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172 Cards in this Set

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positive end-expiratory pressure (ventilatory support)

in ventilatory support, applies positive pressure to keep the alveoli from collapsing between breaths

assist/control mode (ventilatory support)

responds to each breathing attempt by administering a breath, or delivers preset breath

synchronized intermittent mandatory ventilation [SIMV] (ventilatory support)

delivers preset breaths but also allows pt to take unassisted breaths

controlled mandatory ventilation (ventilatory support)

delivers preset breaths without regards to pts attempt to breathe




rarely used except in paralyzed or anesthetized pts b/c of problems w/ synchrony

continuous positive airway pressure [cpap]

+ pressure applied throughout respiratory cycle to a spontaneously breathing pt to promote alveolar & airway stability. helps prevent alveolar collapse




infants: may be applied nasal prongs, nasopharyngeal tubes, or endotracheal tube




criterion: must be able to breathe spontaneously w/ assistance to relieve respiratory distress in infants

chronic obstructive pulmonary disease [copd]

when on 02 therapy, closely monitor for bradypnea b/c it could indicate impending problem. breath sounds are often diminished, but if still diminished following cpt it should be noted




monitor pulse oximetry & ABGs to ensure proper oxygenationadequate hydration is one of the simple, effective ways to achieve clear breath sounds. hypoxemia helps stimulate pts respiratory effortsprovide incentive spirometry & encourage deep breathingprovide high calorie, protein rich foods to promote healingpt should receive o2 at 1-2Lmin to prevent respiratory depressionwhen prolonged disease or injury has made lungs less capable of meeting body's o2 needs


"good lung down" & tripod positionex: chronic bronchitis, emphysema & asthmarisk factors: tobacco smoke, passive smoking, occupational exposure to dust & chemicals, ambient air pollution, genetic abnormalitiesactivity intolerance: estab. regular exercise routine

pursed-lip breathing (purpose)

good to teach w/ emphysema pt.


*prolongs exhalation & builds pts ability to control rate & depth of respirations (increase airway pressure) & ease sob. allows airways to not collapse between breaths. strengthens respiratory muscles

pneumonia

key indicators of development: fever, tachypnea, cough, & crackles


productive cough, rhonchi, wheezing & pleural friction rub


lobar pneumonia: exudate infiltrates & fills alveoli which leads to ventilation-perfusion mismatch & altered ABGs

bronchiectasis

chronic dilation of bronchus or bronchis/s: chronic cough, purulent secretions, hemoptysis, & clubbing

lung abcess (s/s)

dyspnea, fatigue, anorexia & wt loss

orthopnea (positioning)

high-fowler's w/ something like a pillow or table for the pt to rest on to help reduce fatigue & dyspnea

tracheostomy suctioning

suctioning should be applied no longer than 10-15 seconds as cath is being w/drawn. longer suctioning can cause hypoxia, dysrhythmias, & even cardiac arrest

cromolyn sodium [intal]

inhibits the release of histamine. keeps airway from narrowing in response to exercise or cold

tonsillectomy (nursing care)

mntr for patent airway

hypoxia

neurological effects are often first distinctive sign ex. mental confusion




chronic renal failure is likely to predispose pt to hypoxia due to associated decrease in production of erythropoietin which is required for RBC production

asthma

**airway obstruction caused by swelling of the bronchial lining & filling of the bronchi w/ mucus




**pt should use inhaler in anticipation rather than waiting for troubling symptoms




**restricted air movement through narrowed airway causes wheezing




**no stuffed animals (collect dust)

mantoux TB skin test

raised area of 10mm or more is a positive skin reaction in a child under 4 yrs old or having medical risk factors like hodgkin's disease. a positive skin reactions indicates sensitivity to the tuberculosis bacillus.




this test uses purified protein derivative (pdd) & is unlikely to cause an allergic reactionnegative reaction: raised area less than 5mm

pneumococcal vaccine

priority in those w/ cystic fibrosis b/c consequences of pneumococcal disease are very serious in cystic fibrosis

atelectasis

"incomplete expansion". lung collapse (can be due to obstructed airway)causes labored breathing b/c of decreased surface area & obstructed airway. obstructive atelectasis is most common


s/s: marked respiratory depression, dyspnea (orthopnea), tachycardia, tachypnea, pleural pain, central cyanosis, crackles, chest xray (patchy infiltrates & consolidated area)


prevention: fx turning, early mobilization, deep breathing, incentive spirometrysecretion


mngmnt: directed cough, suctioning, aerosol nebulizer tx followed by cpt & bronchoscopy

bronchitis

causes mucus build-up & obstructed airflow

pleurisy

teach comfort measures, turn frequently to affected side to splint chest wall & reduce stretching of pleurae. use hands or pillow to splint when coughing




s/s: knifelike chest pain is classic

pneumothorax

positive pressure (air) w/in chest cavity from accumulated air that can't hape during expiration. leads to atelectasis, mediastinal shift & compression of heart & great vessels




