patho midterm 2 (acute//chronic resp + neuro)

pulmonary system functions 3

1. Ventilation of the alveoli w/ air
2. Diffusion of gases into and out of the blood (co2 and o2)
3. Perfusion of the lungs to allow organs and tissues of the
body receive blood that is rich in oxygen and low in carbon
dioxide

pleura 2

• visceral » surrounds lungs (INNER)

• parietal » lines chest cavity

SPACE INBETWEEN IS PLEURAL SPACE - has some fluid so lungs can comfortably expand

signs of increased work of breathing

• nasal flairing

• indrawing - intercostal and clavicular muscles go INWARDS

both common in peds

• abdo muscle use

• pursed lip breathing - will actually reduce workload

VQ mismatch

• V = VENTILATION - Air into lungs

• Q = PERF - blood flow to alveolar CAP

Vent to lungs/ min over perf to lungs /min

• Rule 1 » Perfusion is Gravity Dependent - IF BLOCKED VENTILATE THE SIDE OF THE GOOD LUNG

• Rule 2» Match Good Ventilation to Good Perfusion

IF HIGH OR LOW ALWAYS LOOK AT V

LOW VQ

• low vent, normal perf » blockage of air coming into lungs, cap perf is normal

• Pneumonia, asthma, bronch COPD, etc

• SHUNT » perforation of alveoli with 0 ventilation

High VQ

• normal vent, low perf

• air flowing into alveoli, but capillarys arent able to recieve o2 - BLOCKAGE OF BLOOD IN PULMONARY ARTERIES

• PE, Pulmonar HTN, emphasemic COPD -

• Dead space » vent of alveoli with 0 PERF
  
  

hypoxemia vs hypoxia

• hypoxemia » low o2 TO BLOOD

• hypoxia » low o2 to PERIPH tissues + organs (ex. o2 sat to finger)

ABG calculation steps

1. PH

2. ROME - resp = opposite, metabolic = same (PH → CO2 vs PH → hco3)

3. compensation (body will comp with opposite system

- fully comp » PH normal but CO₂ and HCO₃ abnormal.

- partial comp » pH abnormal AND both CO₂ and HCO₃ abnormal.

- uncomp »PH abnormal and only one of CO₂ or HCO₃ abnormal

Ph range

7.35-7.45

• too low = ACIDIC

• too high = ALKALOTIC

pco2

35-45

• IF YOU KNOW PH YOU CAN KNOW co2

• low = ALKALOTIC

• high = ACIDOTIC

po2 range

70-100

• <70 = hypoxemia

• ACCEPTABLE PERCENTAGE GRADE RANGE

bicarb range

22-26 - ACTS AS BUFFER

• low = ACIDOTIC

• high = ALKALOTIC

atelectasis overview

aspiration overview

• foreign material - typically food enters lungs

• airway obstruction inflammation injury or infection

• commonly due to dsyphagia » elderly pop, peds, post op and neurological issues GERD

• can follow infectios process - fever, chills WBC SOB

• hearing crackles wheezez rhonchi or diminished breath sounds

• prevent with swallowing assessments, upright positioning during meals, proper oral hygiene &
  feeding techniques, elevated HOB

atelectasis overview

• collapse of alveoli

• common in recent surge, bed rest obesity, immobility airway obstruction, hypoventillation

• SOB, chest tightness, tachypnea, tachy decreased o2 sat

• diminished or absent breath sounds,

• prevent with incentive spiro, deep breathing and coughing, early ambulation and adequate pain management

pneumothorax general

• AIR in pleural space resulting in collapsed lung (partial or complete

• can be open closed or tension

- closed » no external wound

- open » air enters through chest wall opening

- tension » SERIOUS, open pneumo with RAPID air accumulation ↑↑ pressure

pneumothorax HTT

• Inspection» Unequal chest expansion, tachypnea, cyanosis, apprehension,

• Palpation: Subcutaneous emphysema, crepitus, chest expansion decreased on affected side,
  tachycardia, and decreased blood pressure.

