NU101 Exam 2

idiosyncratic effect

unusual, unexpected response to a drug that may manifest itself by over response, under response, or response different from the expected outcome

pharmacokinetics

movement of drug molecules in the body in relation to the drug’s absorption, distribution, metabolism, and excretion. it is the effect of the body on the drug

pharmacodynamics

process by which drugs alter cell physiology and affect the body

pharmacogenetics

the study of how genetic variation affects an individual’s response to drugs

pharmacotherapeutics

dynamic that achieves the desired therapeutic effect of the drug without causing other undesirable effects

digoxin (lanoxin), metoprolol (lopressor), furosemide (lasix), hydrochlorothiazide, potassium chloride

cardiovascular and renal drugs (5 drugs)

warfarin (coumadin), heparin, aspirin (ASA)

hematologic drugs/anticoagulants/antiplatelets (3 drugs)

penicillin, azithromycin (zithromax), vancomycin

antimicrobials (3 drugs)

morphine, acetaminophen (tylenol), ibuprofen (motrin), diazepam/lorazepam, gabapentin (neurontin), sertraline (zoloft), zolpidem (ambien), donepezil (aricept)

CNS drugs/analgesics/psychotropics (8 drugs)

albuterol (proventil), diphenhydramine (benadryl), prednisone, pantoprazole (protonix), docusate, miralax, senna

respiratory, immune, and GI drugs (7 drugs)

ADME: absorption, distribution, metabolism, excretion

4 phases of pharmacokinetics

absorption

stage 1 of ADME

• drug is transferred from the site of entry > body > bloodstream

• influenced by the following factors:

  • liquid solubility

  • pH

  • blood flow

  • conditions at the site of administration

  • dosage

distribution

stage 2 of ADME

• occurs after a drug has been injected or absorbed into the bloodstream

• distribution depends on:

  • adequacy of blood circulation

  • protein binding

  • selectively permeable blood-brain barrier that protects the CNS

metabolism

stage 3 of ADME

• the change of an active drug from its original form to an inactivated or new form

• liver is the primary site for drug ____

• most drugs are inactivated by the liver and transformed to inactive substances for excretion

• physiologic changes associated with aging, the presence of liver disease, or other factors that impair the functioning of the liver decreases its ability to ____ drugs

• other tissues also play a role: GI tract, lungs, and kidney

• drugs given orally move from the intestinal lumen to the liver by way of the portal vein

• drugs with extensive or variable first-pass effects are not given orally because most of it will be destroyed by the liver

• some drugs are ___ by the liver to an inactive form reducing the amount of active drug left in the body

• other drugs do not undergo ___ at all in the liver, and others may be ___ to an active drug metabolite that might be more active than the original drug

first-pass effect

some drugs are extensively metabolized in the liver and do not make it to the systemic circulation. this reduction in bioavailability is referred to as the:

excretion

stage 4 of ADME

• the process of removing a drug, or its metabolites (products of metabolism), from the body

• the kidneys is the primary site for ___ of most drugs through urine

• the lungs are the primary route for the ___ of gaseous substances, such as inhalation anesthetics

• some drugs or their metabolites are ___ through bile (feces or returned to the liver and ___ by the kidney)

• some medications may be contraindicated, or dosages may need to be adjusted, if renal ___ is impaired

• poor disney function can decrease their ability to ___ drugs, thus requires lower doses of many medications

half-life

expected time for blood concentration to measure one half of the original dose due to elimination

therapeutic range

serum level of concentration of drug that produces desired effect without toxicity

onset of action

time the body takes to respond after administering a medication

peak

highest plasma concentration, measured when absorption of medication is complete

trough

lowest plasma concentration, indicating the rate of elimination of medication

by maintaining constant drug level in the body

how does therapeutic drug action occur?

standard/routine order

prescription that remains in effect indefinitely or for a specified period of time