**may have no symptoms. sharp pain on inspiration does occur but is diagnostic




s/s: may have sharp pain inc chest or referred to shoulder/arm on affected side, restlessness, anxiety, dyspnea, cough, cessation of normal mvmnts on affected side, absent BS on affected side, pallor, cyanosis, shock, tracheal deviation to unaffected side

flail segment

detached rib segmentcauses paradoxical chest movement w/ difficulty breathing

pleural effusion

abnormal accumulation of fluid in pleural space, usually secondary to other disease




**s/s: dyspnea & tracheal deviation** pleuritic pain that is sharp & increases w/ inspiration, dry nonproductive cough, dyspnea on exertion, tachycardia, decrease breath sounds & elevated temp




can result in cardiac tamponade

tension pneumothorax

**classic signs: air hunger & agitation




mediastinal shift to the opposite side of the chest




1-way leak.may occurs during mechanical vent or cps or complication of spontaneous or traumatic pneumothorax

laryngectomy

removal of vocal chords. pt must learn alternative communication methods. stoma should be protected from water. stoma should never be tightly covered b/c it would obstruct pts airway. eventually pt may learn to speak using the esophagus or electric larynx.




total laryngectomy: permanent tracheostomy. pt may lose sense of smell & taste

acid-base

metabolic acidosis: low or normal PaCO2 & pH< 7.4


metabolic alkalosis: high or normal PaCO2 & pH>7.4


respiratory acidosis: combo of PaCO2 > 40 & acidosis


respiratory alkalosis: low PaCO2 & alkalosis

respiratory acidosis

excess CO2 retention. pH<7.35 | HCO3 >26 mEq/L (if compensating) | PaCO2 >45 mmHg




respiratory acidosis is an an attempt of the body to compensate for excessive PaCO2. can be caused by any situation that would cause respiratory depression




cns depression, asphyxia, hypoventilation due to pulmonary, cardiac, musculoskeletal or neuromuscular disease, obesity, postop pain, ab distentions/s: diaphoresis, h/a, tachycardia, confusion, restlessness, apprehension, drowsiness, tremor, myoclonic jerks, asterixis, stupor (co2 narcosis) & hypoxia

respiratory alkalosis

excess co2 excretion. pH>7.45 | HCO3<22 mEq/L (if compensating) | PaCO2<35 mmHg (if compensating)




compensatory mechanism aimed to increase excretion of HCO3 & retention of the hydrogen ions. from any condition that causes the respiratory system to be overstimulated




hyperventilation > decreased PaCO2 > ^ ratio of bicarb concentration to PaCO2 > ^ pH = respiratory alkalosis




alveolar hyperventilation (leads to decreased partial pressure of arterial PaCO2) due to anxiety, pain or improper ventilator settings. respiratory stimulation, gram-neg bacteremia, compensation for metabolic acidosis (chronic renal failure)




chronic respiratory alkalosis: pH is almost norm to norm




s/s: rapid, deep breathing, paresthesia, light-headedness, twitching, anxiety, fera, confusion, cramps, syncope, hyperpnea, tachypnea, carpopedal spasm, peripheral & cirumoral paresthesia

metabolic acidosis

HCO3 loss, acid retention. pH<7.35 | HCO3<22mEq/L | PaCO2<35 mmHg (if compensating)




body is pulling HCO3 into the cells as a buffer which depletes plasma level.




HCO3 depletion due to renal disease, diarrhea, or small-bowel fistulas. excessive production of organic acids due to hepatic disease, & endocrine disorders




s/s: rapid deep breathing, fruity breath, fatigue, h/a, lethargy, drowsiness, n&v, & coma (if severe)

metabolic alkalosis

HCO3 retention, acid loss. pH>7.45 | HCO3>26 mEq/L | PaCO2>45 mmHg




loss of hydrochloric acid from prolonged vomiting or gastric suctioning. loss of K due to increased renal excretion (as in diuretic therapy) or steroid overdose excessive alkali ingestion. compensation for chronic respiratory acidosis




s/s: slow shallow breathing, hypertonic muscles, restlessness, twitching, confusion, irritability, apathy, tetany, seizures, coma (if severe), h/a, & lethargy

thoracentesis (position)

involves insertion of a needle on affected side. pt should be positioned sitting on edge of bed w/ arms & head resting on over-the-bed table

peak expiratory flow meter

pt must be standing. lips should be closed tightly around mouth piece, blow out as hard & quickly as possible. each use should include 3 separate readings w/ a 30 second wait between each attempt

activity intolerance in pts w/ chronic respiratory disease

regular structured exercise (aerobic, strength, & inspiratory muscle training) is recommended to prevent deconditioning that comes from activity intolerance

ABG values (normal)

pH: 7.35-7.45


PaCO2: 35-45


HCO3: 22-26 mEq/L


PaO2: 80-95 mmHg


SaO2: 95%-99%

ABGs (PaCO2)

decreased ventilation has a higher value & increased ventilation has a lower value




hyperventilation causes alkalosis because the patient is blowing off CO2 and hypoventilation causes acidosis because the patient is retaining CO2.