• Percussion: Hyper-resonant DUE TO AIR

• Auscultation: Breath sounds decreased or absent, voice sounds decreased or absent.

tension pneumo SS

• SIGNS WILL BE SAME AS REST OF ASSESSMENT IN ADDITION TO NIGHT SWEATS

• Tracheal shift to opposite side (unaffected side), severe respiratory distress, tachycardia and hypotension

hemothorax vs chylothorax

• hemothorax » BLOOD in pleural space » PE, trauma, cancer

• chylothorax» LYMPHATIC fluid in pleural space, white or light pink - trauma, surge, cancer

pleural effusions - general 3

FLUID BUILDUP IN PLEURAL SPACE (like pericarditis of lungs)

• exudative » FLUID AND CELLS FROM INFECTION - pulmonary cancer, infection PE

• transudative » PRESSURE CHANGE FROM BLOODSTREAM - common in CHF or cirrhosis

• empyema » PUS - creamy green or yellow, common with TB pneumonia or abcess

pleural effusion HTT

• Inspection: Unequal chest expansion, tachypnea, increased WOB, accessory muscle use.

• Palpation: chest expansion decreased on affected side

• Auscultation: Breath sounds decreased or absent over fluid, pleural rub

• Percussion: Dullness over fluid.

diagnostics (effusion and chest wall disorders)

• xray » air or fluid confirmation, chest tube placement

• CT» better imaging

• thoracentesis » colour characterstics and PH of fluid, allows for Culture and sensistivity

labs

• CBC

• CRP/ESR

• ABG

• BNP and LFT

planning + interventions

• lung assessment and expansion

• o2 as prescribed

• monitor o2 rest status lung sounds

• high fowlers + encourage resp

• monitor for complications

Chest tube care

• Patient assessment » RR, depth, effort Breath sounds, symmetry and expansion

• Dressing – dry, drainage, secured (3 SIDES NOT 4 IN EMERGENCY), anchor intact, no redness or emphysema

• drainage//system » no leaks or tubing issues, colour consistency and amount of drainage, suction and emergency equip present

• Patient teaching » Ambulation, DB&C exercises, splinting Chest tube safety Symptoms to report immediately?

- tracheal shift, SOB low sats, increase work of breathing

pneumonia - general

• infection of LOWER resp tract caused by bacteria viral fungal protozoa parasitic

• enter via inhalation aspiration or blood

• immune response initiated leading to damaged mucous membranes and alveoli-capillary membranes

FLUID AND GUNK BUILDUP - leads to VQ mismatch hypoxemia and dyspnea

• community, hospital or aspiration aquired

• can be lobar or broncho (patchy all over)

pneumonia SS// HTT

• fever chills fatigue - INFECTION

• productive PURULENT cough

• tachypnea SOB chest pain

• changes in perf and o2

• dullness in areas with gunk buildup

• decreased breath sounds, bronchial sounfds or crackles

pneumonia risk factors

• aging » lowered immune sys, weaker muscles, asperation risk

• prolonged immobility » up risk for atelectasis

• decreased immune sys//transplant rejection drugs

• environmental » chemical exposure, vaping, smoking, pollution

TB - genreal

• infection by mycobacterium tuberculosis, an acid-fast bacillus

• HIGHLY CONTAGIOUS - airborne precautions

• Will become latent - PEOPLE WITH HEALTHY IMMUNE SYS are able to live with TB without passing it on - asymp

• if activated or reduced immunity TB will reactivate

TB SS

symptoms are similar to that of pneumonia

Productive cough with purulent sputum, fever, night sweats, general anxiety, dyspnea, chest pain, hemoptysis, decreased O2 sats, hypoxemia

TB HTT

• Inspection: Cough initially nonproductive, later
  productive of purulent, yellow-green sputum, may be blood-tinged. Dyspnea, orthopnea, fatigue, weakness.

• Palpation: Skin moist at night from night sweats.

• Auscultation: Normal or decreased breath
  sounds.

• Percussion: Resonant initially. Dull over any effusion.

