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60 Cards in this Set
- Front
- Back
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What is ventilation?
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Air moving in and out of lungs
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What is diffusion?
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Exchange of O2 and CO2 between alveoli and blood
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What is perfusion?
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Blood transports gases of O2 and CO2 to and from body cells
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What factors affect respiration?
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Integrity of the airway system (ventilation)
Functioning cardiovascular system (perfusion) Functioning alveoli (diffusion) Functioning medulla & chemoreceptors |
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What is inspiration?
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Air flows into lungs
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What is expiration?
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Gases flow out of lungs
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What is intrapulmonic or intra-alveolar pressure
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Pressure within alveoli
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What is intrapleural pressure?
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Pressure within the intrapleural space (always negative)
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What factors affect ventilation?
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Lung elasticity- ability to recoil
Lung compliance- ability to stretch Airway obstruction Muscular condition Neurological controls |
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What % of our energy should it take to breath?
What % of energy does it take a person with lung disease who has decreased lung compliance to breath? What nursing diagnosis addresses this problem related to poor oxygenation? |
3%
30% Activity intolerance and fatigue |
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Describe the diffusion of alveoli gas exchange
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Air reaches alveoli
Oxygen from alveoli spaces moves into pulmonary capillary (oxygen uptake) via diffusion Oxygen diffuses across alveoli membranes moving from high concentration (alveoli) to lower concentration (pulmonary capillary) |
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What is partial pressure?
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Individual pressure exerted by a particular gas in a mixture of gases
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What is surfactant?
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A mixture of lipids and proteins secreted by type II alveolar cells. Interspersed among the water molecules in the liquid film that surrounds each alveoli. Water molecules create greater surface tension which keeps alveoli stretched and maintains recoil. Surfactant creates reduced surface tension:
-increases pulmonary compliance-reducing the work of inflation -reduces the lungs tendency to recoil-alveoli -keeps surfaces moist -prevents atelectasis |
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What is newborn respiratory distress syndrome?
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Premature birth where the baby doesn't have enough surfactant and it takes a greater effort to inspire
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What is lung compliance?
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Elasticity of lung tissue and flexibility of rib cage
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What is lung recoil?
What happens to lung recoil in COPD patients? |
The ability of the lungs to recoil after being stretched
In COPD there is decreased lung recoil leading to impaired respirations |
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Describe perfusion
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Transport of O2 and CO2 via blood to tissue and back
Volume of blood flowing through lungs affects amount of oxygen and gases exchanged Adequate blood supply and cardiovascular functioning are needed Oxyhemoglobin HbO2 (or SaO2) |
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True or false
When taking a pulse oximetry reading on a severely anemic client the nurse will expect to always get low SaO2 values |
False
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What does the rate of O2 transport depend on?
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Cardiac output
Activity level CO2 transport |
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What are the neurological/chemical controls of respiration?
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Peripheral chemoreceptors
Central chemoreceptors Medullary respiratory center Spinal cord Phrenic nerve Diaphragm |
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What factors affect oxygenation?
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Environmental pollutants
Stress Exercise Age Smoking (primary, secondary) Medications Fluid balance Skeletal abnormalities Respiratory disorders Diversity |
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What is involved in the subjective assessment of respiratory function?
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Difficulty breathing?
SOB? Chest pain? Coughing? Sputum production? Nocturnal diaphoresis Fatigue Sleep with 2 or more pillows |
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What conditions could a finding of nocturnal diaphoresis and hemoptysis indicate?
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Emphysema
Sleep apnea Asthma Tuberculosis |
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What is hemoptysis?
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Coughing blood into tissue
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What is the first thing to do when a patient is suspected of tuberculosis (TB)?
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Take airborne precautions- isolation
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What is involved in the respiratory assessment?
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Allergies
Medications Medical History Smoking Lifestyle/Activity level Stressors Recent exposures Developmental level |
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When a patient states difficulty breathing you can assess it by using PQRST. This stands for...
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P- provokes
Q- quality R- region/radiation S- severity scale T- timing |
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What is tachypnea?
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Respiratory rate greater than 24
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What is bradypnea?
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Respiratory rate less than 10
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What is apnea?
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Temporary cessation of breathing
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What are the respiratory depths?