ABGs (HCO3)

regulated by the kidneys & evaluates the metabolic component. below 22 is considered acidosis & above 26 is alkalosis. several days could be required to normal compared to PaCO2 abnormal levels which can be adjusted more quickly

ABGs

ABGs (compensation)

acid is regulated by the respiratory system, alkaline is regulated by metabolic and if compensated everything shifts in the opposite direction

pulmonary arterial htn [PH]

progressive & ultimately fatal disease that presents as elevated bp in the pulmonary arteries. evolves as comorbidity of other disease or conditions (connective tissue disease, lung diseases, liver disease, pregnancy, hiv, L heart failure, & others)


affect both pulmonary & cardio systems w/ potential neg impact on life

pulmonary arterial htn [PH] (dx)

on average PH is not dx until pulmonary vascular bed is significantly damaged resulting in sob. ECG may reveal R ventricular hypertrophy & strain & R atrial enlargement. ECG can't dx PH alone




s/s similar to other pulmonary diseases: sob, exertional fatigue, nonspecific subjective & objective findings of PH resemble those of heart failure, possible differential dx include sleep apnea, cor pulmonale, PE, hypothyroidism, mixed connective tissue disease & portal htn

PH associated w/ L heart disease

systolic dysfunction, diastolic dysfunction, & valvular disease

PH as a result of lung disease &/or hypoxemia

copd, interstitial lung disease, other pulmonary disease w/ mixed restrictive & obstructive pattern, sleep-disordered breathing, alveolar hypoventilation disorders, chronic exposure to high altitudes, & developmental abnormalities

classification of PH

pulmonary arterial htn, pulmonary ht associated w/ L heart disease, pulmonary htn as a result of lung disease &/or hypoxemia, chronic thromboembolic pulmonary htn, pulmonary htn w/ unclear &/or multifactorial mechanisms

pulmonary htn w/ unclear &/or multifactorial mechanisms

hematological disorders: myeloproliferative disorders, splenectomy; systemic disorders: sarcoidosis, pulmonary langerhans cell histiocytosis; metabolic disorders: glycogen storage disease, gaucher's disease, thyroid disorders (may exacurbate PH); others: tumoral obstruction, fibrosing mediastinitis, chronic renal failure on dialysis

world health organization functional classes

class I: no symptoms-induced limits on physical activity


class II: slight symptoms-induced limits on physical activity


class III: marked symptoms-induced limits on physical activity


class IV: R-sided heart failure w/ dyspnea & fatigue at rest & inability to perform any physical activity w/o symptoms

pulmonary arterial htn [PH] (s/s)

pt may reveal non-specific symptoms like dyspnea, fatigue, angina, syncope, weakness & ab distention & symptoms at rest occur in very advanced stages of PH




L parasternal lift, abnormal heart sounds, jvd, hepatomegaly, peripheral edema, ascites, cool extremities may be present

PH (dx testing)

supraventricular arrhythmias may be present in advanced stages of PH. chest radiograph may reveal R atrium & ventricular enlargement & pulmonary artery dilatation. pulmonary function tests identify underlying lung disease & assess severity of PH (lungs of PH are more stiff & smaller). decreased lung diffusion capacity for carbon monoxide. CT can detect interstitial lung disease along w/ possible emboli & give info on the heart




doppler echocardiography more specific for DXing PH, measures pulmonary artery pressures noninvasively, pumping ability of R & L ventricles & valve function & can detect congenital heart defectsexercise tolerance test, 6-minute walk test (6MWT). healthy individual: minimum of 500 meters in 6 mins, pt w mod PH may be able to walk only 300 meters




R heart cath is most accurate test for PH, normal MPAP at rest is between 12-16mmHG. pt w/ resting MPAP > or equal 25 is dx w/ PH. MPAP>30 while exercising is definitive for PH

PH (meds)

meds that restore vasodilator effects & prevent overgrowth of cells in n attempt to decrease PA pressures & increase CO




Calcium channel blockers: nifedipine, amlodipine besylate, & diltiazem hydrocholride used initially if pt has + response to vasodilator challenge


prostanoids: epoprostenol (mimics prostoglandins, dilates blood vessels, prevents platelets from clumping, increases CO & slows growth of smooth muscle cells), iloprost & treprostil may be used in PH pt who has a + response to vasodilator challenge.