PRN order (as needed)

the patient receives medication when it is requested or required, and when the specifics of the order are met

one time order

the directive is carried out only once, at a time specified by the prescriber

STAT order

prescription that remains in effect indefinitely or for a specified period of time immediately

parts of a medication order

• patient’s name and a secondary identifier (i.e. DOB or MRN)

• date and time the order is written

• name of the drug to be administered

• dosage of the drug

• route by which the drug is to be administered

• frequency of administration of the drug

• signature of the prescribing provider

oral route

routes of administration

• takes the longest to be absorbed

• liquids that do not need to be dissolved have a faster absorption rate than capsules or tablets

IM or subQ injections

routes of administration

• usually absorbed more rapidly than oral medications

• must be injected

IV route

routes of administration

• placed directly into the bloodstream

• technically not absorbed and take effect quickly

skin and mucous membranes route

routes of administration

• drugs administered through intact skin, unless formulated specifically for systemic absorption (transdermal patches), tend to have primarily local effects

• drugs administered via a mucous membrane (oral mucosa, eye, nose, vagina, or rectum) are absorbed both locally and systemically, which means the drug acts right at the site of administration, but also passes directly into the bloodstream

smaller

a larger gauge of a needle means that the diameter is ____

criteria to choose needles and syringes by

• route of administration: a longer needle is required for an IM than for an intradermal or a subQ injection

• viscosity of the solution: some medications are more viscous than others and require a needle with a large lumen to inject the drug

• body size: an obese person requires a longer needle to reach muscle tissue than a thin person. a thin person or an older adult with decreased muscle mass requires a shorter needle

• type of medication: there are special syringes for certain uses. i.e. an insulin syringe used only to inject insulin

administering intradermal injections

injections

• administered into the dermis, just below the epidermis

• has the longest absorption time of all the parenteral routes

• used for sensitivity tests, such as tuberculin and allergy tests, and local anesthesia

• injection sites:

  • inner surface of the forearm

  • the upper back, under the scapula

• dosage: small, usually less than 0.5 mL

• angle: 5-15 degrees

administering subQ injections

injections

• administered into the adipose tissue layer just below the epidermis and dermis

• this tissue has few blood vessels

• drugs administered here have a slow, sustained rate of absorption into the capillaries

• used to administer drugs such as insulin and heparin

• injection sites:

  • outer aspect of the upper arm

  • the abdomen

  • the anterior aspects of the thigh

  • upper back

  • upper ventral or dorsogluteal area

• considerations:

  • avoid sites that are bruised, tender, hard, swollen, inflamed, or scarred

  • look for old sites of injection

  • absorption rates differ among the different sites

    • injections in the abdomen are absorbed the most rapidly

    • injections in the arms are absorbed somewhat more slowly

    • those in the thighs, even more slowly

    • those in the upper ventral or dorsogluteal areas have the slowest absorption

  • no more than 1 mL can be given in one injection

• equipment:

  • a 25-30 gauge, 3/8” to 1” needle can be used

  • 3/8” and 5/8” needles are the most commonly used

• dosage: no more than 1 mL can be given in one injection

procedure for subQ injections

procedure for injections

1. administered at a 45-90 degree angle

   1. 45-degree angle is used only for small patients with a limited amount of subcutaneous tissue

2. use alcohol pad to clean site

3. pinch skin and then insert needle at appropriate angle

4. release the skin and stabilize the base of the needle

5. if blood or clear fluid appears at the site after withdrawing, apply gentle pressure

6. don’t massage site

7. rotate sites of injection

8. injections should be given an inch away from the previous injection site

administering IM injections

injections

• delivers medication through the skin and subcutaneous tissues into certain muscles

• muscles have a larger and greater number of blood vessels than subQ tissues

• faster onset of action than with subQ injections

• used to administer drugs such as antibiotics, hormones, and vaccines, such as the pneumococcal and hepatitis vaccines

• injection sites:

