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33 Cards in this Set
- Front
- Back
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Assessment: Subjective Data
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Shortness of Breath:
- When: day, night, with or without activity -orthopnea (difficulty breathing when lying down) Cough: dry, productive, hacking -treatment an success of treatment Sputum: -color, consistency, odor, blood - Chest pain: -location, description, treatment and success of treatment Past medical history Family History Lifestyle Allergy and environment |
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Assessment: Objective Data
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Four techniques:
Inspection Palpation Percussion Auscultation |
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Inspection
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Configuration of the thorax:
-AP diameter approximately one hald the width of lateral diameter -pigeon chest, barrel chest, funnel chest, kypho-scoliosis Physician signs of pre-existing pulmonary disease -clubbing of digits, scars, pursed lip breathing Breathing Pattern: -normal: rate 12-20, smooth, effortless, regular and symmetrical -ABNORMAL: tachypnea, bradypnea, hyperventialtion, hypoventilation, cheyne-stokes, apnea Signs of labored breathing: -gasping, difficuylty speaking, nasal flaring, pursed lip breathing, accessory muscle use -fatigue and breathlesness upon exertion skin and nail beds: -pale flushed, mottling (blotchy), cyanosis, clubbing Presence of cough Level of Consciousness |
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Memory Board (when doing assessment)
CRAMP |
*Chest -wall symetry
*Respiratory rate and pattern *Accessory muscle use *Masses or scars *Paradoxical movement |
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Food for thougt
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men, children, infrants and singers usually use abdominal or diaphramatic breathing.
most women usually use chest or intercostal breathing |
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Palpation
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*Symmetric chest expansion
*measure chest excursion *Tactile fremitus (palpable vibration) *Detects crepitus or any abnormal shapes |
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Percussion
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Resonance is the noranl sound heard over the lungs
Flat: thigh: consolidation, atelectasis Dull: thudlike: solid areas like pneumonia Hyperresonant: stomach: hyperinflation of the lungs Typanic: drumlike: pneumothorax |
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Auscultation
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Have the patient breathe through the mouth
Nose breathers alter breath sounds Should be systematic |
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Voice Sound
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Bronchophoney "99"
Egophony "E" Whispered pectroiloquy "123" |
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Measurements
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Respiratory Rate
Pulse Rate Weight Oxygen Saturation |
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Diagnostic Tests
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Sputum Exam
Chest X-Ray, CT scans, MRI Pulmunary function test -measure lung size, airway patency, vital capacity and tidal volume Peak expiratory flow rate (peak flow) Aterial blood gases Complete Blood count Bronchoscopy Thoracentesis Pulse oximetry Angiography |
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Nursing Diagnosis
(Ineffective Breathing Pattern) |
-state in which a person's inhalation and/or exhalation pattern does not enable adequate pulmonary inflation or emptying
-RELATED FACTORS: pain, neuromuscular impairment, anxiety, fatigue, musculoskeletal impairment DEFINING FACTORS: Dyspnea, shorness of breath, tachypnea, cyanosis, abnormal ABG |
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Nursing Diagnosis
(Ineffective airway clearance) |
-state in which a person is unable to clear secreation or obstructions fro the respiratory tract to maintain airway patency.