endothelin receptor antagonists


phosphodiesterase inhibitors




lung transplantation: option when meds don't help pt improve

empysema

permanent enlargement & loss of surface area for gas exchangeolder, thin, severe dyspnea, quiet chest, x-ray: hyperinflation w/ flattened diaphragmdistinguishing character: airflow limitation caused by thick elastic recoil in the lungsexertional dyspnea w/o cyanosispt teaching: drink 2L/day to help liquefy sections

pulmonary embolism

causes ventilation-perfusion mismatch resulting in hypoxemia & intrapulmonary shunting




massive consequence is pulmonary htn which ultimately leads to R-sided heart failure




assist w/ admin o2 & intubation & mechanical ventilation if respiratory failure occur.admin meds

thoracotomy

incision into pleural space in chest




**airway clearance is one of the critical concerns following a thoracotomy b/c retained secretions can cause various complications

respiratory distress in infants (clinical manifestation)

**rapid breathing, retractions, grunting, nasal flaring & pallor

laryngeotracheobronchitis (clinical manifestation)

**stridor on inspiration is one of the defining manifestations




typically low-grade fever

bronchospasms (complications)

uncontrolled can lead to status asthmaticus, an emergency that can develop into respiratory arrest

ineffective airway clearance (nursing instructions)

6-8 glasses of water a day (helps liquify & loosen secretions), use pursed-lip breathing prior to coughing & avoid cigarette smoke

way to optimize gas exchange in a pt on a vent

frequent repositioning is a key intervention

cfc-based metered dose inhaler (mdi)

canister floats=MDI is empty




cfc-based MDI stands up straight on bottom of container=3/4 full




MDI should be held upright & tilt head slightly back. inhalers w/o spacer are positioned 1-2 inches away from mouth. spacer is usually placed in mouth

epiglotitis

combo of croupy cough, drooling & agitation suggests epiglotitis which is rapidly progressive & serious




s/s: fever, severe sore throat, drooling & muffled voice

cigarette smoking

increases ciliary (part of body's defense against RI) paralysis

asthma (long-acting meds)

alleviate symptoms & improve airway function. needs to be taken regularly, not prn

incentive spirometer

enhances lung expansion allowing max intake per inhalation while maintaining relatively low airway pressure (ideal for pt w/ atelectasis)




helps maximize diffusion & alveolar surface area & can help prevent atelectasis

cyanosis (nursing intervention)

indicates obstruction of airway




child in recovery rm, initial response should be suction

upper respiratory infection (uri)

increasing humidity helps liquify secretions. warm or hot showers & hot packs can help w/ relief of congestion.


maintenance of patent airway, relief of pain

tracheostomy (prevent obstruction from secretions)

humidify air being inspired

orthopnea

anxious, restless & breathless while lying down. upright position will usually provide relief after 10-30 mins

pulmonary edema

collection of fluid in interstitium & alveoli as pressure rises in pulmonary vessels




L ventricle can't effectively pump from heart, w/ increased resistence to L ventricullar filling fluid backs up into lungs. surface tension increases, alveoli shrink & lungs b/c stiff




s/s: tachycardia, tachypnea, dyspnea, increased respirations, orthopnea, pulmonary htn, jvd, elevated pawp, pink frothy sputum, crackles




tx: PA catheter, diuretics, intubation, mechanical vent, morphine to decrease preload respiratory rate & anxiety, for those who don't respond to med tx intra-aortic balloon pump to temporarily assist failed L ventricle or surgery

pulmonary edema (nursing consideration)

admin o2 (aids ventilation, improve Pao2 & reverse hypoxemia), place pt in semi-fowler's, mntr i&o, meds for pain, frequently change positions to prevent ulcers & encourage lung expansion

respiratory depression
morphine sulfate


respiratory rate may decrease, causing hypoventilation allowing build up of CO2 which causes cerebral
wheezing
usually heard on expiration and commonly found w/ asthma, chronic bronchitis or bronchiectasis
empyema
pus in pleural space


objective: drain pleural cavity (needle aspiration, tube thoracostomy or open chest drainage via thoracotomy) & achieve complete expansion of lungs. admin appropriate antibiotics in large doses
pulmonary function tests
measure long volume and airflow
dx pulmonary disease, mntr disease progression, evaluate disability and evaluate response to bronchodilators
xerostomia
dryness of mouth from variety of causes
pressure release ventilation (aprv)
mechanical ventilation that allows unrestricted, spontaneous breaths throughout ventilatory cycle


