NUR 311 - Final Exam (Exam 2 SLOs - Gas Exchange)

What is crepitus?

crepitus or subcutaneous emphysema is indicated by the presence of air bubbles in the subcutaneous tissues or underlying muscle; upon palpation, the sensation of bubbles under the fingers can be felt and, occasionally, crackling can be heard

What is fremitus?

the detection of palpable sound vibration transmitted to the chest wall as the patient speaks is called tactile fremitus

Where does the primary drive to breathe come from?

a low O2 level (that is why if O2 is administered at a high enough rate to raise the PaO2 to normal, there is a risk of obliterating hypoxic drive)

What are the three processes involved in external respiration?

- ventilation (the act of breathing)

- perfusion (blood flow to the alveoli)

- diffusion (movement of gases from a higher area of concentration to a lower area across alveolar-capillary membranes)

What is tidal volume?

the volume of air inhaled and exhaled with each breath

What is inspiratory reserve volume?

the maximum volume of air that can be inhaled after a normal inhalation

What is expiratory reserve volume?

the maximum volume of air that can be exhaled forcibly after a normal exhalation

What is residual volume?

the volume of air remaining in the lungs after a maximum exhalation

What is vital capacity?

the maximum volume of air exhaled from the point of maximum inspiration

What is inspiratory capacity?

the maximum volume of air inhaled after normal expiration

What is functional residual capacity?

the volume of air remaining in the lungs after a normal expiration

What is total lung capacity?

the volume of air in the lungs after a maximum inspiration

Define orthopnea.

inability to breathe unless sitting or standing

What are some practical ways to relieve dyspnea?

- placing the patient at rest with the head elevated

- encouraging patient to lean forward with arms and upper body supported on a table (orthopneic position)

- pursed-lip breathing

Profuse, frothy, white or pink material, often welling up into the throat, may indicate ____ ________.

pulmonary edema

Describe cheyne-stokes breathing.

regular cycle in which the rate and depth of breathing increase and then decrease until apnea (usually about 20 seconds) occurs

What are the steps for using an incentive spirometer?

- assume an upright position

- breathe using the diaphragm

- place mouthpiece firmly in the mouth, and breathe in deeply and slowly, holding each breath in for 3-4 seconds and exhaling slowly

- repeat 6-10 times per session

- use spirometer every hour while awake

- if secretions are present, try coughing, with splinting of incision, after each use

Describe the process of postural drainage.

- uses specific positions that allow gravity to aid in the removal of pulmonary secretions

- the patient changes positions so that secretions can drain from the affected bronchioles into the bronchi and trachea and then be removed by coughing and suctioning

- usually performed 2-4 times daily

What is pneumonia?

the infection of the lower respiratory tract caused by a variety of microorganisms, including bacteria, viruses, fungi, protozoa, and parasites

What are some ways that pneumonia can be classified?

- microbiologic cause

- host condition

- host setting

When do most cases of CAP occur?

in the winter and early spring months

Define HAP (hospital-acquired pneumonia).

the onset of pneumonia symptoms more than 48 hours after admission in patients who had no evidence of infection at the time of hospitalization

Define VAP.

a type of HAP that is associated with endotracheal intubation and mechanical ventilation; it is defined as pneumonia that develops in patients who have been receiving mechanical ventilation for at least 48 hours

HAP occurs when at least one of three conditiosn exist:

1. host defenses are impaired

2. microorganisms reach the lower respiratory tract (usually by microaspiration or oropharyngeal microorganisms)

3. a highly virulent organism is present

What are some typical pneumonia vectors?

- normal flora present in patients whose resistance has been altered

- aspiration of flora present in the nasopharynx or oropharynx

- the inhalation of airborne microorganisms from other people

- contaminated water sources or respiratory equipment

- blood-borne organisms that enter the pulmonary circulation and become trapped in the pulmonary capillary beds

What are some risk factors for pneumonia?

- smoking

- alcohol use disorder

- pre-existing hypoxemia

- acidosis

- toxic inhalations

- pulmonary edema- altered mental status

- presence of comorbid conditions

- malnutrition

- immunosuppresive therapies

- poor dental hygiene

- IV drug use

- regular contact with children

- 10 or more people in one household

- previous episodes of pneumonia

- working and environmental conditions

What are the classic clinical manifestations of pneumonia?

- fever

- cough

- dyspnea

- leukocytosis

- chills/rigors

- pleuritic chest pain

- tachypnea

- use of accessory muscles

- tachycardia

- fatigue

- anorexia

What are some physical examination findings of an individual with pneumonia?

- bronchial breath sounds over consolidated lung areas

- crackles

- increased tactile fremitus

- percussion dullness

- egophony

When is the best time to collect sputum?

in the morning (more concentrated and less likely to be contaminated with saliva and nasopharyngeal secretions)

Describe the treatment regimen for a patient with pneumonia.

- duration is a minimum of 5 days

- patients should be afebrile for at least 2 days before antibiotics are discontinued

- patients with nosocomial pneumonias are treated for 7-10 days

Each liter of oxygen flow is approximately an addition of __ FiO2.

4%

What are some supportive care measures for patients with pneumonia?