  • ventrogluteal site

    • landmarks: anterior superior iliac spine, the greater trochanter of the femur, the top of the iliac crest

    • offers a large muscle mass that is relatively free from major nerves and blood vessels

    • patient can be on their back, abdomen, or side for the injection

    • procedure:

      • find the center of a V formed by placing your right palm on the patient’s left trochanter, your forefinger on the iliac spine, and your second finger spread to reach the iliac crest

      • injection is given in the center of the triangle

  • vastus lateralis

    • landmarks: a hand’s breadth above the knee and a hand’s breadth below the greater trochanter

    • there are no large nerves in its proximity, and it does not cover a joint

    • site is best for infants and children

    • in adults it hurts

    • procedure:

      • injection is given in the outer middle third of the vastus lateralis

  • deltoid

    • landmarks: lower edge of the acromion process and below by a line drawn from the upper edge of the axilla

    • recommended site for vaccines for adults

    • may be used for children between 3 and 18 years of age for vaccine administration

• equipment:

  • patients who are obese may require a longer needle

  • thinner patients may require a shorter needle

  • appropriate gauge is determined by the medication being administered

    • in general, biologic agents and medications in aqueous solutions should be administered with a 20-25 gauge needle

    • medications in oil-based solutions should be administered with an 18-25 gauge needle

• procedure:

  • volume of medication that can be administered varies based on the intended site

  • in general, 1-5 mL is the accepted volume range

  • the less-developed muscles of children and older adults limit the injections to 1-2 mL

• considerations:

• the deltoid is the recommended site for vaccines for adults

• the ventrogluteal site is recommended for general injections in adults

solid medication

medication

• scored tablets contain an indented mark to be used for possible breakage into partial doses

  • if a tablet isn’t scored, don’t break it by hand as it can give an inaccurate dose

• solids are tablets, capsules, and pills

• enteric-coated tablets and sustained-released capsules delay absorption until the medication reaches the small intestine

  • they shouldn’t be chewed or crushed

  • they are used when an active ingredient in the drug is irritating to the stomach

• capsules contain a powdered or oily medication in a gelatin cover

• extended-release tablets such as SR (sustained release) and ER (extended release) shouldn’t be chewed or crushed as it destroys their extended-release delivery and can result in potential toxic peaks and low troughs

liquid medication

medication

• included elixirs, spirits, suspensions, and syrups

• some are water-based, others are alcohol-based solutions

• disposable, calibrated cups are available for the administration of liquid medications

• the medicine cup has a capacity of 30 mL or 1 oz and is used for orally administered liquids

• for patients who find it difficult to take liquids from a cup, the medication can be placed directly in the mouth by using a plastic oral syringe

  • place the syringe between the gum and cheek and give the liquid to the patient slowly

  • this technique, in addition to having the patient in an upright or side-lying position, helps prevent the patient from choking and aspirating the medication

• shake emulsions and suspensions well and administer them promptly to ensure accurate dosage

• because of the danger of error, do not return unused medications to their bottles and don’t transfer medications from one pharmacy container to another

special techniques for administering medications if the patient doesn’t like the taste of the medication

special techniques for administering non-parenteral medications

• crush the medication (if appropriate) and add it to a food or drink so that the patient can swallow it. this masks the taste of the medication

• allow the patient to suck on a small piece of ice for a few minutes before taking the medication. the ice numbs the taste buds

• store oily medications in the refrigerator. cold oil is less aromatic than oil at room temperature

• place the medication in a syringe and place the syringe on the back portion of the tongue (near the cheek), being careful not to trigger the patient’s gag reflex. this places the medication on the part of the tongue with few taste buds

• offer oral hygiene after giving the medication

• give the medication with generous amounts of water or other liquids, if permitted, to dilute the taste

special techniques for administering medications for older adults

special techniques for administering non-parenteral medications

• allow extra time to administer medications because their reflexes may be slowed and their understanding of the treatment may be decreased