• Adventitious sounds: Crackles over upper lobes common, persist after full expiration and cough

pneumonia and TB diagnostivs

• xray » identifies infiltraites monitors improvement//complications

• CT » more detailed image

TB vs pneumonia labs

• TB » CBC, ABG, ACID FAST BACILLI SPUTUM

• pneumonia » CBC, viral + sputum+ blood cultures, ABG

testing for infection and VQ mismatch

guides treatement esp pneumonia if viral bacterial etc

resp tract infections treatment

• med regime

• prevent spread

• PFT & chest xrays

• isolation - esp TB

• prevent and manage complications

ARDS - general

• acute lung inflammation and extensive alveolar cap injury

• MOST COMMON CAUSE IS SEPSIS

- trauma burns aspiration, surge, gas inhalation, fat emboli overuse of supp o2 DIC (clotting across body)

ARDS patho

• MASSIVE inflammation causing severe pulmonary edema due to damage to alveolar cap membrane

• SHUNTING - low VQ (low to no vent, normal perf) & hypoxemia

• Lungs become less compliant increasing thework of breathing, ventilation of alveoli decrease and hypercapnia develops leading to acute respiratory failure

ARDS SS// assessment

• dyspnea

• inspiratory crackles

• resp alk - will turn into resp acid due to co2 buildup (unable to clear)

• hypoxemia unresponsive to O2

• alveolar infiltrates WOUT Cardiac disease

• productive cough with thin frothy sputum

• indrawing of chest

• tachycardia and hypotn

ARDS labs and diagnostics

diagnostics» ground glass or whiteout on XRay

labs » CBC, blood cultures, ABG, CRP + ESR, plts (if intubating

ARDS nursing management

• lung ventilation - postioning (prone)

• monitor ABG and o2 sats

• patent airway- vent and intubation'

• nutrition and fluid balance » IV TPN esp if intubated'

• CO and tissue perf maintenance

vent care

• resp assessment » ET tube secure, RR depth and effort, breath sounds and expansion equal

• o2 sats and ABG

• Ventialtor and suction settings

• pain» distress and sedation management

• prevent complications » semi fowlers, oral hygiene, suction, reposistioning

CF general

• Autosomal recessive disorder (1/4 chance if both parents are carriers)

• Mutation of CFTR gene - protien that regualtes NA and CL movement in and out of cells

• less water due to cl + sodium not going out = sticky secretions

• affects lungs pancreas billiary and reproductive tract - mucus, sweat saliva tears and diegestive enzymes are affected

mucous secretions block bronchioles - cillia impaired + unable to clear ↑ risk for lung infections

chronic infection and inflammation leads to airway destruction over time

CF resp SS

• recurrent wheezing, pneumonia np cough

• cough will eventually have purulent grey sputum due to ↑ WBC and debris

• ↑ obstruction and mucus accumulation

• bronchiectasis (widening and scarring of bronchioles), dyspnea, hemoptysis. chest pain recurrent sinusitis and infection, nasal polyps

• Barrel shaped chest, cyanosis, clubbing of fingers and toes DUE TO CHRONIC HYPOXEMIA

CF GI SS

thickened secretions block ducts - pancreatitis, billiary issues, gallstones, etc

• meconium illeus in babies » bowel perf with first BM

• Large, bulky, loose, frothy, foul smelling stool (steatorrhea)

• Rectal prolapse & incontinence - excessive coughing

• Small bowel obstruction

• Pancreatic insufficiency

• Biliary cirrhosis with portal hypertension » blockage in bile trunk can lead to

• Voracious appetite (early); loss of appetite (late)

• FTT: Lack of weight gain, skeletal muscle wasting and weakness, failure to grow, distended abdomen

• Nutritional deficiencies, vitamin deficiencies, anemia

CF PANCREAS

Chronic cough and wheezing

Failure to thrive

Pancreatic insufficiency

Alkalosis and hypotonic dehydration » alkalosis as comp (can also trap CO2), dehydration due to NACL loss

Neonatal intestinal obstruction (meconium ileus)// Nasal polyps

Clubbing of fingers//chest radiograph with characteristics changes

Rectal prolapse

Electrolyte elevation in sweat, salty skin

Absence or congenital atresia of vas deferens OR increased viscocity of cervical secretions (secretions thickened and blocked)