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Deep-diaphragmatic (normal)
Shallow (abnormal) |
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How would you describe a regular respiratory rhythm?
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Even and symmetrical
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What is Cheyne-stokes?
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Abnormal breathing with periods of apnea
Seen at end of life situations |
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Where is Kussmauls seen?
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Seen in diabetic kedoacidosis
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What is apneustic breathing?
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gasping
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What is Biot's?
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ataxic-without rhythm
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What is orthopnea?
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When someone can't breath well in the flat supine position
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What is retraction?
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When you can see intercostals sucking in during extreme distress
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What are some ways to palpate to test oxygenation?
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Capillary refill
Temperature Crepitus Tactile Fremitus Pitting edema |
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How would you describe the respiratory quality?
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No difficulty- eupmeic/unlabored
Dyspnea Othopnea Retractions Use of accessory muscles |
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What 3 sounds do you auscultate for in the thorax and lungs?
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Vesicular
Bronchial Bronchovesicular |
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What is a major initial sign of hypoxia?
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restlessness
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What is a non-productive cough?
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Nothing coming up-
could be impaired gas exchange, ineffective airway clearance |
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What are some adventitious sounds?
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Crackles (rales): fine, medium, coarse
Wheeze: sibilant, sonorous (rhonchi) Stridor: classic sound of upper airway foreign body obstruction Stertor: sounds like a snore Pleural friction rub |
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What are some common respiratory diagnostic tests?
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Sputum
nose/throat cultures CBC (complete blood count) ABG (arterial blood gases) CXR (chest x ray) PFT (pulmorary function tests) Pulse oximetry Other: Scopes, CT, MRI, PET |
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What is hyperventilation?
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Patient blows off too much CO2
Breath into paper bag so that they start to breath back in their own CO2 |
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What does FBO mean?
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Foreign Body Obstruction
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What are some nursing diagnoses related to oxygenation needs?
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Ineffective airway clearance
Risk for aspiration Ineffective breathing pattern Impaired gas exchange Ineffective tissue perfusion; cardiopulmonary Activity intolerance |
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What would be some examples of proper planning ?
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Patient will demonstrate adequate ventilation as evidenced by SaO2 > 95%, eupnea, RR 16-20 and clear lung sounds by...
Patient will demonstrate effective cough as evidence by production of sputum by... |
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What are some independent nursing interventions related to oxygen needs?
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Airway maintenance
Positioning Deep breathing & coughing Pursed-lip breathing Abdominal/ diaphragmatic breathing Hydration Patient education |
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What are some dependent/collaborative nursing interventions related to oxygen needs?
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Incentive spirometry
Percussion/ postural drainage Suctioning Oxygen therapy Medications |
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What are some methods of oxygen therapy?
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Nasal canula
simple face mask Partial & non-rebreather mask Venturi mask tent |
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Besides BiPap/CPap, which oxygen device is capable of delivering the highest concentration of oxygen (FIO2)?
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Non-rebreather
Delivers up to 95% Mask maintains a supply in the reservoir bag |
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What is important to consider in administering oxygen therapy?
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Flow rate
Humidification Hydration Positioning Safety precautions Document MD order required |
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What are some oxygen safety precautions?
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Oxygen Toxicity:
H/A, nose stuffiness, substernal pain, N & V, fatigue, nonproductive cough and hypoventilation Signs: "No smoking. Oxygen in use" Remove matches, lighters and cigarettes Grounded electrical equipment Avoid materials that generate static electricity |
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What do mucolytic expectorants for?
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to loosen secretions
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What do corticosteroids do?
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decrease inflammation
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What should the RN know concerning oxygenation and health promotion?
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Smoking cessation
Avoidance of pollutants Influenza vaccination Pneumococcal vacination Avoidance of triggers |
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Select a priority nursing diagnosis for the following scenario:
A 62 y.o. male with hx of emphysema with decreased PO2, increased CO2 levels who is dyspneic and restless |
Impaired gas exchange
emphysema causes distruction of the alveoli |
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Select a priority nursing diagnosis for the following scenario:
A 30 y.o. male admitted to the ED post MVA with notable blood loss, BP= 80/50, P=120, R=30 |
Ineffective tissue perfusion; cardiopulmonary
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