• older adults may have difficulty swallowing medications and can find it easier to take their medications when crushed or given in liquid form

  • initiate swallowing by gently massaging the laryngeal prominence or the area just below the chin prominence. the pressure from the gentle massage creates the desire to swallow

• reevaluation of the drug dosage is necessary with the older adult. weight and age should be used as criteria for determining the dosage

• assist the older adult to set up a schedule as a reminder to take medications as scheduled at home. associate medication with activities (such as breakfast or a television show) and not a specific time

• monitor the patient carefully for adverse effects that may result from the drug regimen

• encourage the patient to have all prescriptions filled at one pharmacy

• teach patients the names of drugs, rather than distinguishing them by color

sublingual and buccal medications

non-parenteral medications

• certain drugs, such as nitroglycerin, are administered sublingually; that is, a tablet is placed under the patient’s tongue

• another method is to administer the medication between the cheek and gum, known as buccal administration

  • these areas are rich in superficial blood vessels, which allow the drug to be absorbed relatively rapidly into the bloodstream for quick systemic effects

• sublingual and buccal medications should not be swallowed, but rather held in place so that complete absorption can occur

• before administering a sublingual or buccal drug, offer the patient a drink of water (if the patient is permitted to have fluids) or oral care (if the patient is NPO). this ensures that the tablet will dissolve appropriately

topical medications

non-parenteral medications

• applied to the skin or mucous membranes, including the eyes, ears, nose, rectum, vagina, and lungs

• they are usually intended for direct action at a particular site, although some can have systemic effects and are given for systemic effect. the action depends on the type of tissue and the nature of the agent

• if the site of application is readily accessible, such as the skin, an agent can easily be placed onto it

• if it is a cavity, such as the nose, or is enclosed, such as the eye, a mechanical applicator may be needed to introduce the drug

• topical medications should not be shared

• for medications administered routinely, patients in the hospital will have their own medications labeled with their names for individual use

powder

typical preparations applied to the skin areas

use

• promotes drying of the skin

• prevents friction on the skin

nursing considerations

• use caution when applying to prevent inhalation of the powder

• apply powder to gauze square, then apply to the desired site to minimize inhalation of the airborne particles

ointment

typical preparations applied to the skin areas

use

• provides prolonged contact of a medication with the skin

• softens the skin

nursing considerations

• massage thoroughly into intact skin

creams and oils

typical preparations applied to the skin areas

use

• lubricates and softens skin

• prevents drying of the sin

nursing considerations

• when applying to large parts of the body, warm preparation in the hand or fingers to prevent the patient from experiencing chilling

lotions

typical preparations applied to the skin areas

use

• protects and soothes the sin

nursing considerations

• shake thoroughly before using

• apply with cotton balls or gauze

transdermal: reservoirs, micro-reservoirs, adhesives, matrices

typical preparations applied to the skin areas

uses

• these systems are a “sandwich” of layers, each with a specific job. an impermeable backing prevents drug diffusion from the exposed portion. the drug layer of the system contains drugs, with a rate-controlling layer to slow the release of the drug over time. it ends with an adhesive layer to enhance the attachment of the system to the patient’s skin

nursing considerations

• wear gloves

• handle by edges to avoid touching drugs when handling system

• rotate application sites to avoid skin irritation

eye drops

giving eye instillations

1. offer the patient paper tissues to remove solution and tears that may spill from the eye during the procedure

2. clean the eyelids and eyelashes of any drainage with cotton balls or gauze squares moistened with water or normal saline solution, as needed

   1. use each area of the cleaning surface once, moving from the inner towards the outer canthus

3. tilt the patient’s head back slightly if sitting, or place the patient’s head over a pillow if lying down

4. remove the cap from the medication bottle, being careful not to touch the inner side of the cap or the tip of the bottle