Sputum with Staph or Pseudomonas

CF HTT

NEURO: Concerns with self image, confidence, depression, anxiety

CV: edema, risk for cor Pulmonale, PAH

RESP: breathing quality, increased work of breathing, crackles, wheezes, productive sputum –greyish , ↓ oxygen saturation, nasal polyps, high risk for infections, pneumothorax

GI: GERD, pancreatic insufficiency-diabetes, pain, bloating, anorexia, wt loss, rectal prolapse, small bowel obstruction, meconium ileus in newborns, require high protein/high calorie diet

GU: stress incontinence

CF Diagnostics

• NEWBORN SCREENINGS

• genetic testing for CTFR gene mutation

• SWEAT CL test » must be 2 weeks + for suffecient sweat

• PFT

if older » family history, pmhx of pancreatitis, chronic infections FTT, infertility

CF labs 6

• CBC » infection, anemia, inflamm

• lytes » nutrition and hydration

• BG//A1C » gluc or panc insuff

• LFT » liver and panc insufficiences

• lipase » elevated in pancreatitis- spill over into blood stream + unable to digest fat soluble vits

• sputum cultures » pathogen testing

CF complications

• cysts caused by mucus pooling and trapping can rupture - CAUSE CLOSED PNEUMOTHORAX

• blockage in billiary tract - gall stones

• absorption issues in bones - OP

• intussception » telescoping of intestine - more common in peds - gut secretions are also affected turning stool hard intestines struggle to push allong and slide inwards

• volvulus » bowel twisting

CF pharm

• CFTR Modulators » Improve CFTR protein function Improves lung function and nutritional status Reduces exacerbations

• Vitamin supplements » A,D,E,K

• Pancreatic enzymes » Aid in digestion allowing for proper absorption

• Mucolytics » Thin secretions

• Bronchodilators

• Antibiotics - can also be prophylactic

• Diabetes management

CF nursing management 5

• Promote clearance of secretions

• Manage and minimize lung infections

• Provide adequate nutrition

• Minimize complications

• Promote coping independence

CF interventions 7

• Chest physiotherapy

• Feeding & Chest tube care

• Airway clearance support

• Proper hydration and nutrition

• Medication administration

• Infection prevention

• Support groups

Pulmonary fibrosis general

• Chronic, progressive, fibrosing disorder of the lower respiratory tract (limited to lungs).

• High incidence in occupations with environmental exposures.

• Usually onset 50 to 70 years of age; more frequent in males

• Median survival is only 2-4 years after diagnosis

• Characterized by irreversible scarring of the lung parenchyma

• Leads to decreased lung compliance and impaired gas exchange

PF risk factors

• Cigarette smoking

• Viral infection

• Environmental pollutants

• Chronic aspiration

• GERD: acid reflux/heartburn

• Genetic predisposition

• More common in men than women - traditional trade exposure

PF patho

• exposure to triggering agent - damages lung epithelium

• fibro and myofibroblasts activated to heal the damage but are left ON - excessive scar tissue production leading to tissue stiffness, decreased O2 diffusion, hypoxemia, increased WOB, low TC and hypervent with hypercapnia

PF SS

• history of environmental exposure

• BILATERAL VELCRO CRACKLES, clubbing hypoxemia, cyanosis?

• exertional dsyspnea, tachypnea, dry persistent cough

• bilateral honeycomb//netting on CXR

diagnostics PF

• PFT » testing tidal volume and o2 absorption

• CXR » netting or honeycomb pattern, monitors progression

• CT » better image - scarring of lungs

• bronchoscopy » tube via mouth nose to lungs - ROOT OF INFECTION NOT DIAGNOSIS

• lung biopsy

PF labs 5

• WBC » infection and inflamm

• lytes » monitor nutrtion and hydration

• CRP » inflammation monitoring - ↑ in progression

• LFT » toxic effects from medications

• ABG » monitor O2 needs hypercapnia and progression

• 
  

PF HTT

NEURO: anxiety, fatigue

CV: cor pulmonale, dysrrhythmias (afib or tachy)