on inspiration pt receives preset lvl of continuous + airway pressure & pressure is periodically released to aid expiration
chest physiotherapy (cpt)
used to remove bronchial secretions, improve ventilation & increase efficiency of respiratory muscles
fraction of inspired o2 (FiO2)
concentration of o2 delivered. 1.0–100% o2
hypoxemia
decrease in arterial o2 tension in blood hypoxia, decrease in o2 supply to tissues & cells
pressure support ventilation (psv)
mechanical ventilation in which preset + pressure is delivered w/ spontaneous breaths to decrease work of breathing
dullness over lungs
when air–filled lung tissue is replaced by fluid or solid tissue
asymmetric excursion
may signal pleurisy, fractured ribs, trauma or unilateral bronchial obstruction
bradypnea
associated w/ intracranial pressure, brain injury & overdose
acute tracheobronchitis
clinical manifestations: dry, irritating cough & expectorates, scanty amount of mucous sputum. fever, chills, night sweats, h/a & general malaise.


as disease progresses SOB, noisy inspiration & expiration & produce purulent sputum
coughing at night
L–sided heart failure or bronchial asthma
dry cough
URTI of viral origin or side effect of ACE inhibitor
funnel chest
depression in lower portion of sternum, may compress heart & great vessel


occurs w/ rickets or marfan's syndrome.
morning cough w/ sputum
bronchitis
irritative, high pitched cough
laryngotracheitis
pigeon chest
occurs as result of displacement of sternum


may occur w/ rickets, marfan's syndrome or severe kyphoscoliosis
foul smelling sputum & bad breath
lung abscesses, bronchiectasis or anaerobic infection
assessing tactile fremitus
air does not conduct sound. consolidation such as in pneumonia has increased fremitus
purulent sputum (thick & yellow, green or rust colored) or change in color
bacterial infection
profuse, pink, frothy sputum
pulmonary edema
pharyngitis
fiery–red pharyngeal membrane & tonsils, lymphoid follicles are swollen & flecked w/ white–purple exudates, enlarged & tender cervical lymph nodes & no cough. fever, malaise & sore throat may be present. can be virlal
clubbing of fingers
chronic hypoxic conditions, chronic lung conditions or malignancies of the lungs
sinusitis (complications)
acute may lead to meningitis, brain abscess, ischemic brain infarction or osteomyelitis
biot's breathing
cycles of breathing that vary in depth & have varying periods of apnea seen w/ some CNS disorders
cheyne–stokes breathing
alternating episodes of apnea & deep breathing. deep respirations b/c increasing shallow. duration of apnea b/c progressively longer


associated w/ heart failure & damage to respiratory center
high risk recommended for pneumonia vaccine
65 yrs or older, immunocompetent w/ chronic illness, immnocompromised
sputum sample
1. rinse mouth w water to reduce contamination by normal flora
2. breathe deeply several times
3. cough deeply
4. expectorate raised sputum


suction or bronchoscopy
tuberculosis
place pt on isolation precaution including high–efficiency particulate mask (N95 mask) by those coming in contact w/ pt to prevent inhalation of potentially infectious respiratory sections. pt should be placed in neg–airflow rm


s/s of active TB: cough w/ frothy pink sputum, night sweats, anorexia & wt loss
cuffed endotracheal tube
inflated cuff prevents aspiration of gastric contents
excess tidal volume
causes too much CO2 to be blown off causing respiratory alkalosis
color of mucous membranes
great indicator of pt's oxygenation status
laryngotracheobronchitis
nasal flaring, severe retractions, croupy or barking cough, & tachypneic
montelukast sodium (singulair)
leukotriene receptor antagonist that is used for prophylaxis & chronic tx of asthma.


1 tab qd
process for antibiotic therapy for serious infection
culture infected site
while waiting, admin antibiotic known to tx common organisms
susceptibility testing done when causative organism is IDed
admin narrow spectrum antibiotic
sigh mechanism
delivers a RXed # of sighs per hour to mimic normal respirations to prevent atelectasis
TB meds
rifampin
pt should notify if skin b/c jaundiced b/c it's indicative of onset of hepatotoxicity
imbalanced or mismatched VQ scan
indicates some type of prob w/ ventilation or perfusion
pneumocystis carinii infection
pts are often acutely ill & fatigued b/c of hypermetabolism from AIDS
unilateral lung disease
"good lung down"
high o2 concentration
may depress breathing
hypercapnia
caused by poor ventilatory effort (ex. chest trauma which decreases lung ventilation)
pulmonary fibrosis
causes alveolar–capillary interface to b/c thicker increasing amount of time it takes for gas to diffuse across membrane
barbituate
CNS depression


