more horizontal (90 degrees) to spine.) |
Due to COPD, asthma, cystic fibrosis, lung hyperinflation, advanced age.
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What does tachypnea indicate?
(Rate >20 breaths/min; >25 breaths/min in elderly) |
Magnitude of increase above normal rate reflects increased work of breathing. Due to fever, anxiety, hypoxemia, restrictive lung disease.
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What do kussmaul respirations indicate?
(regular, rapid, and deep respirations.) |
Increase in rate aids body to increase CO2 excretion in metabolic acidosis.
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What does cyanosis indicate?(Bluish color of skin best seen in lips and on palpebral conjunctiva)
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reflects 5-6 g of hemoglobin not bound with oxygen due to decrease O2 transfer in lungs, dereased cardiac output. Is nonspecific, unrealiable indicator.
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What is clubbing indicative of? (sponginess of distal portion of finger.)
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due to chronic hypoxemia. Indicates cystic fibrosis, lung cancer, bronchiectasis.
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What is abdominal paradox indicative of? (inward movement of abdomen on inspiration. Inefficient and ineffective breathing pattern. )
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Nonspecific indicator of severe respiratory distress
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What is a tracheal deviation indicitave of?
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change in posision of mediastinal structors. Emergency if caused by tension pneumo. Trachea deviates to the side opposite of the collapsed lung,
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What is increased tactile fremitus indicitave of?
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pneumonia, pulmonary edema
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what is decreased tactile fremitus indicitave of?
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decreased in pleural effusion
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what is absent tactile fremitus indicitave of?
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pneumothorax and atelectasis
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what is unequal chest movement indicative of?
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atelectasis, pneumothorax, pleural effusion, splinting
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what is equal but diminished movement of the chest indicative of?
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barrel chest, restrictive disease, neuromuscular disease
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what is hyperresonance on percussion indicative of?
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lung hyperinflation (COPD), lung collapse, air trapping (Asthma)
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What is dullness on percussion indicative of?1
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increased density (pneumonia, large atelectasis), increased fluid in the pleural space (pleural effusion)
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On auscultation, what do fine crackles indicate? (sounds like rubbing strands of hair together= heard just before the end of inspiration)
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Rapid equalization of gas pressure when collapsed alveoli or terminal bronchioles suddenly snap open.
Pulmonary fibrosis, interstitial edema, alveolar filling (pneumonia), loss of lung volume (atelectasis), early phase of heart failure, |
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What do coarse crackles indicate?
(sounds like blowing through a straw under water- bubbling quality. On inspiration and sometimes expiration.) |
Caused by air passing through airway intermittently occluded by mucus, unstable bronchial wall, or fold of mucosa.
Indicates heart failure, pulmonary edema, pneumonia with severe congestion, COPD |
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What do rhonchi indicate?
(rumbling, snoring sound) |
Obstruction of large airways with secretion.
Indicates COPD, cystic fibrosis, pneumonia, bronchiectasis |
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What do wheezes indicate?
(high-pitched squeaking) |
rapid vibration of bronchial walls
Indicates bronchospasm, airway obstruction, COPD |
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What does stridor indicate?
(musical/crowing sound of constant pitch) |
partial obstruction of larynx or trachea
Indicates croup, epiglottitis, vocal cord edema after extubation, foreign body |
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What does Absent breath sounds indicate?
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pleural effusion, mainstem bronchi obstruction, large atelectasis, pneumonectomy, lobectomy
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What does a pleural friction rub indicate?
(creaking or grating sound) |
roughened, inflamed surfaces of the pleura rubbing together
indicates pleurisy, pneumonia, pulmonary infarct. |
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What does bronchophony/ whispered pectoriloquy indicate?
(spoken/whispered syllable more distinct than normal) |
pneumonia
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What does egophony indicate?
(spoken "e" similar to "a") |
altered transmission of voice sounds
indicates pneumonia, pleural effusion |
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Hematocrit measures:
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ratio of red blood cells to plasma.
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what is an increased level and what does increased hematocrit indicate?
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>54% males,
>47% females hypoxemia |
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what is normal levels for hemoglobin?
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13.5-18 males
12-16 females |
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Waht is the normal level for hematocrit?
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40-54% males
38-47% females |
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What does ABC measure?
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acid base balance, ventilation status, need for O2 therapy, change in O2 therapy, or change in ventilator settings.
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Avoid change in oxygen therapy for at least ____ minutes before obtaining ABG sample.
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20
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Collect blood into ____ syringe for ABGs and place sample in _____
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heparinized; ice
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What are factors that can alter accuracy of pulse oximetry readings?
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motion, low perfusion, cold extremeties, bright lights, use of intravascular dyes, acrylic nails, dark skin color, carbon monoxide, and anemia.
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For SpO2, notify physician of ______ % from baseline or results below _____ %.
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+/- 4%
90% |
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For SvO2 (in pulmonary artery catheter), notify physician of ____% change from baseline of if results is below ____%.
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+/- 10%
60% |
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What is a computed tomography (CT) of the chest to test for?
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to diagnose lesions difficult to assess by Xray.
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What are nursing considerations for CT scans?
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- contrast media given IV/orally
- BUN and creatinine done prior to contrast - assess if patient is allergic to shellfist (iodine) - hydrate pt. before and after so can excrete dye |
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What is MRI of the chest to test for?
