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49 Cards in this Set
- Front
- Back
Bradypnea
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slow respiratory rate-less than 10 per minute
Chart resting respirations (RR) could be cause by PCA or other Medications(Narcotics) |
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Cheyne-stokes
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"death rattle"
4-5 cycles per min. irritation to medulla R/O nuerologic problem |
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Dyspnea
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Difficulty (labored breating)
Dyspnea when .... Some conditioning Some disease pattern |
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Eupnea
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Normal Respirations
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Gasping
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Inspiratory Effort ( asthma, hurts to breathe, etc.)
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Hyperpnea
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Increased RR (what they are doing- running up stairs, resting etc.)
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Hypoventilation
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BR, sedatives, meds,
sleeping(slow and shallow) |
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Kussmaul's
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DM- keto acisosis(metabolic)
Fruity smelling breath (keytones). Attempt to rid CO2 |
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Orthopnea
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Difficulty breating while lying flat - raise HOB
sleep in recliner could be respiratory or cardiac problem |
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Rales andor rackles
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Heard at end of respiration
Fluid around alveoli can't cough out crackles Dieretics and RT makes it better Fluid rises (from bottom to top) Pulmonary Edema |
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Rhonchi coarse
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Chest cold - mucus in bronchioles
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Tachypnea
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rapid respiratory rate
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Wheeze
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Squeaks
Air meets resistance going in and/or out Note where you hear it - What side - inspiratory - Expiratory - with or w/o stethoscpoe More swelling = more distress |
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Stridor
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Inspiratory - difficulty getting air in (upper Respiratory- larger air passages) MEDICAL EMERGENCY!!!
Obstruction, croup |
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Respiratory Distress
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Dyspnea- what activity with dyspnea (can't talk, eat, or think)
Abnormal secretions/ Nursing Care (Respiratory tree inflammed and/or infected [swollen, red, hot, fluid] hear secretions - describe productive cough- How much / what color TCDB Raise HOB Suction (prn- no DO needed) Humidified Air (need DO) Hydration (Check I&O) Postural Drainage (RT) |
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Postural drainage
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RT
Head Down, on side (Left side if rt sided secretions, vis versa) Morning, Before meals,and before sleep (not after meals) |
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Nebulizer treatments
(treatment modalities) |
Meds through inhalation
Reduces side affects on other parts of the body |
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Incentive Spirometer
(treatment modalities) |
Dr order required
Can measure progress Involve Pt. & family |
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Tracheostomy
(treatment modalities) |
Problem with upper airway occlusion
Can be done preop Provides a patent airway & area to suction |
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Tracheostomy
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Opening into trachea
Cuff Neck ties Suctioning Trach care |
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Tracheostomy - Cuff
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Normal inflated
Seals airway around tube Helps prevent aspiration |
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Tracheostomy - Neck ties
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Neckties (old method) use knots
Velcro straps (more secure) holds trachea in place in the neck Rarly- a trach is sutured if permanent |
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Suctioning
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Suction trachea to lungs than suction mouth/nose
Sterile technique Through nose into Rt or Lft lung one hand with sterile glove Insert with no suction applied Hit carnis, pull back a little than advance as far as it will go Intermittant suction (hold breath) hold suction (1,2,3) Whole procedure should only take 10-15 sec. Suction cath should be 1/2 the size of the trach No more than 3X's per procedure(takes air, causes irritation and errosion) |
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Trach Care
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Sterile technique
Remove intercannula clean (trache cleaning kit) Replace |
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Replacing a trach
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If trache is accidently coughed out replace it with a new one
Tell patient to imitate whistling |
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Hemoptysis
(Respiratory distress) |
Coughing up blood (little & big clots)
how big & how often |
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cough
(respiratory distress) |
excessive- seen in asthma pts
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Hypoxia
(respiratory distress) |
Pulse Ox, syonotic, blood gases
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Increased pulse
(respiratory distress) |
1st thing seen
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Increased BP
(respiratory distress) |
may see a slight change but not a reliable indicator
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Restlessness
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Due to brain sensitivity to low O2
Irritated Lethargy Non-responsive |
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Respiratory distress
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Heart working properly?
Hemoglobin? Air to lungs? |
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Hypercapnea
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CO2 elevated in arterial blood (blood gases)
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Cyanosis
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Low O2 (SEVERE)
Lips Mucous Membranes Fingertips (could be caused by poor circulation) |
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Polycythemia
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Increase in H/H
Chronic hypoxia Blood doping COPD Thick blood (heart problems/clotting) |
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Cor Pulmonale
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Enlargement of the rt ventricle(rt ventricle to lungs)
overworking Chronic respiratory disease |
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Pneumothorax
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Air in Plueral space
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Digital clubbing
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Chronic hypoxia
COPD Heart defects Fat or squaring off at the ends of fingertips or toes |
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Chest X-Ray
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diagnostic of pneumothorax & pneumonia
Screener for pneumonia, fluid in lungs, size of heart, if lung is expanded |
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CT or MRI
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Fluid in chest, thoratic cavity, and pleura space
tumor mass- defines fluid & mass |
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Bronchoscope
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Can be done @ beside
Takes 5-10 minutes Rt, Lft or both bronchi OP permit(puncture lung-cause pneumothorax), NPO(for 4-6 hrs-Aspirate), Gag reflex, Bleeding, Subcutaneous Emphysema/crepitus Remove foreign objects, Biopsy, deliver Meds. Could cause subcutaneous edema or rupture bronchi Comfort pt, Check RR, VS, monitor for bleeding |
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Thoracentesis
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Can be done @ BS, Needle into pleura space(lower aspect of lobe),Saginous fluid goes into sealed pleura vac
Op permit, position and support pt, specimens(label), Auscultate(could puncture lungs, chest X_Ray (to follow), fluid taken off goes on output record |
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Sputum Exam
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Primarly lookin @ organisims(C&S) 1st thing in AM
#1 problem-no sputum-spit Needs to be a coughed speci. Speci goes to lab IMMEDIATELY Culture- what bacteria Sensitivity- what antibiotic will attack bacteria Final report in 48hrs, Intermediate report in 24hrs AFB-acid fast bacilli (TB) 3 tests confirm active TB |
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Skin Tests
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Allergy testing- Immune response(reation to candida)
TB (PPD)- prensence of antigen for TB(+ does not mean you have TB. It means you have been exposed to TB. Reactor- (- to +) Not a valid test after having a + test result |
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Pulmonary Function test
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Look @ dynamics of the lungs
Adequate volume or retaining volume |
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Vital Capacity
(decreased with chronic illness) |
Maximum amount of air that can be completely expired follwing maximum deep inspiration 4000-5000ml
breath in as much as possible than breath out as much as possible Respiratory disease and chronic resp. conditions(decrease volume-gets worse) Acute condition (will return to normal) |
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White Blood Cell Count
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5000-10000
Elevates with infection/inflammation Decreases rapidly with antibiotic therapy |
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Red Blood Cell Count
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4.8 - 5.5 million
O2 carrying capacity ability to carry O2 RR & HR will increase due to problems with oxygenation due to blood loss |
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Pulse Oximetry
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Greater than 95%
O2 saturation Differs from ABG Some causes of decrease: Resp. problems, pain meds., PCA, BR,etc. |