5. have the patient look up while focusing on something on the ceiling

6. place the thumb or two fingers near the margin of the lower eyelid immediately below the eyelashes and apply pressure downwards over the bony prominence of the cheek. the lower conjunctival sac is exposed as the lower lid is pulled down

7. hold the dropper close to the eye but avoid touching the eyelids or lashes

8. squeeze the container and allow the prescribed number of drops to fall in the lower conjunctival sac. do not allow medication to fall into the cornea. this may injure the cornea or cause the patient to have an unpleasant sensation

9. release the lower lid after the eyedrops are instilled. ask the patient to close the eyes gently

10. apply gentle pressure with your gloved finger over the inner canthus to prevent the eyedrops from flowing into the tear duct

11. instruct the patient not to rub the affected eye

12. evaluate the patient’s response to the medication within the appropriate time frame

ointments (eye)

giving eye instillations (eye)

1. usually used for a local infection or irritation

2. eye ointments are dispensed in a tube

3. a small amount of ointment is distributed along the exposed lower conjunctival sac after the eyelids and eyelashes have been cleansed

4. about 1/2” of ointment is squeezed from the tube along the exposed sac moving from the inner canthus to the outer canthus of the eye

5. after the application, the eyes should be closed. the warmth helps to liquefy the ointment

6. instruct the patient to move the eye because this helps to spread the ointment under the lids and over the surface of the eyeball

7. explain that the ointment may temporarily blur vision; encourage the patient not to rub the eye

ear drops

giving ear instillations

1. clean the external ear of drainage with cotton balls moistened with water or normal saline solution

2. put the patient on their unaffected side in the bed, or if ambulatory, have them sit with the head well tilted to the side so that the affected ear is up

3. straighten the auditory canal by pulling the pinna:

   1. adult: pull pinna up and bback

   2. child older than 3: pull pinna straight back

   3. infant and less than 3: pull pinna down and back

4. hold dropper in ear with tip above auditory canal

5. instruct patient to remain lying down for 5 minutes

giving nasal medications

medication administration

1. provide the patient with paper tissues and ask that the patient blow their nose before instilling the nose drops

2. have the patient sit up with head tilted back. tilting the patient’s head should be avoided if the patient has a condition that limits their range of motion

3. instruct the patient that, depending on the medication, it may be necessary to inhale gently through the nose as the spray is being administered

4. agitate the bottle gently, if required for specific medication. insert the tip of the nose piece of the bottle into one nostril

5. close the opposite nostril with a finger. instruct the patient to breathe in gently through the nostril, if required. compress or activate the bottle to release one spray at the same time the patient breathes in

6. keep the medication compressed and remove from the nostril. release the container from the compressed state. do not allow the container to return to its original position until it is removed from the patient’s nose

7. instruct the patient to hold their breath for a few seconds and then breathe out slowly through the mouth. repeat in the other nostril, as prescribed or indicated

8. wipe the outside of the bottle nose piece with a clean, dry tissue or cloth and replace the cap. instruct the patient to avoid blowing the nose for 5-10 minutes, depending on the medication

giving medication rectally

medication administration

1. rectal suppositories are used primarily for their local action, such as laxatives and fecal softeners

2. do not administer suppositories with patients who have had recent rectal or prostate surgeries

3. assess recent laboratory values, particularly WBC’s and platelet counts

4. patients who have thrombocytopenia or are neutropenic should not receive rectal suppositories

5. do not administer rectal suppositories to patients at risk for cardiac arrhythmias due to the risk of a vasovagal response

6. use clean disposable gloves to prevent contamination with feces and microorganisms

7. after the suppository is inserted, the patient should remain in that position for 5 minutes

8. if the suppository is for laxative purposes, it must remain in position for 35-45 minutes, or until the patient feels the urge to defecate

pulmonary ventilation (breathing)

• the movement of air into and out of the lungs

• inspiration (inhalation)

• expiration (exhalation)

