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occurs when the rate and depth of respirations are decreasedand CO2 is retained and alveolar ventilation is compromised;may be related to: COPD general anesthesia impending respiratory failure OR any other conditions that result in decreased respirations

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hypoventilation

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occurs when rapid and deep breathing results in excess loss of CO2 (hypocapnia) ; may be related to feeling lightheaded and tingly anxiety infection shock hypoxia drugs (aspirin, amphetamines) diabetes mellitus acid-base imbalance

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hyperventilation

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refers to the ease of lung inflation

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lung compliance

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refers to the tendency of the elastin fibers to return to their original position away from the chest wall after being stretched (think of stretching a rubber band, then letting go of it)

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lung elasticity

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resistance to airflow within the airways. the larger the diameter of the airway, the more easily air moves through it.

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airway resistance

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-Environment -Lifestyle choices -Medication -Conditions affecting chest wall movement -Respiratory Infection -CNS and Neuromuscular abnormalities

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Risk Factors Affecting Oxygenation

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Risk Factors Affecting Oxygenation: air quality, allergies (pollen), pollution, elevation, work conditions (mining, body shop)

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Environment

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Risk Factors Affecting Oxygenation: exercise, smoking, etc.

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Lifestyle choices

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Risk Factors Affecting Oxygenation: pain medications, sedatives, bronchodilators, steroids

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Medication

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Risk Factors Affecting Oxygenation: obesity, trauma, pregnancy

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Conditions affecting chest wall movement

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Risk Factors Affecting Oxygenation: spinal cord injury, ALS

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CNS and Neuromuscular abnormalities

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Assessment Resp Effort: THE FIRST SIGN OF HYPOXEMIA

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RESTLESNESS, AGITATION, ETC.

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Assessment Resp Effort: can't breathe lying down

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Orthopnea

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Assessment Resp Effort: wake up b/c they weren't breathing

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Paroxysmal Nocturnal Dyspnea

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Assessment Resp Effort: moments of not breathing, snoring

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Sleep apnea

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Assessment Resp Effort: high-pitched squeaking/breathing often due to obstruction

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Stridor

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Assessment Resp Effort: pneumonia, etc.

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Diminished or absent breath sounds

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Developmental Factors Affect Oxygenation: upper respiratory infections (URIs) and airway obstruction, asthma, allergies, ENT (ears, nose, throat) abnormalities

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Infants and toddlers

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Developmental Factors Affect Oxygenation: exposed to respiratory infections, asthma and second-hand smoke and begin cigarette smoking

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School-age children and adolescents

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Developmental Factors Affect Oxygenation: exposed to cardiopulmonary factors, unhealthy diet, lack of exercise, obesity stress, cigarette smoking, and pregnancy

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Young and middle-age adults

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Developmental Factors Affect Oxygenation: calcification of valves, conduction problems, atherosclerosis, LV dysfunction, myocardial muscle thickening

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Older adults

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The heart's pumping action moves "used" blood that returns to the heart through the veins through the_______ into the _________.

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right atrium; right ventricle

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The right ventricle then pumps the blood back out of the heart into the ________ to be replenished with oxygen

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lungs

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The heart's pumping action moves oxygen-rich blood as it travels from the lungs to the _______, then on to the ___________, which pumps it to the rest of the body.

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left atrium; left ventricle

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The left ventricle supplies most of the heart's pumping power, so it's larger than the other chambers and essential for normal function. In left-sided or left ventricular (LV) heart failure, the left side of the heart must ________ to pump the same amount of blood

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work harder

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________________ usually occurs as a result of left-sided failure. When the left ventricle fails, increased fluid pressure is, in effect, transferred back through the lungs, ultimately damaging the heart's right side. When the right side loses pumping power, blood backs up in the body's veins. This usually causes swelling in the legs and ankles

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Right-sided or right ventricular (RV) heart failure

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-Hypertension, MI, primary cardiomyopathy, valve disease -Pulmonary congestion -Tachypnea -Dyspnea -Crackles -Cyanosis -Gallops

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Left Sided HF

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-Pulmonary disease, MI, primary cardiomyopathy, valve disease -Peripheral edema -Jugular venous distention -Ascites -Hepatomegaly (abnormal enlargement of the liver)

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Right Sided HF

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Big, "floppy" left ventricle-most common in...

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Left Sided Heart Failure

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Ineffective airway clearance Ineffective breathing pattern Impaired gas exchange Activity intolerance Decreased cardiac output Fatigue Anxiety Impaired spontaneous ventilation

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Examples of Nursing Diagnosis

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Maintain patent airway Manage secretions Improve comfort and ease of breathing Maintain or improve pulmonary ventilation and oxygenation Improve ability to participate in physical activity Prevent associated risks

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Nursing Goals

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To evaluate these goals, you have to _______ breath sounds, other signs of adequate resp. status, etc.

