Core exam 3 blue blueprint

Nurses observe and trust their instincts, even when nothing is obviously wrong. Instinct is just another word for

nursing judgement. We prefer to catch the issue when it is small and fixable, not when it is big and deadly

The Brain is the most sensitive to decreased oxygen because

it uses that largest percentage of oxygenated blood

what organ will tell you first if the patient is getting low O2

the brain

early stages of hypoxia

- tachypena
- tachycardia
- restlessness, anxious, agitated
- elevated BP
- Accessory muscles

late stages of hypoxia

- Decreased LOC such as stupor
- Cyanosis
- Bradypnea
- Bradycardia
- Hypotension
- Cardiac dysrhythmias

change in mental status can be a sign of

oxygenation issues

Comfort and oxygenation

poor oxygenation can cause pain and decrease level of comfort

Ischemia

decreased level of oxygenation that can cause pain in affected tissues

Inferior lobes of lungs are the largest and most important to auscultate because

fluid settles in lower lobes

Alveoli interface with pulmonary capillaries at end of bronchioles to

facilitate gas exchange, workhorses of respiratory system

Alveoli that deflate or filled with fluid are called, Number one respiratory complication after surgery

atelectasis

ventilation

movement of air in and out of the lungs, breathing

inspiration

- inhalation
- movement of muscles inn thorax bringing air into the lungs
- active phase

expiration

- exhalation
- breathing out, movement of air out of the lungs
- passive phase

Diffusion

movement of O2 and CO2 between alveoli and blood in the capillaries
- as pressure of oxygen increases it facilitates movement of O2 from alveoli to capillaries

Perfusion

the process by which oxygenated capillary blood passes through body tissues

Eupnea

normal respirations
adults 12-20 BMP
Older adults 12-24 BMP

hypercarbia/hypercapnia is

high CO2 in the blood

Too much CO2 in the blood can

raise the blood PH

chemoreceptors sites

carotid arteries and aorta

when chemoreceptors are triggered to high CO2 it tells the body to

increase respiratory rate

COPD patients are used to function on lower levels of oxygen

- their breathing is regulated by hypoxic drive
- we breathe because of ↑ CO2. People with lung disease (that retain CO2) breathe because of ↓ O2. We can make them stop breathing by giving them even slightly too high levels of supplemental oxygen

Ventilation, diffusion, perfusion

all three are required for adequate oxygenation

Tachypena

more than 20 breaths per minute

Bradypnea

less than 12 breaths per minute

apnea

absence of breathing

dyspnea

difficult or labored breathing

orthopnea

difficulty breathing when lying down

subjective data

what the patient says
"I smoke a pack a day"

objective data

what the nurse can see or measure with her senses/assessments
- cyanosis noted in fingertips

lifestyle behaviors to increase oxygenation

- quit smoking
- ROM exercises
- light cardio
- incentive spirometer
- receive flu and pneumonia vaccine

Respiratory nursing assessment Observe for

- chest symmetry (should have equal movement on both sides, COPD patients have barreled chest)
- respiratory effort/ use of accessory muscles
- oxygenation status (pulse ox on warm finger to gauge oxygen sat)

Respiratory nursing assessment auscultate for

- normal/ expected breathing sounds ( clear bilaterally)
- adventitious breathing sounds ( not clear sounds, wheezing, crackles, ect.)

Lung Auscultation expected sounds

bronchial, bronchovesicular, vesicular

Lung Auscultation unexpected sounds

- crackles or rales
- wheezes
- rhonchi
- pleural friction rub
- absence of breath sounds
- stridor

bronchial breath sounds

loud, high-pitched, hollow sounds normally heard over the trachea and the large bronchi

bronchovesicular sounds

normal breath sounds heard over the upper anterior chest and intercostal area

Vesicular breath sounds

soft, fine, breezy, low-pitched sounds heard over peripheral lung tissue

rales or crackles

- bubbly sound of fluid expanding and falling in alveoli
- air moving through fluid (not good).
- does not clear with coughing

wheezes

- air moving through a narrowed airway (narrowed by bronchoconstriction on the outside of the airway or swelling of the lining of the airway on the inside)
- louder on expiration