• the accessory muscles of the abdomen, neck, and back are used to maintain respiratory movements at times when breathing is difficult

• a stiff, noncompliant lung requires a greater inspiratory effort to inflate. decreased elasticity of lung tissue

  • i.e. emphysema and the normal changes associated with aging

• airway resistance is obstruction in the lungs. can result from foreign substances or from secretions or tissues

  • i.e. tumors or edemas

  • i.e. bronchial constriction in asthma

respiration

• gas exchange between the atmospheric air in the alveoli and blood in the capillaries via diffusion

• influenced by changes in the surface area available, thickening of alveolar-capillary membrane, and partial pressure. any change hinders diffusion

atelectasis

• change in lung surface area

• incomplete lung expansion or the collapse of alveoli, thus causing complete or partial collapse of one or more lobes or the entire lung

• conditions that cause patients to be at risk of atelectasis:

  • obstructions of the airway by a foreign object

  • mucus

  • airway constriction

  • external compression by tumors or enlarged blood vessels

  • immobility

thickening of the alveolar-capillary membrane

• any disease or condition that results in thickening

• examples of conditions that results in thickening:

  • pneumonia

  • pulmonary edema

partial pressure

• examples of a partial pressure that results in less oxygen include

  • environmental oxygen is reduced

  • a person at higher altitude or in presence of toxic fumes

perfusion

• oxygenated capillary blood passes through body tissue

• perfusion is greater in dependent areas

• depends on a person’s activity level

• greater activity increases the need for cellular o2 by body tissues and an increase in cardiac output and increased blood return to lungs

• depends on adequate blood supply and proper cardiovascular functioning

medulla

where is the respiratory center located?

hypoxia

• condition where an inadequate amount of o2 is available to cells

• if a problem exists in ventilation, respiration, or perfusion, this can occur

• common symptoms:

  • vitals and assessment: dyspnea (difficulty breathing), increased blood pressure, decreased pulse pressure, increased respiratory rate, increased pulse rate, pallor, cyanosis

  • subjective: anxiety, restlessness, confusion, drowsiness

• caused by hypoventilation

• can be a chronic condition

• effects: altered thought process, headaches, chest pain, enlarged heart, clubbing of fingers and toes, anorexia, constipation, decreased urinary output, decreased libido, weakness of extremity muscles, and muscle pain

hypoventilation

decreased rate or depth of air movement in lungs

stroke volume (SV)

quantity of blood forced out of left ventricle on each contraction

cardiac output (CO)

the amount of blood pumped per minute

• average in adult: 3.5-8.0 L/min

• volume is determined by a formula: CO = SV x HR

• CO increases during physical activity and decreases during sleep

• hemorrhage or the loss of blood decreases CO

oxygenation

impaired cardiovascular function can lead to impaired ___

3.5-8.0 L/min

what is the average CO in adults?

dysrhythmia or arrhythmia

disturbance of rhythm of the heart

caused by

• abnormal rate of electrical impulses from SA node or other sites

• abnormal conduction of electrical impulses through the heart

occurs with

• heart disease, hypertension, damage to the heart, various drugs, decreased oxygenation of the heart tissues, and trauma

causes disturbances with the

• heart rate, heart rhythm, or both, and the pumping action of the heart

symptoms

• decreased blood pressure, dizziness, palpitations, weakness, and fainting

ischemia

decreased oxygen supply to the heart caused by insufficient blood supply

leads to

• impaired oxygenation of tissues in the body

caused by

• atherosclerosis

can cause

• angina

• myocardial infarction

cause disturbances with the

• heart rate, heart rhythm, or both, and the pumping action of the heart

symptoms

• pain, anxiety, nausea, vomiting, indigestion, and shortness of breath

atherosclerosis

disease of the arteries from plaque buildup that creates blockages and narrows the vessels, reducing blood flow