opioid overdose develops hypercapnic respiratory failure which results from decrease in respiratory rate & depth. overdose can cause ARDS (adult respiratory distress syndrome)
bipap
bilevel positive pressure ventilation requires pt initiate adequate respiratory rate to allow adequate gas exchange
positive pressure ventilation (ppv) & PEEP
complication: subcutaneous emphysema
positive end–expiratory pressure (peep)
+ pressure maintained by ventilator at end of exhalation to increase functional residual capacity & open collapsed alveoli


improves gas exchange & oxygenation by preventing alveolar collapse during expiration
ARDS, fibrotic phase
chance for survival is poor b/c permanent damage to alveoli has occurred
gram–neg sepsis & increased respirations
ARDS may be developing
FEV1/FVC
indicates disease progression. ratio will be smaller when COPD worsens
aminophylline
changes in smoking patterns will have impact on amount of aminophylline needed


therapeutic range is 10–20 mcg/mL
inhaler
lips tightly sealed encourages nasal breathing which interferes w/ effectiveness
acute lung injury
umbrella term for hypoxemic, respiratory failure


ARDS is severe form
alpha 1 antitrypsin deficiency
deficiency puts pt at increased risk for developing panacinar emphysema even in absence of smoking

alpha 1 antitrypsin is protective agent for lung
thoracic aortic aneurysm
s/s: substernal chest pain, back & neck pain, dyspnea, cough & stridor. respiratory symptoms are due to pressure on trachea
bronchoscopy
informed consent required, explain what to expect during procedure, pt should be NPO for min of 6 hrs prior to procedure


post–procedure check for gag reflex, VS, mntr for laryngeal edema, dyspnea, stridor & hoarseness
pneumonectomy
post–op: positioned either supine or on operative side to facilitate ventilation & perfusion. this allows fluid drainage to consolidate in pleural space on operative side rather than in pt's remaining lung
alpha1–antitrypsin deficiency
tachycardic, diminished BS w/ wheezing & exertion dyspnea
chronic hypoxia
elevation of H/H is a compensatory response
acute respiratory failure
Partial pressure of arterial O2 is below 60 mmHg or arterial O2 sat is below 91%PaCO2 above 50 mmHg & pH below 7.35
chPaO2 decrease or PaCO2 increase of 10 mmHg from baseline in pts w/ chronic lung disease


s/s: tachycardia, tachypnea, periorbital or circumoral cyanosis, diaphoresis, accessory muscle use, diminished lung sounds, inability to speak in full sentences, impending sense of doom & altered mental status
chronic respiratory failure
long–term condition that develops over time like w/ COPD. less apparent than acute
respiratory failure (3 types)
1) hypoxemic RF (failure to exchange o2)
2) hypercapnic RF (failure to exchange or remove CO2)
3) perioperative RF (subtype of (1) & results from lung or alveolar atelectasis
respiratory failure (s/s)
SOB, mental–status changes & decreased SpO2
respiratory failure (nursing care)
asses tissue oxygenation status regularly. brain is extremely sensitive to o2 supply, decreased o2 can lead to altered mental status, angina signals inadequate coronary artery perfusion
carbon monoxide poisoning
CO is a colorless, odorless, tasteless gas. binds to hemoglobin molecule 200–250 times more tightly than O2. PaO2 is still norm, vasodilation caused by CO causes "cherry–red" skin
croup syndrome
airway obstruction


LTB (acute usually occurs in fall or winter in N Am. mild), laryngitis or acute spasmodic laryngitis (obstructive narrowing of larynx b/c of viral infection, genetic or emotional distress. common in kids w/ allergies)
epiglottitis
serious inflammation of epiglottis resulting in obstruction, bacterial in origin (usually Haemophilus influenzae). usually abrupt & preceded by sore throat, emergency situation.


s/s: hgih fever, irritability, restlessness, red/inflamed throat w/ cherry edematous epiglottis, difficulty swallowing & drooling, muffled voice, inspiratory & sometimes expiratory stridor, suprasternal & substernal retractions, tripod positioning (child thrusts chin forward & opens mouth in attempt to widen airway), color of mmild hypoxia (possibly progressing to cyanosis)


