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80 Cards in this Set
- Front
- Back
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Upper Air way |
- Nasal passages - mouth - pharynx |
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lower airway |
- larynx - trachea - bronchi - bronchioles |
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the lungs |
- Right lung: 3 lobes - Left lung: 2 lobes |
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Alveoli |
- Type 1: gas exchange - Type 2: produce surfacant |
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Ventilation |
Movement of air into/out of the lungs
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Respiration |
- exchange of O2/CO2 - alveolar capillary/capillary cell membrane - CO2 primary stimulus for breathing |
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How is breathing controlled? |
- By the respiratory center located in the brain stem (medulla) - Chemomreceptors - |
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How long can the brain go without oxygen before sustaining irreversible brain damage? |
4-6 minuntes |
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Kussmaul's breathing |
deep rapid breathing |
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Cheyne Stokes |
respirations progressively increasing in depth, then progessively decreasing in depth, followed by a period of apnea |
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Blot's respirations |
quick shallow followed by apnea |
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Diagnostic tests |
- Complete blood count - chest xray - pulmonary function tests - arterial blood gases - pulse oximetry - sputum specimens - throat cultures - bronchoscopy - thoracentesis - peak expiratory flow rate |
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Hyperventilation |
increased rate and depth of breathing |
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Hypoventiliation
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decreased rate and depth of breathing |
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What can cause hypoventilation? |
- Immobility - pain - medications - muscle/nerve dysfunction - restrictions to expansion - fatigue |
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What can cause hyperventilation? |
- severe anxiety - fear - metabolic diease |
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What can cause dyspnea? |
-variety of neurological, respiratory, metabolic, and cardiac conditions |
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Common manifestations of Respiratory compromise |
- Hypoxia - sputum production - Cyanosis - shortness of breath - Orthopnea - chest pain - Cough - abnormal breath sounds - Clubbing - use of accessory muscles - Rapid Pulse - restlessness |
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How would you assess respiratory status? |
- Doyou have any history of respiratory disease such as…? - Haveyou had and shortness of breath at rest? - Haveyou had any shortness of breath with activity? - Haveyou had a (new/different) cough? - Haveyou brought up any phlegm? What color? - Haveyou coughed up blood (hemoptysis) - Haveyou had pain with breathing (pleuritic pain)? - Haveyou had shortness of breath? - Haveyou had any wheezing? |
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Factors Affecting Respiratory Function |
- Developmental - Environmental - Lifestyle - Physiological - Psychological |
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Environmental factors |
- Risk for respiratory disease associated with the quality of the air we breathe: *Allergens *Air pollution *Workplace exposure *Home exposure |
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Lifestyle factors |
- Smoking - Stress - Pregnancy - Nutrition - Obesity - Exercise - Substance abuse - Medications (pain meds, esp. narcotics which can cause respiratory depressions) |
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Physiological factors |
- Neuromuscular - Cardiovascular - Peripheral vascular - Oxygen transport - Metabolic - Respiratory disorders |
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During the physical exam inspect for: |
- Vitals: Resp rate, O2 sat, HR, BP, Temp - Respiratorypatterns - Barrel chest - Signsof respiratory distress - Clubbing - Cheststructure - Skin color - Useof Accessory Muscles - Nasal flaring - Mucousmembrane color - Restlessness - Sputumcharacteristics - Retractions |
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Altered breathing patterns: |
- Tachypnea - Cheyne stokes - Bradypnea - Kussmauls breathing - Apnea - Orthopnea - Hyperventilation - Hypoventilation |
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During the physical exam palpate for: |
- Tactile fremitis (vibration of the chest wall during speaking) - Abnormal lumps or masses - Capillary refill should be less than 3 seconds - Palpate for edema, pulse quality and rate - Skin temperature - heart pulsations - Percussion over lung fields |
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Percussion |
- Detect presence of abnormal fluid or air in the lungs
- Determined diaphragmatic excursion |
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Ausculation |
Assess for normal or abnormal breath sounds and see if breaths are: - clear - diminished breath sound - wheeezing - ronchi - crackles |
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black sputum? |
coal dust, smoke, or soot inhalation |
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white or clear sputum?
