Adult 3 - Exam 2

Components of respiratory assessment

o   Health history: tobacco pack per year history, occupational history, sputum production, SOB, dyspnea, cough, anorexia, weight loss, chest pain, oral and inhalant respiratory medicines, OTC drugs, allergies (medications and environmental), last chest x-ray and TB screen

o   Inspection: head, neck, fingers and chest; accessory muscles, sternal retractions, nasal flaring, asymmetrical chest movements, open-mouth breathing, and gasping breathes

o   Respiratory rate: tachypnea (>20), bradypnea (<10), assess rate and depth and altered patterns

o   Abnormal breathing patterns: Cheyne-stokes (cyclical with apneic periods; CHF & nervous system disorders), Kussmaul’s (deep, regular, and rapid w/out pauses; diabetic ketoacidosis and other metabolic acidosis), Apneustic (gasping inspirations followed by inefficient expiration; brain lesions)

o   Palpation: evaluate -> chest wall excursion, tracheal deviation, chest wall tenderness, subcutaneous crepitus, tactile fremitus

o   Percussion: resonance (normal lung sound, low pitches hallow sound), dullness (denser than normal tissues; lung mass, blood, etc.), flatness (air is absent), hyperresonance (increased amount of air), tympany (air-filled area)

o   Auscultation: assess breathe sounds, presence of adventitious lung sounds, voice sounds, quiet environment, systemic approach

o   Breath sounds: normal (bronchial, bronchovesicular, vesicular), adventitious sounds (crackles, rhonchi, wheezes, pleural friction rub, stridor)

pH number

7.35-7.45

PaCO2 number

35-45

HCO3 number

22-26

respiratory acidosis

Decrease in pH, increase in PaCO2, normal HCO3

respiratory alkalosis

Increase in pH, decrease in PaCO2, normal HCO3

pulse oximetry (SpO2)

-Measure saturation of oxygen in pulsatile blood (arterial blood)

-Factors that alter readings: artifact from pt movement, edema, poor perfusion, nail polish, or acrylic nails at sensor site

End-tidal carbon dioxide monitoring (ETCO2)/capnography

-Measurement of alveolar co2 at the end of exhalation when co2 is at its peak; reflects PaCO2

-Assess pt’s response to vent settings/resp treatments/proper position of ETT

-Monitor and assess trends in ventilatory status

-Normal range 35-45 mm Hg

pH

-PH- concentration of hydrogen ions

-If the H+ (hydrogen ion) increase the pH decreases – acidemia

-If the H+ decreases this results in an increase in the pH (> 7.45) patient is alkalotic

PaCO2

-Regulated by lungs – partial pressure of CO2 in arterial blood

-PaCO2 < than 35 indicates respiratory alkalosis

-PaCO2 > than 45 indicates resp acidosis

-During hypoventilation, CO2 is retained – leads to resp acidosis (PaCO2 > 45)

-During hyperventilation, excess CO2 excreted by lungs leads to resp alkalosis (PaCO2 <35)

HCO3

-Base substance that buffer acids

-Regulated by kidneys

-HCO3 greater than 26 indicates metabolic alkalosis (loss of fluids – vomiting, NG suctioning, diuretics)

-HCO3 less than 22 indicates metabolic acidosis (diabetic ketoacidosis, renal failure, drug overdose)

Respiratory acidosis causes/symptoms

-CNS depression (anesthesia, narcotics, sedatives, drug overdose), neuromuscular disorders, trauma (spine, brain, chest wall), resp depression (COPD), altered diffusion

-Feeling of fullness in head, mental cloudiness, muscular twitching, convulsions, warm, flushed skin, unconsciousness, ventricular fibrillation

Respiratory alkalosis causes/symptoms

-Anxiety, fear, pain, fever, head injury (central neurogenic hyperventilation), overventilation

-Light headedness, inability to concentrate, low calcium, numbness and tingling, circumoral paresthesia

Metabolic acidosis causes/symptoms

-Gain of strong acid: DKA, lactic acidosis

-Loss of base: renal failure, diarrhea, high K+ or high Cl-

-Headache, confusion, drowsiness, increased RR and depth, N/V, peripheral vasodilation (warm and flushed), decreased CO if pH falls below 7.1

Metabolic alkalosis cause/symptoms

-Gain of base: excessive use of antacids, excess administration of Na bicarb

-Loss of acids: vomiting, NG suctioning, low K+ and low Cl-, diuretics w/ loss of K+ or Cl-

-Depressed respirations (compensatory action),

-Related to decreased calcium ionization: dizziness, tingling of fingers and toes, circumoral paresthesia, carpopedal spasm, hypertonic muscles  

nasal cannula

• Provide o2 concentrations between 24-44% flow rates 6 L/min

• An increase in oxygen flow by 1L/min increase o2 delivery by 4%

• Flow rates higher than 6L/min are not effective

• Consider humidity

high-flow nasal cannula

§  Provides high concentration of oxygen ranging from 60-90%

§  O2 delivered at rates ranging from 15-40 L/min

§  Heats and humidifies

§  High flow flushes out expired CO2 from upper airway

§  WOB may be decreased

simple face mask

§  Creates an additional oxygen reservoir

§  Provides concentrations of 30-90% oxygen

§  Mask must have tight fit

§  Flow rate must be set at 5 L/min or higher – this prevents rebreathing CO2

§  Oxygen is delivered flow rates 5-12 L/min

face mask with reservoirs

§  Parital rebreather and non-rebreather like simple mask but have oxygen reservoir bag

§  Reservoir increases amount of oxygen available to pt

§  Partial-rebreather mask: 10-15 L/min (35-60% O2)

§  Non-rebreather mask: 10-15 L/min (60-80% O2)

venturi mask

§  Delivers consistent FiO2

§  2-15 L/min (24-60%)

§  Best for COPD: don’t want to O2 overload

manual resuscitation mask

§  Ventilate and oxygenate pt manually

§  Attached to face mask, ETT, or trach

§  Set O2 flowmeter attached to bag at 15 L/min

§  Used in emergency situations

incentive spirometer

o   Measures volume of inspiration

o   Slow, steady deep breath in

o   COPD, post op from anesthesia, rib fracture, etc.

nursing diagnoses of impaired gas exchange

§  Impaired gas exchange related to changes at the alveolar/capillary level and decreased O2 carrying capacity secondary to…

§  Ineffective airway clearance related to decreased level of consciousness. Excessive secretions, airway constriction secondary to…

§  Ineffective breathing pattern related to depressed respiratory drive or overstimulation of the respiratory drive secondary to…

nursing interventions for impaired gas exchange

§  Maintain pt airway – suctioning, ET/tract, CPAP, BiPAP

§  Administer oxygen therapy as ordered

§  Prepare for possible intubation and mechanical ventilation

§  Administer meds as ordered – bronchodilators, steroids, etc.

§  Reposition the pt

§  Treat underlying cause

§  Replace fluids with caution

§  Mange anxiety and respiratory depression

§  Ask pt to cough and deep breath

§  Pulmonary rehab referral

§  Collaborate with respiratory therapist