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for diagnosis of lesions difficult to assess by CT
*contrast media is not iodine-based |
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what is a VQ(ventilation- perfusion) scan of the chest used for?
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to identify areas of lung not receiving airflow or blood flow.
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What indicates the probability of a pulmonary embolus in a VQ scan?
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ventilation without perfusion
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What is a pulmonary angiogram used for?
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to visualize pulmonary vasculature and locate obstruction of pathologic conditions such as pulmonary embolus.
*contrast injected through catheter into pulmonary artery. |
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What is positron emision tomography (PET) scan for?
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to distinguish benign and malignant lung nodules. Involves IV injection of a radioisotope with a short half-life
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What is a bronchoscopy used for?
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to dx, biopsy, obtain specemens, and assess changes. Can suction mucous plugs, lavage the lungs, or remove foreign objects.
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When having a bronchoscopy or a lung biopsy, thhe patient must be NPO for ____hours prior. Keep NPO post procedure until ______ returns. Monitor for _______.
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6-12 hours
gag reflex laryngeal edema |
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What does a mediastinoscopy test for?
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for inspection and biopsy of lymph nodes in mediastinal area
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Specimens can be obtained by transbronchial, percutaneous, or transthoracic needle aspiration (TTNA),videa-assisted thoracic surgery (VATS); or open lung. These are used to obtain specimen for lab analysis. What is the test?
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lung biopsy
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What is a thoracentesis used for?
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to obtain specimen of pleural fluid for dx, to remove pleural fluid, or to instill medication.
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After this test you must do a chest xray to check for pneumo.
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thoracentesis
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What are Pulmonary function tests used for?
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to evaluate lung function.
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What is the normal value of tidal volume?
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0.5L
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What is the normal value for expiratory reserve volume?
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1.0L
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What is the normal value for residual volume?
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1.5L
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what is the normal value for inspiratory reserve volume>
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3.0L
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What is the total lung capacity?
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6.0L
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What is the normal value for functional residual capacity (TLC)?
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2.5L
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What is the normal value for vital capacity?
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4.5L
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What is the normal value for inspiratory capacity?
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3.5L
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The volume of air inhaled and exhated with each breath; only a small proportion of total capacity of lungs
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tidal volume(VT)
(0.5L) |
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Additional air that can be forcefully exhaled after normal exhalation is complete
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expiratory reserve volume (ERV)(1.0L)
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Amount of air remaining in lungs after forced expiration; air available in lungs for gas exchange between breaths
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residual volume (RV) (1.5L)
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Maximum volume of air that can be inhaled forcefully after normal inhalation
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inspiratory reserve volume (IRV) (3.0L)
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Maximum volume of air that lungs can contain
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Total lung capacity (TLC) (6.0L)
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Volume of air remaining in lungs at end of normal exhalation
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functional residual capacity (FRC) (2.5L)
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Maximum volume of air that can be exhaled after maximum inspiration, higher for men generally.
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Vital capacity (4.5L)
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What is the normal value for functional residual capacity (TLC)?
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2.5L
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What is the normal value for vital capacity?
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4.5L
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What is the normal value for inspiratory capacity?
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3.5L
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The volume of air inhaled and exhated with each breath; only a small proportion of total capacity of lungs
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tidal volume(VT)
(0.5L) |
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Additional air that can be forcefully exhaled after normal exhalation is complete
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expiratory reserve volume (ERV)(1.0L)
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Amount of air remaining in lungs after forced expiration; air available in lungs for gas exchange between breaths
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residual volume (RV) (1.5L)
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Maximum volume of air that can be inhaled forcefully after normal inhalation
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inspiratory reserve volume (IRV) (3.0L)
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Maximum volume of air that lungs can contain
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Total lung capacity (TLC) (6.0L)
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Volume of air remaining in lungs at end of normal exhalation
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functional residual capacity (FRC) (2.5L)
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Maximum volume of air that can be exhaled after maximum inspiration, higher for men generally.
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Vital capacity (4.5L)
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Maximum volume of air that can be inhaled after normal expiration
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inspiratory ccapacity (3.5L)
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Amount of air that can be quickly and forcefully exhaled after maximum inspiration
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forced vital capacity (FVC)
(over 80% of predicted is normal) |
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Amount of air exhaled in first second of forced vital capacity; grades severity of airway obstriction
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forced expiratory volume in first second of expiration (FEV 1)
(over 80% of predicted is normal) |
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Dividing of value for FEV1 by value for FVC; useful in differentiating obsructive and restrictive pulmonary dysfunction
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FEV1/FVC ratio
(normal for age<50: >/= 70% predicted |
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Measurement of airflow rate in middle half of forced expiration; early indicator of disease of small airways
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Forced midexpiratory flow rate (FEF 25-75%)
(normal for age<50: >/= 75% predicted) |
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deep beathing as rapidly as possible for specified period; fairly nonspecific test that gives info about exercise capacity. Used in conjunction with exercise stress test.
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Maximal voluntary ventilation
(normal for age<50: >/= 70% predicted) |
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Maximum airflow rate during forced expiration; aids in monitoring bronchoconstriction in asthma; can be measured with peak flow meter
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Peak expiratory flow rate
(normal is up to 600L/min) |
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