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possible viral infection |
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yellow or green sputum? |
possible bacterial infection |
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rust colored sputum? |
possible pneumonia, TB, or old blood |
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Hemoptysis |
bloody sputum |
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pink and frothy sputum? |
- possible pulmonary edema - congetstive heart failure (chf) |
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Nursing diagnosis |
- AirwayClearance, ineffective - Aspiration,risk for - GasExchange, impaired - Ventilation,impaired spontaneous - VentilatoryWeaning Response, dysfunctional - Infection,risk for |
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Nursing interventions for altered resp. function |
- Positioning - Aspiration precautions - Ambulation - Humidifaction - Stimulating respiration - Hydration *Deep breathing - Medications *incentive spirometry - Oxygen therapy *coughing - Chest physiotherapy *pursed lip breathing - Opening airways - Non-rebreather mask - Oxygen tent |
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Non-rebreather mask |
- Provides the highest [ ] of oxygen - 2 one way valves to prevent conservation of exhaled air - Flow rate: 10-15mL/min - Delivers 95-100% |
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Oxygen tent |
- a light portable structure attached to a motor driven unit - the motor circulates and cools the air in the tent - mostly used in pediatrics - does not allow maintenance of a satisfactory or precise oxygen concentration |
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Positioning |
- Raise HOB to 60-90 degree (High Fowlers) when client having difficulty breathing - Lying down limits ling expansion - Position to increase drainage and expectoration (may need postural drainage) |
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Suctioning |
- Assess lung sounds, vitals, and oxygen saturation before and after |
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Incentive Spirometry |
- Keeps alveoli from collapsing, helps with the exchange of gases and clearing secretion |
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How to use incentive spirometer |
1. Instruct client to exhale normally, place lips around mouthpiece 2. Inhale slowly and as deeply as possible through the mouth piece 3. Hold breath and count to three 4. Remove lips from the mouthpiece and exhale normally 5. Complete breathing exercises about 10 times/hour |
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MDI |
- metered dose inhaler - a pressurized container prefilled with several doses of a drug and an eco-friendly substance called HFA for propelling the medication forward. |
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teach client to use metered dose inhaler (MDI) |
1. The patient inhales while pushing the canister's pump to release a measured dose of medication through a mouthpiece. 2. sometimes an extender is attached tot he mouthpiece to enhance the delivery of medication into the respiratory tract 3. Mediation is pumped into the extender instead of directly into the patient's mouth 4. The patient inhales the drug from the chamber |
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Stimulating respiration - Pursed-lip breathing - Coughing - Deep breathing |
Used with patients who have COPD to decrease the amount of air trapping and resistance |
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Pursed-lip breathing |
a technique of mouth breathing that creates slight resistance to exhalation by contracting the lips to reduce the size the of the opening |
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Diaphragmatic (abdominal) breathing |
majority of ventilatory work is accomplished by the diaphragm and abdominal muscles |
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Chest physiotherapy |
percussion/postural drainage is an effective intervention for PNA (pneumonia) |
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Respiratory medications |
Respiratory medications |
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Bronchodilators |
relaxes smooth muscles lining the airway |
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Anti-inflammatory |
decreases inflammation |
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cough preparations |
reduces rough |
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nasal decongestants |
relieves stuffy blocked nasal passages |
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antihistamines |
prevent the effects of histamine release related to allergies |
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mucolytic agents |
used to liquefy or loosen thick secretions |
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diuretics |
decrease fluid in the lung tissue |
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antibiotics |
kill infections |
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Ways to open the airways |
- if airway obstruction caused by bronchoconstriction-->treat with bronchodilators - Chest physiotherapy |
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5 oxygen delivery systems |
1. Nasal Cannula 2. Simple oxygen mask 3. partial rebreather mask 4. nonrebreather mask 5. Venturi mask |
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oxygen flow rate |
- measured in liters/minute - prescribed by physician - monitor client frequently |
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humidifying oxygen |
- oxygen is dry and dehydrate the mucous membrane - distilled or sterile water is used |
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Nasal cannula |
- 2-6L/min delivers - delivers 24-44% |
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Simple oxygen mask |
5-8L/min |
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venturi mask |
- delivers the most precise [ ] of oxygen - delivers 24-50% |
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simple oxygen mask |
- connect to oxygen tubing, a humidifier, at flow rates of 5-8L/min - delivers 40-60% |
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partial rebreather mask |
- client re-breathes about 1/3 of the expired air from the reservoir bag - the remaining exhaled air exiys through the tube vents - flow rate 6-10L/min - delivers 40-60% |
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non-rebreather mask |
- providesthe highest concentration of oxygen with a mask to a spontaneously breathingclient. - has a two one-way valves toprevent conservation of exhaled air. - thereservoir bag is filled with oxygen that enters the mask on inspiration –exhaled air escapes through side vents. - Flow Rate: 10-15L/min - Delivers 95-100 |
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precautions for oxygen administration |
- avoid open flames - place no smoking signs in conspicuous place at home and hospital - oxygen toxicity - electric equipment in good working order |
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Stroke volume (SV) |
the amount of blood ejected with each contraction |
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cardiac output |
SV x HR |
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Factors affecting heart rate |
- Age - gender - disease states - exercise - fever - medications - hypovolemia - stress - position change |
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BP=CO x SV |
BP: blood pressure CO: cardiac output SV: stroke volume |
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RiskFactors for Coronary Artery Heart Disease |
- Non-modifiable Risk Factors - ModifiableRisk Factors - other risk factors |
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Non-modifiableRisk Factors |
- Heredity
- Age - Gender - Race |
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ModifiableRisk Factors |
- Elevated lipids - HTN - Cigarette smoking - Diabetes - Obesity - Sedentary Lifestyle |
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Other risk factors |
- Heat/cold - Previous Health Status - Stress/Coping - Dietary factors - ETOH (ethyl alcohol) - Elevated Homocysteine - Elevated CRP (plasma protein that rises in the blood with certain diseases) |
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PreventThrombus Formation |
- TCDB
- Smoking Cessation |
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PromoteVenous Return |
- Elevation
- Ambulation - ROM - Antiembolic Stockings |
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Electricalconduction |
Sinoatrial (SA) node
- Pacer maker of the heart - Initiates an impulse that trigger a heartbeat - 60-100 beats/min Atrioventricular (AV) node Bundles of His Purkinje fibers |
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CardiovascularMeds |
- Vasodilators
- Beta-adrenergic Agents - Diuretics - Positive Inotropes |