angina

chest pain due to lack of blood to the heart

myocardial infarction

heart attack

age in older adults affecting respiratory function

factors affecting respiratory function

• elasticity in tissues and airways of respiratory tract decrease

• power of respiratory and abdominal muscles decrease

• chest is unable to stretch as much

• airways collapse more easily

• these all increase risk for disease, especially pneumonia and other chest infections

nursing strategies for decreased gas exchange and increased work of breathing

nursing strategies

• encourage rest periods, as necessary

• encourage cessation or moderation of smoking and second-hand smoke exposure

• teach breathing exercises

• remind about avoiding air pollutants

• caution about effect of extreme weather conditions

• instruct to avoid opioids and sleeping pills

• discuss home management with patient and family

• teach avoidance of infection and preventative measures

• use pillows as necessary to sleep

nursing strategies for decreased ventilation and ineffective cough

nursing strategies

• encourage increased fluid intake, especially water, as allowed

• use cool-mist humidifier (teach proper cleaning technique)

• encourage attendance at pulmonary exercise rehabilitation program

• discourage use of over-the-counter medications

• teach how to splint thorax and cough effectively

• instruct in use of supplemental oxygen

• teach avoidance of milk products if they are troublesome

nursing strategies for decreased CO and ability to respond to stress

nursing strategies

• encourage the inclusion of physical activity in the daily routine

• pace activities

• encourage a healthy low-fat, low-salt diet, including plenty of fruits, vegetables, and whole grains

• assist with smoking cessation and/or avoid the use of tobacco

• teach the importance of regular check-ups

• assist with weight control

• teach the importance of medication compliance

• teach stress-reduction activities

medications affecting respiratory function

factors affecting respiratory function

• patients receiving drugs that affect the CNS need to be monitored for respiratory complications

• i.e. opioids: chemical agents that depress the respiratory center in the medulla

  • result: rate and depth of respirations decrease

• when giving narcotics or sedatives, watch out for respiratory depression or arrest

• watch out for meds that decrease heart rate

lifestyle choices affecting respiratory function

factors affecting respiratory function

• sedentary activity affects expansion of alveoli and deep breathing

• regular physical activity increases heart and lung fitness, improves muscle fitness, and decreases risk of heart disease

• cultural factors: assess impact of practices and beliefs to treat an illness

• smoking contributes to lung and heart disease. most important risk factor for COPD

environmental factors affecting respiratory function

factors affecting respiratory function

• air pollution

• asbestos

assessing for oxygenation

nursing process

a. patient’s health history

• info gained provides why the patient needs care and what kind of care is required to maintain sufficient oxygenation of tissues

• before interview, make sure that the patient isn’t in acute distress

  • if the patient is in respiratory distress, do appropriate actions immediately to help relieve symptoms

  • interview patient at a later point when the patient is able

  • if no emergency intervention is needed, obtain patient health history

b. physical assessment

• inspect, palpate, percuss, and auscultate for cardiopulmonary systems

• note vitals, especially RR, HR, and BP

• inspection (observe general appearance)

  • distress, restlessness, anxiousness

  • AO3 (due to respiratory or cardiac distress)

  • skin, mucous membranes, general circulation

    • pallor and mucous membranes indicate decreased oxygen

    • cyanosis indicates decreased blood flow or poor oxygen

  • chest

    • curving of the spine and leaning forward decreases respiratory ventilation

    • barrel chest = aging, COPD (emphysema)

  • respiratory rate, rhythm, and depth

    • respirations are normally quiet and nonlabored

    • RR = 12-20 bpm

  • flaring of nostrils, muscular retractions, tachypnea (rapid breathing), or bradypnea (slow breathing)

• palpation (palpate chest)

  • note skin temp and color

  • chest expansion should be symmetrical

  • note any masses, edema, or tenderness

• percussion

  • assess position of lungs, density of lung tissue, and changes in tissue

• auscultation (listen for normal and adventitious sounds)