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ASSESS

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major concern/goal in hospice

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Managing terminal dyspnea

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-Vaccinations Influenza, pneumococcal -Healthy lifestyle Eliminate risk factors, eat right, regular exercise -Environmental pollutants Second-hand smoke, work chemicals, and pollutants

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Implementation: Health Promotion

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is recommended for children between 6 months to 59 months, adults over 50, and those with chronic illnesses. They are also recommended for those who are in contact with high-risk groups (health care providers) and the immunosuppressed and HIV-positive.

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Flu shot

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difficult or labored breathing

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dyspnea

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is recommended for those over 65, those at risk for pneumonia, or those with chronic illnesses or immunosuppression (such as AIDS or HIV).

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Pneumococcal vaccine

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People who work as farmers, painters, or carpenters might benefit from the use of ___________ to reduce inhalation of particles.

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particulate filter masks

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Nursing/Medical Interventions: The most effective position for promotion of lung expansion is the ___________. This position uses gravity to assist in lung expansion and reduces pressure from the abdomen on the diaphragm

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45 degree semi-Fowler's (30 degrees at least, 45 DEGREES BEST)

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Nursing/Medical Interventions: Deep Breathing and Coughing -Abdominal breathing -____________- For COPD or emphysema

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Pursed lip breathing

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Nursing/Medical Interventions: need an order- usually PT does it

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Percussion, Vibration

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Nursing/Medical Interventions: example-right-sided heart congestion-turn patient on left side so congestion (fluid) moves...

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Postural drainage

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Nursing/Medical Interventions: Clients use __________ to prevent or treat atelectasis (partial or complete collapse of the lung)

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incentive spirometry

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Nursing/Medical Interventions: deficiency big contributor to pneumonia; frequently forgotten

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Hydration

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Nursing/Medical Interventions: We need to promote _________, __________, and maintain a __________ to help meet oxygenation needs

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Lung expansion; mobilize secretions; patent airway

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-loosens secs, expands collapses alveoli, facilitates gas exchange, etc. -Anyone who has had general anesthesia, or is limited in their mobility for extended time with pulm involvment or risk should be doing this -Decreases atalectasis. -better to sit patient up

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Incentive Spirometry

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See this a lot/mostly with cystic fibrosis kids Also with-right sided pneumonia

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Postural Drainage

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Helps to thin secretions, kind of like oil for the engine.

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Hydration

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-Either have patient cough deeply and cough stuff up into cup (not simply spitting) OR suction it out -Not "spit" - needs to be from deep in chest -Best just after awakening or just after PVPD, or breathing treatment -For culture, or identification of acid-fast bacilli (diagnosis of TB)

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Sputum Analysis

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-is an endoscopic technique of visualizing the inside of the airways for diagnostic and therapeutic purposes -Evaluation of lower respiratory tract diseases -Foreign body removal -Tracheal wash, Bronchial brush biopsy, -Selective bronchial culture -Forceps biopsy of lesions, -Diagnosis of collapsed trachea

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Bronchoscopy

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-To draw off excess fluid from the intrapleural space -To instill chemotherapeutic drugs into the intrapleural space -Strict sterile technique -Positioning -diagnostic procedure done in patients who have abnormal amounts of fluid accumulation in the pleural space -The needle is placed through the chest wall into the pleural space and fluid is then withdrawn into a syringe

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Thoracentesis

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In caring for a client with a tracheostomy, the nurse would give priority to the nursing diagnosis of: a. Risk for ineffective airway clearance b. Anxiety related to suctioning c. Social isolation related to altered body image d. Impaired tissue integrity e. Risk for infection

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Correct answer: A While other diagnoses may be applicable, maintaining a patent airway by tending to excessive secretions is a priority.

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-removing fluid AND air ( as little air as possible) -To remove secretions from the nasopharynx, oropharynx, or trachea -Can cause dysrhythmias and sever hypoxia so ASSESS before and after!!!!

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Suctioning

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Suctioning: exception>>>?

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bulb syringe for infants

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Suctioning: Sterile procedure? - Oropharynx-? -Nasopharynx-? -Trachea-?