RESP: dyspnea, cough, respiratory failure

GI: loss of appetite, anorexia

PF treatment

o2 » o2 89-92 BUT ALSO DEPENDS ON PT BASELINE

corticosteroids (lowers inflamm)

antifibrotics » manages exacerbation and NEW scarring

cytotoxic meds » can be secondary to cancer

PF nursing management 6

• Improve oxygenation

• Reduce dyspnea and fatigue

• Promote activity tolerance

• Prevent respiratory infections

• Support medication adherence

• Optimize quality of life

PF interventions 7

• Monitor respiratory status

• Adequate oxygenation

• Manage dyspnea

• Promote airway clearance

• Medication administration

• Infection prevention

• Support group

COPD general

• chronic obstructive airway diseases - includes emphysema and chronic bronchitis

• AIR TRAPPING - prolonged exhalation period leading to VQ mismatch (LOW)

• causes » smoking, irritant exposure, infection, aging or genetics

COPD brochitis

• Hypersecretion of mucous glands

• narrowed airways

• Obstructed airflow

AIR TRAPPING IN ALVEOLI - cant go in and out

• BUILD UP OF CO2 CAN LEAD TO PULMONARY CONSTRICTION

COPD emphysema

• DESTRUCTION OF ALVEOLI WALLS

• LOSS OF RECOIL

• alvioli collapse duing exhalation

• air trapping in alveoli

COPD HTT

NEURO: Fatigue, anxiety

CV: cor pulmonale, dysrhythmias

RESP: dyspnea, chronic cough, wheezing, barrel-shaped chest, cyanosis, respiratory failure

GI: loss of appetite, anorexia

GU: stress incontinence

COPD treatment

Oxygen therapy

Bronchodilators

Anticholinergics » DRY SECRETIONS

Corticosteroids

Antibiotics

COPD interventions

• Assess respiratory status

• Position High Fowler's » NEVER TRENDELENBURG FOR ANYONE WITH RESP

• Administer prescribed oxygen

• Encourage pursed-lip breathing

• Administer bronchodilators –rescue inhalers vs maintenance

• Promote airway clearance

• Monitor ABGs and SpO₂ » 88-92

• Teach smoking cessation and exacerbation prevention

pulmonary artery HTN general

• Mean elevated pulmonary artery pressures (PAP) > 25 mmHg at rest or > 30 mmHg with exercise

• caused by abnormalities in pulmonary arterioles - - increased pulmonary vascular resistance or increased pulmonary venous pressure

• Leads to right ventricular (RV) dilation and remodeling-- then RV failure and death [when RV compensation cannot sustain normal cardiac function]

common causes

• ideopathic

• LV disease failure

• Chronic lung disease - COPD

• hypoxia

pulmonary artery HTN SS early vs late

Early Symptoms may include: » Progressive exertional dyspnea, Fatigue, Chest discomfort, Tachypnea

Later Symptoms [signs of Right heart failure]

• cyanosis

• Exertional presyncope

• Peripheral edema

• RV heave // S3

• Jugular vein distention

• Tricuspid regurgitation murmur » hear blood flow back into RA

pulmonary artery HTN HTT

NEURO: fatigue, anxiety

CV: chest discomfort, syncope, JVD, murmurs, dysrhythmias, cor pulmonale

RESP: dyspnea, tachypnea, hypoxemia, respiratory failure

pulmonary HTN labs/diagnosticcs

• CBC » anemia and plt (venous stasis)

• serum antibodies » autoimmune ruleout

• ecg » R axis deviation (widening) peaked P waves

• CXR

• PFT

• R heart catheterization » to diagnose, but also treatment to relieve pressure and widen artery

cor pumonale

Right ventricle enlargement (hypertrophy, dilation or both)

• Secondary to a lung disorder that causes pulmonary artery hypertension increasing pressure on RV and leading to RV failure

• ENLARGEMENT AND FAILURE OF RV DUE TO ↑ BP IN PULMONARY ARTERIES

• Injury or predefining factors cause vasoconstriction, pulmonary HTN, RV hypertrophy