thumb sign is classic finding in lateral neck radiograph
epiglottitis (nursing interventions)
assess for respiratory distress, axillary temp not oral, don't attempt to visualize posterior pharynx using tongue depressor (could result in spasm), maintain NPO, & mntr hydration status & i&o
laryngotracheobronchitis (infectious croup)
caused by inflammation of mucosa lining the larynx & trachea cause narrow airway. stridor. primarily affects children less than 5 yrs, gradual onset often preceded by URI
laryngotracheobronchitis (stages)
stage 1: anxiousness or fear, *hoarseness, croupy cough (barking seal) & inspiratory stridor
stage 2: respiratory stridor b/c continuous, soft tissue of neck may retract, intercostal retractions of lower ribs, accessory muscles of respiration are used, labored respiration, mild wheezing
stage 3: signs of anoxia & Co2 retention develop (tachypnea, restlessness & anxiety), sweating & pallor
stage 4: intermittent cyanosis to permanent cyanosis & respiratory failure
laryngotracheobronchitis (nursing interventions)
mild croup (no stridor at rest) can be managed at home. educate on respiratory distress, progress to stage 2 need med attention, cool temp therapy (cool mist humidifier or night air), elevate head at rest, provide humidified o2, fluids & antipyretics, avoid cough syrups & cold meds, admin nebulized epinephrine in those w/ severe, resuscitation equip available
acute spasmodic laryngitis
brief attacks of laryngeal obstruction chiefly at night. child suddenly awakens w/ characteristic barking, metallic cough, noisy inspirations, hoarseness & restlessness. none – mild inflammation, on fever, duration is few hrs & child feels well the next morning.


nursing intervention: steam from hot bath or shower or cold steam from humidifier. attempt exposure to night air


admin cough/cold meds if needed, admin bronchodilator if bronchospasm suspected, mod severe may need hospitalization
bacterial tracheitis
involves mucosa upper trachea, exhibits features of croup & epiglottitis, preceded by URI w/ croupy cough, may be complication fo laryngotracheobronchitis

s/s: rever, brassy cough, inspiratory stridor, *HALLMARK production of thick purulent tracheal secretions which can result in obstruction & even respiratory arrest
sinusitis
predisposing factors: allergic rhinitis, vasomotor rhinitis, rhinitis medicamentosa, URI, nasal polyps, immunodeficiency factors & environmental factors. most begin as unresolved URI of 7–10 days


s/s: purulent nasal secretion, increased posterior pharyngeal secretions, mucosal erythematic, periorbital edema, tenderness overlying sinuses


tx: focuses on eradicating bacterial infection. 1st line med: amoxicillin, bactrim, erythromycin
sleep apnea
3 types: obstructive, central & mixed
sinusitis (nursing management)
aside from completing course of antibiotics, non pharmacological therapies like warm compresses to the sinuses, humidifying air w/ steam or vaporizer, maintaining adequate hydration & smoking cessation
sinusitis (tx)
focuses on eradicating infection, shrinking nasal mucosa & reducing pain
sinusitis vs allergy vs cold
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nasal obstruction
non anatomic causes: chronic sinusitis, allergies, overuse of nasal sprays, birth control pills, htn & thyroid abnormality
anatomic causes: deviated septum, nasal polyps, enlarged adenoids, nasal foreign body & hypertrophic nasal turbinates
surfactant
enables alveoli to remain open


bed rest decreases amount of surfactant produced. along w/ blockage of bronchiole w/ mucus can cause atelectasis (pooled secretions may accumulate in dependent area of bronchiole & effectively block it)
pulmonary fibrosis
highly lethal interstitial lung disease, damage to lung tissue from excessive wound healing


lung injury>inflammation>neutrophilic response>lymphocyte & macrophage response>exudation of serum proteins into alveolar space>collapse of alveolar unites>healing by fibrosis
sarcoidosis (fibrotic lung disease)
hallmark: noncaseating granulomas (can occur in almost any organ or tissue)


most commonly affect lungs (also liver, spleen, lymph nodes, eyes, small bones of hands & feet & skin)


for most spontaneously resolve, others may develop pulmonary fibrosis & severe systemic disease
sarcoidosis (s/s)
nonproductive cough, dyspnea, chest discomfort, severe results in loss of lung compliance & functional ability to exchange gases, cor pulmonale (R–sided cardiac failure)
cystic fibrosis
generalized dysfunction of exocrine glands which affects multiple organ systems. autosomal recessive trait, both parents are carriers, 1 in 4 incidence. lack phenylalanine (lack of essential amino acids leads to dehydration & mucosal thickening in respiratory & intestinal tracts). males w/ CF are sterile


pancreatic enzymes improve absorption & digestion of fat & protein. taken before or w/ meals or snacks. never mix w/ other meds in any fluid. DO NOT use cough suppressants, important to expectorate