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NO; NO; YES

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Suctioning: Used when the client can cough effectively but is not able to clear secretions

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Oropharyngeal and nasopharyngeal

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Suctioning: Used when the client is unable to manage secretions

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Orotracheal and nasotracheal

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Suctioning: Used with an artificial airway

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Tracheal

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Suctioning: risk for hypoxemia, hypotension, dysrhythmias, and trauma to the mucosa of the lungs if _____________

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If you suction the client too much

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Suctioning: Suction back of throat and mouth -use when patient cannot cough up sputum -when patient is brushing teeth but cannot spit everything out, etc. -It won't (shouldn't) fit in the nose!!!!

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YanKauer Suction Catheter

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-Considered a Medication: ordered by physician -Used to relieve or prevent hypoxia -May be administered by nurse in emergency situation (Need an order later) -Safety issues Flammability Humidification Transporting tanks -Need sign - keep 10 feet away from open flame; no smoking; secure cylinders; grounded equip so no sparks; check levels in tanks before transporting

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Oxygen Therapy

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Oxygen Therapy: Room air is _______ 2L =28% 4L=36%

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21%

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Oxygen Therapy: Oxygen Delivery Systems (3) (Depends on needs, comfort, developmental considerations)

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Nasal cannula or prongs Face Mask Face tent

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Oxygen Therapy: For air flows greater than 2L/min, you need to consider adding __________ to prevent drying out the patient's airways.

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humidification (definitely need humidification for 4L/min)

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Oxygen Therapy: 1-6L/min - 24-44% FiO2 Skin breakdown nares and ears is a big issue (if too tight).

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Nasal Cannula

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Oxygen Therapy: Nasal cannula breathing device has an oxygen conserving reservoir in the face piece. Increases oxygen availabitity by as much as 75%. Saves money on home oxygen tanks

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Oximizer

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Oxygen Therapy: Short term (can get oxygen toxicity)---NEVER FOR PATIENTS FOR LONG-TERM COPD 30-60% O2 - not for those retaining CO2

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Simple Face Mask

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Oxygen Therapy: Nonrebreather 60-95% O2 with flow rate of 6-10L/min - bag must be inflated (high conc O2) Common in emergency situations

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Partial-rebreather and Non-rebreather Masks

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Oxygen Therapy: Facial trama, clostrphobia, vent weaning Provides more face space-less claustrophobic feeling like with masks

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Face Tent

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Oxygen Therapy: 24-60% at 4-12L/min depending on adapter used. Delivery of a very persise amount of oxygen COPD pt. Vent weaning *If we give too much oxygen-they can stop breathing

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Venturi Mask

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Oxygen Therapy: patients who cannot stand masks Pediatric Variations

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Oxygen Tent and Oxyhood

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Restorative and Continuing Care: helps the client to achieve and maintain an optimal level of health through controlled physical exercise, nutrition counseling, relaxation and stress management techniques, medications, oxygen, and compliance

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Cardiopulmonary rehab

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Restorative and Continuing Care: helps to keep mucous clear, to thin and water it down. Unless otherwise noted, a client should have a water intake of 1500 to 2000 ml/day.

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Hydration

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Restorative and Continuing Care: Coughing techniques (3)

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Cascade Huff Quad

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Restorative and Continuing Care: Coughing techniques 1-the client takes a slow, deep breath and hold it for 2 seconds while contracting expiratory muscles. The client opens the mouth and performs a series of coughs throughout exhalation, progressively lowering lung volumes.

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Cascade

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Restorative and Continuing Care: 2-clients without abdominal muscle control use this while breathing out with a maximal effort

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Quad

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Restorative and Continuing Care: 3-the client simulates a natural cough reflex that is effective for clearing the airway

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Huff

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Restorative and Continuing Care: deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse

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Purse Lipped-Breathing

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Restorative and Continuing Care: requires the client to relax intercostal and accessory muscles while taking deep inspirations

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Diaphragmatic Breathing

question

-Purposes: To restore negative pressure and re-expand lung To drain collected fluid or blood -Pneumothorax - inserted into upper anterior thorax -Hemothorax (or fluid) - inserted into lower lateral chest wall -Sealed, sterile system

answer

Chest Tubes and Drainage Systems

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So where would the chest tube need to go? Upper Inter-pleural space- ? Lower Inter-pleural space- ?

answer

removes air; removes fluids

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"mia"=? "ia"=?

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blood; tissue

question

Which diagnostic test/exam would best measure a client's level of hypoxemia? a. chest x-ray b. pulse oximeter reading c. ABG d. peak expiratory flow rate

answer

Correct answer: C The term "hypoxemia" means low blood oxygen level. Arterial blood gas sampling is the most direct way in which the level of oxygen in the blood can be measured. (ABGs=tests how much oxygen is in the blood)

Oxygenation (14)- Week 10 – Flashcards

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