RELATED FACTORS: fatigue, decreased energy, increased secretions, cognitive impairment, trauma, incision pain DEFINING FACTORS: abnormal breath sounds, tachypnea, ineffective cough, cyanosis |
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Nursing Diagnosis
(Impaired gas exchange) |
-state in which a person experiences a decreased passage of O2 and/or CO2 between the alveoli of the lungs and the vascular system
RELATED FACTORS: hyper and hypoventilation DEFINING FACTORS: confusion, irritability, restlessness, increased or decreased respiratory rate |
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Planning
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Goals and outcome are directed at:
-maintaining a ptent airway -maintaining adequate gas exchange -promoting good lung expansion -mobilizing pulmonary secretions -maintaining tissue perfusion -increasing endurance -performance of activities of daily living |
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Implementation
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Interventions are aimed at restoring, maintaing and promoting pulmonary health
*Health promotion: -Influenza (yearly) and pneumococal (every 5 yrs) vaccine -Lifestyle changes (smoking, exercise) _Environmental pollutants |
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Implementation: Airway Maintenance
Positioning |
-semi-fowlers or high fowlers positions make breathing easier
-Repositioning clients frequently prevents pooling of secretions -Ambulation: may require O2 supplementation |
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Implementation: Airway Maintenance
Secretion Mobilization |
-Hydration: encourage fluids to liquefy secretions. Avoid milk and dairy, as it tends to thicken secretions
-Aerosol therapy and humidification -Nebulization -Incentive Spirometry -Coughing and deep breathing |
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Implementation: Airway Maintenance
Types of Cough |
Deep cough: take a deep breath and hold for 1-2 seconds, release air and cough
-Cascade or stacked cough: release of several short blast of air -Low flow (Huff) cough: inhale deeply, don't hold and exhales saying "huff" 2-3 times -Quad cough: administer a deep breath, hold for a few seconds and nurse holds below the rib cage and pushes in and up. Rushing air acts to push mucous out of the airway |
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Implementation: Airway Maintenance
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-Suctioning
-Pursed lip breathing -helps release trapped air from hyperinflated lungs -Chest physical therapy and postural drainage (percussion and vibration) |
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Implementation: Airway Maintenance
(Artificial airways) |
-oral airways
-nasal airways -endotracheal tubes -tracheotomy tubes When using artificail airways, air bypasses the body's natural defenses and mechanisms for warming and humidifying |
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Implementation
(Oxygen Therapy) |
-decreases the work of breathing, of the heart and improves tissue perfusion
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Methods of Delivery for Oxygen Therapy
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Nasal Cannula: low flow delivery, do not use when more than 4L/min of O2 is needed
Mask: simple: used for short term and can deliver 30-60% O2 -reservoir: delivers higher concentrations Masks: -venturi: delivers 24-50% with low flow O2 Safety: no smoking or flammable substance Assess: -working of system and flow delivery -HR, RR, level of consciousness, color, O2 saturation |
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Implementation
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Energy Conservation
-organize activity -small, frequent meals -teach strategies for independient ADL's Self Concept: -appearnace -sexuality -dependence -depression |
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Evaluation
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Did the client's behaviors match the behavior stated in the goals and outcomes
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Pharmacology: Antihistamines
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-common drugs: Benadryl (diphenhydramine)
-Actions: (H-1 antagonist). Inhibits action of histamine and causes vasocontriction and decrease respiratory secretions. Relaxes the smooth muscle in the bronchial tree -side effects: drowsiness, dry mouth and nose, hypotension, syncope |
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Pharmacology: Decongestants
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-may be oral or nasal
-common drugs: Afrin (oxymetozoline) and sudafed (pseudoephredrine) -actions: shrink enlarged nsal mucosa and relieve stuffiness by stimulating alpha adenergic receptors causing vasoconstrition -side effects: insomnia, nervousness, tremors -sustained use (greater than 3 days) of nasal decongestants can cause rebound congestion and worsening of symptoms |
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Pharmacology: Antitussives
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use with caution
-common drugs: vicsk formula (dextromethorphan) -actions: suppresses cough through direct action on the couhg reflex center in the medulla -side effects: dizziness, drowsiness, nausea |
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Pharmacology: Expectorants
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Aide in the removal of mucous
-common drugs: Roitussin (guaifissen) -actions: works by reflex stimulation to loosen thick secretions which in turn lessens the tendency to cough -side effects: nausea and vomiting -drug interactions: anti thyroid drugs, lithium, potassium sparing diuretics |
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Respiratory Infection
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Affects airway clearnance and breathing patterns by changing the amount and characteristics of secretions
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Restrictive diseases
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-limit lung expansion
-decrease lung volume -decrease pulmonary compliance -increase work on breathing |
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Obstructive disease
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-impedes air flow to lung
-can be cause by edema of the airway or tongue |
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Complications of Oxygen
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-O2 induced hypoventilation
-O2 toxicity -Atelectasis -Ocular damage |