s/s: excessive salty taste to skin, barrel chest, clubbing of fingers & toes, crackers & wheezing, cyanosis, dyspnea, failure to thrive, poor wt gain, distended and, fx bouts of pneumonia, steatorrhea, fx URI, meconium ileus (intestinal obstruction in infants), persistent cough & thick secretions
cystic fibrosis (tx)
diest w/ increased fat & NA, salt supplements, pancreatic enzyme replacement, breathing exercises, chest percussion & postural drainage, inhaled beta–adrenergic, broad–spectrum antimicrobials, NA channel blockers, heart or lung transplant, drones alfa (pulmozyme), high fx chest compression vest, o2 therapy prn, bronchodilators, mucolytic aerosols & corticosteroids
cystic fibrosis (nursing considerations)
amin pancreatic enzymes w/ meals & snacks, perform CPT, o2 therapy, high–calorie/high–protein diet w/ plenty of fats, admin vat A, D, E & K if deficient, plenty of liquids to prevent dehydration, provide exercise & activity periods, encourage deep–breathing
asthma
s/s: chest tightness, coughing w/ thick clear or yellow mucous, cyanosis (late sign), diaphoresis, nasal flaring, pursed–lip breathing, sudden dyspnea, tachycardia, tachypnea, use of accessory muscle for breathing & wheezing accompanied by coarse rhonchi
tx: low–flow humidified o2, steroids, singular, bronchodilators
nursing considerations: high fowler's, anticipate intubation & mechanical vent, mntr serum theophylline lvls, perform postural drainage & chest percussion
status asthmaticus
severe stoma attack w/ bonchospasm that doesn't respond to conventional therapy. severe mucous impactions & marked inflammatory infiltration has caused death


goal of therapy is to reduce obstruction by relaxing bronchial smooth muscles & reducing inflammation
albuterol
bronchodilator of choice to tx asthma due to quick onset. commonly nebulizer & inhaler for emergencies


ae: tachycardia, tremors, chest pain & dysrhythmia
flail chest
when 2 or more ribs are fractured leading to rib cage instability & possible organ injury resulting in pulmonary emergency


on inspiration flail segment is pulled inward by negative intrathoracic pressure. on expiration the positive pressure forces segment to protrude outward


s/s: chest pain, dyspnea, tachypnea & tachycardia
nursing dx: impaired gas exchange r/t dysfunctional rib cage, acute pain r/t flail chest, anxiety r/t dx of flail chest
exudative effusion
chylous effusion: milky white effusion high in triglycerides
chyliform effusion: resemble chylous effusion but low in triglycerides & high in cholesterol
hemothorax: bloody fluid in pleural space
empyema: pus in pleural space
trapped lung: lung encased by fibrous peel caused by empyema or tumor
latrogenic effusion: can be caused by migration or misplacement of feeding tube into trachea or perforation of superior vena cava by cvc
chronic bronchitis
daily productive cough for 3 months or more in at least 2 consecutive years


over–wt cyanotic, elevated hemoglobin, peripheral edema, rhonchi & wheezing


barrel chest b/c of lung hyperinflation
high o2 concentration
suppress drive to breathe
CO2 narcosis (o2 toxcity)
chronic o2 retention secondary to excessive o2 delivery


s/s: signs of hypoxia, drowsy, irritable, hallucinations, convulsions, tachycardia, arrhythmias & poor ventilation


nursing considerations: keep o2 below 3L/min & no more than 70% o2 delivered
closed (spontaneous) pneumothorax
rupture of sub pleural bulla, tuberculous focus, carcinoma, lung abscess, pulmonary infarction, severe coughing attack or blunt trauma
open (traumatic) pneumothorax
communication between atmosphere & pleural space because of opening in chest wall
pneumothorax (nursing dx & considerations)
ineffective breathing pattern r/t atelectasis
impaired gas exchange r/t abnormal thoracic mvmnt
pain r/t trauma to chest area
fear r/t emergency situation


place sterile occlusive gauze over wound, tape dressing to three sides to allow air to escape during expiration, place pt on affected side to diminish possibility of tension pneumothorax, encourage slow breathing to improve gas exchange
adults respiratory distress syndrome (ards)
aka: shock lung


fluid accumulates in lung interstitium, alveolar spaces & small airways causing lungs to stiffen
severe ads can cause intractable & fatal hypoxemia
hallmark: hypoxemia despite admin of o2
s/s: apprehension, crackles, dyspnea, hypoxemia, intercostal & suprasternal retractions, cough confusion, hypotension, mental sluggishness, motor dysfunction, rapid shallow breathing, restlessness, rhonchi & tachycardia


tx: humidified o2 w/ continuous positive airway pressure, peep, fluid restriction, diuretics, correction of electrolyte & acid/base abnormalities, reverse severe metabolic acidosis w/ sodium bicarb
acidosis (ABGs)
whether respiratory or metabolic in origin, is a CNS depressant

s/s: lethargic, confused or comatose

respiratory acidosis (causes)
COPD, chest wall disorders, obesity, obstructive sleep apnea, CNS depression, lung & airway diseases & lung–protective mechanical ventilation w/ permissive hypercapnia in tx of acute respiratory distress syndrome

pulmonary embolism (dx tests)

positive d-dimer & ventilation/perfusion (v/q) scan indicates pulmonary embolus