• Symptoms of dyspnea or exertional fatigue due to underlying lung disorder

• Symptoms occur with exercise when cardiac output falls

Cor pulmonale SS // diagnostics

As pressure increases so do signs of RHF

• Edema

• s3 & s4

• Tricuspid regurgitation murmur/pulmonic valve murmur

• Chest pain

• JVD

• Hepatosplenomegaly

diagnostics = CXR ECG

cor pulmonale treatment

O2 therapy, diuretics, anticoag BB

BB treatment dependant on HR and pt baseline

cor pulmonale interventions

Assess oxygenation and respiratory status

Administer supplemental oxygen

Monitor for right-sided heart failure

Assess edema, JVD, and daily weight

Administer pulmonary vasodilators and diuretics Monitor BNP, renal function, and electrolytes Encourage energy conservation

Teach medication adherence and symptom monitoring

post op care for R heart cath

Assess airway, breathing, and circulation (ABCs) Monitor insertion site for bleeding

Monitor for dysrhythmias

Assess for pneumothorax (if jugular/subclavian access)

Maintain ordered bedrest and positioning

Perform ongoing neurovascular assessments (CSM)

upper resp tract diseases

• disease above thoracic inlet » 1st rib

• Characterized by inspiratory stridor, hoarseness, and suprasternal retractions - indrawing

Croup - general

• group of acute infections processes

• 1-7 yo peak occurance in fall and winter

• Bacterial, Viral(Influenza A and B, RSV), Allergic component

• Clinical manifestations: Bark-like cough, brassy cough, Hoarseness, inspiratory stridor, varying degrees of respiratory distress due to larynx swelling

• Diagnostics: CXR, nasopharyngeal swab for viral respiratory panel, C&S swab for bacterial respiratory, sputum sample, CBC

NOT TREATED WITH ANTIBIOTICS

foreign body aspiration

• most common in ages 1-3 - kids stick stuff in mouths

• Culprits of Foreign body aspiration: Beads, paper clips, food, marbles, magnets, batteries, hot dogs//meat, peanuts heard candy

• initial signs include choking gaggin wheeze or cough

• diagnosed via CXR direct laryngoscopy or bronchoscopy

types of obstructions and signs 3

• Laryngotracheal obstruction: dyspnea, cough, stridor, and hoarseness, with worsening of obstruction- cyanosis

• Bronchial obstruction: cough, wheezing, asymmetrical breath sounds, decreased air entry, dyspnea.

• Complete obstruction of larynx: Face becomes livid, child may fall unconscious, cardiac arrest

epiglottitis

• inflammation of epiglottis - seals off resp tract when swallowing

• cant swallow - will cause drooling

• ‘thumb’ on xray due to swellinng

• typically go to bed asymp with flu symptoms - progresses quickly

• AVOID TOUNGE DEPRESSOR AND THROAT EXAM - INCREASE IN PRESSURE AND WORSENING SYMPTOMS

General upper resp treatment 6

• corticosteroids - dexamethasone

• epinephrine as nebulizer - VASODIALATES

• antibiotics

• humidified o2

• calm environment

• family education

lower resp tract infections general

• Obstruction of airways below thoracic inlet, produces more expiratory sounds.

• Classic symptom: wheezing

• Common differential diagnosis of wheezing:-Bronchiolitis: first episode of wheezing.

• -Pneumonia: fever, cough, fatigue

• .-Asthma: recurrent wheezing episodes, identifiable triggers

RSV general

• symptoms and lower respiratory infection of the bronchioles due to inflammation

• Epidemiology: <3 yrs, Indigenous children have high rates of RSV hospitalization

• Etiology: most cases are RSV, adenoviruses and parainfluenza viruses; associated cases of Human metapneumovirus

Diagnostics: CXR, nasopharyngeal swab for viral respiratory panel, CBC

RSV inital vs progression vs severe

• Initial: Rhinorrhea, pharyngitis, coughing, sneezing, chest wheezing, ear and/or eye drainage, intermittent fever

• With Progression: Increased coughing and wheezing, tachypnea, retractions, cyanosis

• Severe Illness: Tachypnea >70 breaths/min, listlessness, apneic spells, poor air exchange, decreased breath sounds

RSV management

Oxygen therapy to maintain adequate oxygen saturation

Nasal suctioning to clear secretions

Hydration (oral or IV fluids)

Humidified oxygen Antipyretics

pedatric pneumonia

• inflammation of the pulmonary parenchyma.