Rhonchi

- Rattling noise of mucous in the lungs
- loud, course, low pitched
- can be cleared with coughing

Pleural friction rub

continuous, dry grating sound caused by inflammation of pleural surfaces and loss of lubricating pleural fluid, sounds like sandpaper

Stridor

A high pitched sound generated from partially obstructed air flow in the upper airway
- squeaky toy

best time to take sputum sample

first thing in the morning
- cough it up or endotracheal suction it out

Hemoglobin carries oxygen in blood, it can tell us

how much oxygen is available in blood

arterial blood gasses ( ABGs)

- monitor patients acid base balance
- retrieved from artery not vein
- pH
- carbon dioxide(PaCO2)
- bicarbonate( HCO3)
- PaO2
- SPO2
- most accurate and most invasive measurement of client's oxygen status

Pulse Oximetry (SpO2)

- measures percent of Hemoglobin that bound with O2
- expected is 95-100% ( some Pts vary)
- chronic lung disease 85-89% but with oxygen 88-92%

Respiratory issues diagnostic tests

- chest x ray
- Ct scan (detailed internal image of body)
- MRI (strong magnetic fields generate images)
- bronchoscopy (scope the lungs)

Alterations to oxygenation assessment

- fatigue( can not fully expand chest)
- irritable
- discomfort
- changes in LOC
severe alterations
- hypoxemia
- hypoxia

Chronic hypoxia

- cyanosis is late sign of hypoxemia
- clubbed fingers, commonly seen in COPD

respiratory Independent nursing interventions

- raise HOB at least 30 degrees
- encourage turning, coughing, and deep breathing
- pursed lip breathing for COPD
- positioning
- encourage smoking cessation
- encourage fluid intake to thin secretions

Incentive Spirometer

- encourages deep breathing
- promotes lung expansion
- patient inhales through mouthpiece
- 9-10 times per hour while awake

suctioning can be done

orally, nasally, endotracheal, and to clear airway of hypoxic patients

chest physiotherapy, requires Dr orders

- percussion
- vibration
- postural drainage
all to loosen secretions within the lungs
- contraindicated in pregnancy, head or neck injury, recent abdominal surgery or bleeding disorders
- 1 hour before or two hours after a meal
- monitor for aspiration

collaborative respiratory interventions

- oxygen therapy to increase FiO2
- can apply oxygen in emergencies and then call provider
- with every L of O2 FiO2 increases by 4%

nasal cannula

A device that delivers low concentrations of oxygen through two prongs that rest in the patient's nostrils.
disadvantages:
- 1-6 L per minute
- 24-44% fiO2
- skin breakdown behind ears, on cheekbones, and under nose

simple face mask

an oxygen-delivery apparatus used for patients who require a moderate flow rate for a short period of time via a plastic mask that fits snugly over the mouth and nose
- 6-12 L per min
- 35-50% FiO2
disadvantages:
- impaired eating and drinking
- anxiety in claustrophobic pts
- skin breakdown around border of mask and strap

non-rebreather mask

allows higher levels of oxygen to be added to the air taken in by the patient
- 10-15 L/min
- up to 100% FiO2
- humidification required
- provides the highest amount of oxygen

Venturi

- High flow system
- Delivers 24-50% oxygen
- 4-12 L/min
- most precise delivery system
The oxygen mixes with the air
Clients receive constant O2
concentration regardless of rate or depth of respirations

with oxygen therapy do not use

petroleum based products to prevent burns and combustion

Humidification is requires for oxygen therapy above

4L per minute

atelectasis is most often associated with general anesthesia, pay particular attention to patients that

have had surgery in the last 1-2 days

for dyspneic patients

raise head of bed, asses, intervene, assess, then apply O2 if needed

1. Oxygenation is the name of the game for ABC's

- Airway - get the air in and out
- Breathing - get the air down to the alveoli for gas exchange
- Circulation - perfuse the body's tissues with oxygenated blood and get rid of carbon dioxide

Do not avoid opioid pain medications because of fear of respiratory depression because

- Pain will cause more long-term lung complications in the long run
- Be the patient advocate - provide comfort and be watchful to avoid harm (in other words, be a good nurse!)