  • normal breath sounds: bronchial, bronchovesicular, vesicular

  • adventitious sounds: crackles, wheezes, rhonchi, pleural friction rub, stridor

  • auscultation of heart:

    • assess function of the heart, heart valves, and blood flow

    • listen for normal and abnormal heart sounds

bronchial

• loud

• high-pitched sound

• heard over the trachea and larynx

• I < E

bronchovesicular

• medium pitched

• blowing sounds

• heard over the major bronchi

• I = E

vesicular

• low pitched

• soft sound

• heard over peripheral lung fields

• I > E

crackles

• heard in inspiration

• soft, high-pitched discontinuous popping sounds

• produced by air passing through fluid in airways or alveoli and opening of deflated small airways and alveoli

• occurs due to inflammation or congestion, sputum

• heard in: pneumonia, heart failure (CHF), pulmonary fibrosis, atelectasis (quiet, end-inspirating), bronchitis, and COPD

wheezes

• continuous, high pitched, musical sounds

• produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors

• heard in all lung fields

• doesn’t clear with coughing

• heard in: asthma, tumors, or buildup of secretions

rhonchi

• continuous low-pitched sounds

• heard in expiration

• cleared by coughing

• produced as air passes through or around secretions

• heard primarily over trachea and bronchi, if loud enough can be heard in most lung fields

pleural friction rub

• rubbing or grating sound

• heard loudest over lower lateral anterior surface

• heard in inspiration and expiration

• caused by inflamed pleura rubbing against the chest wall

stridor

• harsh, loud, high-pitched sounds

• heard in inspiration

• narrowing of upper airway (larynx or trachea), presence of foreign body in airway

decreased

pallor and mucous membranes indicate ___ oxygen

decreased

cyanosis indicates ___ blood flow or poor oxygen

12-20 BPM

normal respiratory rate in adults

arterial blood gas (ABG’s)

the most accurate test for oxygen

CBC

complete blood count

cytology

diagnostic test

• examination of sputum and its cells to determine organisms causing infection

electrocardiography

diagnostic test

• most valuable and frequently used diagnostic test

• measures electrical activity of the heart

• identifies ischemia, infarction, heart damage, and drug toxicity

pulmonary function studies

group of tests used to assess respiratory function and evaluate respiratory disorders

spirometry

diagnostic test

• measures volume of air in liters exhaled or inhaled by the patient over time

• evaluates lung function and airway obstruction

• measures airway obstruction and evaluates response to inhaled medications

• patient inhales deeply and exhales forcefully into a spirometer = instrument measuring lung volume and airflow

• promotes deep breathing from surgery and to monitor health status, especially in chronic asthma

peak expiratory flow rate (PEFR)

diagnostic test

• refers to point of highest flow during forced expiration and reflects changes in size of pulmonary airways

• measured using peak flow meter

• used for moderate or severe asthma

• patient stands or sits with their back as straight as possible and takes a deep breath and places peak flow meter in mouth, closing their lips tightly around the mouthpiece

• patient forcibly exhales into peak flow meter and the indicator on the meter rises to a number. this is done 3x and recorded

pulse oximetry

diagnostic test

• noninvasive test that measures arterial oxyhemoglobin saturation (SpO2)

• used for monitoring postop patients

• does not replace ABG analysis

• decreased SpO2 levels indicate abnormal gas exchange but does not indicate low hemoglobin level

  • i.e. patient can have a low hemoglobin level and have a normal SpO2 level but that that patient may not have enough oxygen to meet body needs

• take consideration of preexisting health conditions such as COPD as accepted levels of SpO2 can differ in these patients

  • i.e. a patient with COPD normal SpO2 is 88-92%

• range of 95-100% is considered normal in healthy adults

• < 90% is abnormal, indicates lack of oxygen to tissues and possible hypoxia

< 90%

abnormal SpO2 value

95-100%

normal SpO2 level in healthy adults