• Epidemiology: occurs more frequently in infancy and early childhood.

• Etiology: Virus, or Bacterial pathogen

• Diagnostics: CXR, Nasopharyngeal swab for respiratory panel, CBC, C&S sputum

peds pneumonia ss

• cough Tachypnea, Breath sounds-crackles, decreased air entry, dullness with percussion,

• chest pain,

• pallor to cyanosis,

• indrawing and nasal flaring

• behaviour: irritable, restless, lethargic,

• GI: anorexia, vomiting , diarrhea, abdominal pain

pneumonia management

Monitor resp rate, breath sounds, O2 sats, ABGs Antibiotics

asthma

• Asthma is a chronic inflammatory disorder of the airways characterized by recurring symptoms, airway obstruction, bronchial hyperresponsiveness, and an underlying inflammation process

• MUCOUS PRODUCTION - like COPD

• influenced by allergies

• recurrent episodes of wheezing, breathlessness, chest tightness, and cough;

• symptoms occurring most frequently at night or in the early morning + with exercise

asthma assessment

• Inspection: increased respiratory rate, shortness of breath with audible wheeze, use of accessory neck muscles, cyanosis, indrawing Expiration laboured, prolonged. barrel chest may develop.

• Palpation: Tactile fremitus decreased (CANT FEEL CHEST WALL MOVE WITH VOICE tachycardia.

• Percussion:Resonant. May be hyperresonant if asthma is chronic.

• Auscultation:Diminished air movement. Breath sounds decreased, with prolonged expiration. Voice sounds decreased

• . Adventitious sounds:Bilateral wheezing on expiration; sometimes inspiratory and expiratory

asthma management

Monitor resp rate, breath sounds, accessory muscle use, O2 sats, ABGs

Bronchodilators, corticosteroids

Order of brain meninges and spacing - out to in

• skull

• epidural space

• dura

• subdural space

• arachnoid

• subarachnoid space - contains CSF

• pia

• brain

levels of LOC 7

1. alert » a&o x4

2. confusion» shorten attention span, difficuty following commands

3. disorientation » no longer a&ox4, lost track of person place time

4. lethargy » drowsy and sluggish, CAN BE ROUSED

5. obtundation». difficult to rouse, needs constant stimulation

6. stupor» semiconciousness, respond to strong noxious or painful stimuli

7. coma » no response to internal or external stimuli or needs

occulocephalic - dolls eye

DO NOT USE IF SUSPECTED OR KNOWN SPINAL AS IT TESTS BRAINSTEM FUNCTION

• hold head with two hands and turn

• eyes go to opp side of head = NORMAL

occulovestibular test - caloric ice water

TYPICALLY USED IN BRAIN DEATH DETERMINATION

OR IF SUS SPINAL WHEN DOLLS EYE CANT BE DONE

• eyes move to opposite side where water was injected = normal

breathing patterns 5

• cheyne-stokes » crescendo decrescendo (hypervent to apnea)

• cluster » clusters of disorganized breathing, irregular pauses

• apneustic » brief inspiratory expiratory pause

• agonal » dying gasp-like breathing

• ataxic » completly irregular pattern, some shallow, some deep slow rate

damage to lower brainstem

vomiting WITHOUT nausea, yawning uncontrollably

can happen with compression, diseases or damage

ACUTE NEURO HTT GENERAL

• NEURO: LOC and monitoring for deterioration pupillary changes unilaterally and bilaterally PERRLA , vision changes, heachache, hyperthermia seizures.

• CV: bradycardia hypertensive, widening pulse
  pressure (sign of Cushing’s triad) changes to perf, cap refill, pulses

• RESP: monitor for changes in respirations: bradypnea, tachypnea,
  irregular, Cheyne’s stoke present or absent,

• RENAL: urine output

• GI » projectile vomit w/out nausea