Oxygenation

hemoglobin being loaded with oxygen

Oxygenation problems

COPD, pneumonia, pulmonary edema, anything affecting lungs

Oxygenation Assessment

pulse oximetry, respiratory rate, LOC, SOB, arterial blood gasses are the most accurate representation of oxygenation

Circulation definition

blood traveling to and from all tissues in body

Circulation problems

- occlusions/ blood clots
- sickle cell anemia
- bed rest / restricted movement
- low blood volume
- dehydration
- heart problems

Circulation assessment

capillary refill, peripheral pulses, cyanosis

Perfusion problems

heart dysfunction, ischemia progressing to infarction progressing to necrosis

Assessment of perfusion

- decreased temperature
- cyanosis
- decreased LOC
- altered mental function with decreased perfusion in the brain

blood pressure is measured as

systolic/diastolic

factors that increase blood pressure

- increased age
- stress
- ethnicity (African Americans)
- certain medications
- obesity
- smoking

factors that can lower blood pressure

- certain medications
- consistent exercise

Systemic Vascular Resistance (SVR)

- constriction / dilation of arteries
- SVR increases (constriction)=blood pressure increases
- SVR decreases (dilation) = blood pressure decreases

pulse sites

- carotid, brachial, and femoral are central pulses
- radial
- popliteal
- posterior tibial
- dorsalis pedis ( pedis)

pulse strength

reflects the volume of blood ejected against the arterial wall with each contraction of the heart (stroke volume)

how to take pulse rate for an adult

- measured in BMP
- for regular pulse, count for 30 seconds and multiply by 2
- for irregular pulse, count for a full minute

scale for pulse strength

0= absent
1= diminished
2= normal
3= increased and strong
4= bounding

Tachycardia

- more than 100 BMP
- causes: cardiac dysrhythmias, exercise, anxiety, pain, hypovolemia, hypoxemia

bradycardia

- less than 60 BMP
- S/S: dizziness, hypotension, decreased LOC
- causes: cardiac dysrhythmias, medications, exercise, relaxation, ect.

Apical Pulse/Pulse Deficit

- auscultate apical pulse for 1 full minute
- simultaneously palpate the radial pulse and auscultate the apical pulse to check for deficit

cardiac output=

stroke volume x heart rate

blood pressure=

cardiac output x systemic vascular resistance

stroke volume increases

HR decreases
cardiac output and blood pressure remails the same

stroke volume decreases

heart rate increases
cardiac output and blood pressure remains the same

when stroke volume decreases and heart rate increases too much

the heart does not have time to properly fill with blood
cardiac output and blood pressure decreases

heart sounds

S1 and S2
anything else is abnormal

S1

lub
ventricle systole/ contraction
bicuspid and tricuspid valves

S2

dub
ventricle diastole/ relaxation
pulmonic and aortic valves

Diaphragm of stethoscope

high pitched heart sounds

Bell of stethoscope

low pitched sounds
unexpected heart sounds and bruits

thrill

palpable vibration caused by turbulent blood

bruits

whooshing sound caused by obstructed or turbulent blood

heart failure / broken pump causes

decreased circulation / oxygenation and decreased perfusion

right sided heart failure

think body
- fatigue
- increased peripheral venous pressure
- asities
- enlarged liver and spleen
- distended jugular veins
- GI distress
- weight gain
- dependent edema

left sided heart failure

think lungs
- pulmonary congestion
- restlessness
- dyspnea
- tachycardia
- fatigue
- exertional dyspnea
- cyanosis

arterial blood

- high oxygen
- bright red
- moves distally from the heart
- blockage= ischemia/ infarction
S/S of arterial problem
- pain
- pallor
- pulses diminished / absent
- paresthesia ( abnormal feeling can lead to paralysis)