- hydration

- antipyretics

- warm, moist inhalations

What is a preventative measure for pneumonia?

pneumococcal vaccinations (avoided during first trimester of pregnancy)

Review lung sounds.

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Review oxygen delivery devices.

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What is TB?

an infectious disease that primarily affects the lung parenchyma

Describe the primary infectious agent in TB.

M. tuberculosis (an acid-fast aerobic bacilli that grows slowly and is sensitive to heat and UV light; resistant bacterium that can persist in calcified and necrotic lesions and remain able to reinitiate growth)

How does TB spread?

airborne transition (an infected person releases droplet nuclei through talking, coughing, sneezing, laughing, or singing)

Describe the stages of TB infection.

- the susceptible person inhales mycobacteria and the bacteria are transmitted through the airways to the alveoli, where macrophages ingest the bacilli

- if the bacilli escape the antimicrobial activities of the macrophages, an infection begins (primary TB) - usually clinically silent

- the bacilli are transported via the lymph system and bloodstream to other parts of the body and other areas of the lungs

- the spreading of TB via lymphatics and blood is called miliary TB

- the body responds by initiating an inflammatory reaction

- the initial infection usually occurs 2-10 weeks after exposure

Describe the tissue in the lungs with a latent TB infection.

- granuloas, new tissue masses of live and dead bacilli, are surrounded by macrophages, which form a protective wall

- they are transformed to a fibrous tissue mass, the central portion of which is called a Ghon tubercle

- this mass may become calcified and form a collagenous scar

- then the bacteria become dormant and there is no further progression of active disease

Describe a latent TB infection.

- positive skin or blood test

- no evidence of clinical disease

- the disease cannot be spread because the bacteria is inactive

- approximately 10% of those with latent infection can progress to active disease within years to decades of the initial infection

What are some risk factors for TB?

- born in foreign country with high prevalence

- low income

- underrepresented groups of people under 15 and 15-44

- individuals emigrated from developing countries

- those living in overcrowded housing

- homeless shelters

- health care worker performing high-risk activities/working with high-risk patients

- advanced age

- traveling abroad

- substance use disorder

- immunocompromised

- comorbidities (malnutrition, diabetes, silicosis, CKD, gastric or intestinal bypass surgery)

Describe how latent TB is "reactivated."

- the Ghon tubercle ulcerates, releasing the cheesy material into the bronchi

- the bacteria become airborne, resulting in further spread of the disease

- the ulcerated tubercle heals and forms scar tissue

- the infected lung becomes more inflamed, resulting in further development of bronchopneumonia and tubercle formation

What are some s/s of TB?

- low-grade fever

- cough

- night sweats

- fatigue

- weight loss

- cough becomes mucopurulent

- dyspnea

- chest pain

- heoptysis (blood sputum)

What tests are used to diagnose TB?

- complete history

- physical examination

- TB skin test/blood test

- chest x-ray

- acid-fast bacilli (AFB) smear

- sputum culture

If the patient is infected with TB, what does the chest x-ray normally show? What does the AFB smear contain?

- lesions in the upper lobes

- mycobacteria

Describe the Mantoux test.

- tubercle bacillus extract (tuberculin), purified protein derivative (PPD), is injected into the intradermal layer of the inner aspect of the forearm, approximately 4 in. below the elbow

- creates an elevation in the skin, a wheal or bleb

- test result is read 48-72 hours after injection

- tests read after 72 hours tend to underestimate the true size of induration

How is the Mantoux skin test read?

- a reaction occurs when an induration at the injection site is present

- the site is lightly palpated

- the diameter of the induration (not erythema) is measured in mm at its widest part and the size is documented

- erythema without induration is not considered significant

- 0-4 mm is not significant; 5 or greater may be significant for someone at risk; 10 or greater is considered significant for those who have normal or mildly impaired immunity

What does a positive TB blood test indicate?

a person has been infected with TB and further testing is needed to determine latency vs. active disease

True or False: Monotherapy is often used for active TB to reduce the risk of mycobacterium developing antibiotic resistance.

false; monotherapy is never used

What is COPD?

a heterogeneous (diverse) lung condition characterized by chronic respiratory symptoms, due to abnormalities in the airway, and/or alveoli that cause perisstent, often progressive airflow obstruction

Describe GETomics.

the pathological changes that characterize COPD are complex and include interactions between genes (G) and environment (E) over a lifetime (T) of the individual

What is emphysema?

a pathologic condition that is characterized by loss of lung elasticity, abnormal enlargement of the airspace beyond the terminal bronchioles with destruction of the walls of the alveoli (parenchymal destruction)

What is chronic bronchitis?

a disease of the small airways, and has the hallmark feature of a productive cough for at least 3 months per year over 2 consecutive years

What are some characteristic changes in chronic bronchitis?

- chronic mucus hypersecretion has been implicated as a cause of lung function decline, exacerbations, and infections

- thickening of the epithelium, smooth muscle hypertrophy, and airway inflammation are implicated in remodeling of the airways

Describe how air trapping occurs in emphysema.

- air trapping is increased because of the loss of elastic recoil in airway support structures; hyperinflated lungs flattens the diaphragm

- air sacs are replaced by bullae and capillary area is proportionally diminished

What are the risk factors for COPD?

- tobacco smoke

- environmental tobacco smoke

- genetic factors

- occupational exposure to chemical agents and fumes

- exposure to particles (organic and inorganic dusts, open fires from wood, animal dung, crop residue, and coal)

- air pollution

- biomass cooking in poorly ventilated areas

True or False: A host risk factor for COPD is a deficiency of an enzyme inhibitor that is an inherited mutation in the SERPINA1 gene that protects the lung parenchyma from injury - alpha1-antitrypsin.

True

What are the primary symptoms of COPD?

- dyspnea/adventitious sounds

- chronic cough

- sputum production

- barrel chest/clubbing

What are exacerbations of COPD marked by?

- increased airway inflammation

- mucus production

- air trapping

- worsening airflow limitation and dynamic lung hyperinflation causing dyspnea

_________ is used to evaluate airflow obstruction.

Spirometry

What are some key management tools for COPD?

- smoking cessation as a priority

- bronchodilators by metered dose inhaler (MDI) and spacer: anticholinergics and sympathomimetics

- corticosteroids

- oxygen therapy

- surgery

- rehabilitation

What standards are used to classify COPD? How?

GOLD guidelines (lung function measurement and exacerbation history)

What is a metered-dose inhaler?

a pressurized device that contains an aerosolized suspension of medication; a measured amount of medication is released with each activation of the canister

What is the correct technique for using metered-dose inhalers?

- remove cap

- shake for 5-6 seconds

- place mouthpiece of the inhaler in your mouth with your tongue and teeth out of the way

- as you depress the inhaler take a deep breath with your mouth wide open; inhale for 5-6 seconds if you can; slower is better

- at the end of the deep breath, hold your breath for at least 3-10 seconds

- exhale through pursed lips

- if more than one puff is prescribed, repeat the above steps

- after your last puff, rinse your mouth and rinse the mouthpiece

What are the primary causes of acute exacerbations of COPD?

- infection

- response to pollutants and allergens

- nonadherence to treatment

- associated comorbidities

What does a DECAF score indicate?

it predicts hospital mortality risks for patients with COPD

What are the concepts associated with a DECAF score?

- Dyspnea

- Eosinopenia

- Consolidation

- Acidemia

- Atrail Fibrillation

Describe BNPs role in diagnosing heart failure.

BNP is secreted from the overdistended cardiac chambers. High BNP levels indicate abnormal ventricular function or symptomatic heart failure. BNP levels are useful for diagnosing heart failure. The higher the BNP level, the more severe the heart failure.

What is the target oxygen saturation for COPD patients?

88-92%

A nurse teaches a COPD patient not to smoke because smoking:

increases the amount of mucus production

What is asthma?

a common heterogeneous disease of the airways that is complex and characterized by recurring and variable symptoms, expiratory airflow limitation, and usually bronchial hyperresponsiveness

What is the key underlying feature of asthma?

inflammation

What are the main symptoms of asthma?

- cough

- chest tightness

- wheeze

- dyspnea

What are some different asthma phenotypes?

- allergic asthma

- nonallergic asthma

- adult onset or late-onset asthma

- asthma with persistent airflow limitation

- asthma with obesity

What is the strongest predisposing factor for allergic asthma?

atopy (the genetic predisposition for the development of an IgE-mediated (antibody associated with allergic reaction and inflammation) response to allergens)

What is the underlying pathology in asthma?

reversible and diffuse airway inflammation and an exaggerated hyperresponsiveness to a variety of stimuli

What are the defining characteristics of asthma?

- acute inflammation leads to airflow limitation, hyperresponsiveness, airway edema, and mucus hypersecretion

- mast cells, neutrophils, eosinophils, and lymphocytes are involved and cause epithelial injury

What are some risk factors for the development of asthma?

- genetic predisposition

- exposure to environmental factors

- airborne allergens

- viral respiratory infections

What are the most common manifestations of asthma?

- cough

- dyspnea

- wheezing in a pattern of exacerbations

What are some common asthma triggers?

- pollens

- molds

- house dust mite

- cockroaches

- dander

- foods

- occupational exposures

- drugs

- viral respiratory infections

- occupational irritants

- GERD

- sinus infection and postnasal drip

- cigarette smoke and odor

- forceful respiratory maneuvers

- cold, dry air

- vapors, gases, aerosols

- endocrine factors (menses, pregnancy, thyroid disease)

- exercise

- air pollution

- scented products

- emotions and stress

- obesity

What are the goals of asthma management?

- symptom control

- maintenance of pulmonary function and activity

- prevention of recurrent exacerbations

- provision of optimal pharmacotherapy

- patient education

What is status asthmaticus?

a severe asthma episode that is refractory to initial therapy (medical emergency)

What are some symptoms of status asthmaticus?

- tachypnea

- tachycardia

- use of accessory muscles

- diaphoresis

- inability to speak in full sentences or phrases

- inability to lie supine due to breathlessness

- pulsus paradoxus (a fall in systolic bp of more than 12 mmHg during inspiration)

Review the asthma action plan.

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