Respiratory Assessments and Interventions - Flashcards

Flashcards covering respiratory function, assessment, pathophysiology, and management based on the lecture notes.

What are the primary functions of the respiratory system?

Transports oxygen to tissues, removes carbon dioxide, and helps maintain acid-base (pH) balance.

Differentiate between ventilation and respiration.

Ventilation is the exchange of air between the lungs and ambient air; respiration is cellular gas exchange.

The normal oxygen saturation target for most patients is __%.

94-98%

CO2 retention leading to acidosis is called __ (hypercapnia due to hypoventilation).

Respiratory acidosis (hypercapnia)

Early signs of hypoxia include __; late signs include __.

Agitation (early); confusion/decreased LOC (late)

A tripod posture during assessment indicates __.

Respiratory distress

During respiratory assessment, auscultation is performed in how many areas?

10 areas

What is the breathing pattern where CO2 is retained and expiration is prolonged, common in COPD?

Pursed-lip breathing (associated with COPD as a compensatory pattern)

Normal adult respiratory rate range is __ breaths per minute.

12-20

Normal pediatric respiratory rate range is __ breaths per minute.

30-60

Cystic fibrosis is a hereditary condition characterized by thick mucus; chest physiotherapy is suggested.

Cystic Fibrosis; management includes chest physiotherapy.

Emphysema (pink puffer) characteristics include __; and CO2 retention.

Alveolar destruction with hyperinflation, pursed-lip breathing, tachypnea; CO2 retention and no overt cyanosis (per notes)

Chronic bronchitis (blue bloater) is characterized by __, cyanosis, and edema.

Recurrent productive cough with sputum; cyanosis; edema

Pneumonia symptoms include fever, chills, productive cough and __.

Dyspnea and tachycardia with crackles/wheezing; can require IS and chest physiotherapy

Allergen response can lead to anaphylaxis, a __ multi-system reaction.

Serious systemic hypersensitivity reaction

Nursing priorities follow the ABCs: __.

Airway, Breathing, Circulation

Infants with airway obstruction show the following initial response: 5 back blows and 5 chest thrusts; if unconscious, begin CPR and consider intubation.

Emergency management of choking in infants

A thoracentesis is performed to manage _ and relieve lung compression.

Pleural effusion (fluid in pleural space)

A water-seal chest tube drainage system requires monitoring for: __, and should be unclamped only briefly to assess air leaks.

Fluctuation (tidal movement) indicates functioning; system should remain below insertion level; do not clamp except briefly

Tracheostomy care aims to maintain airway patency and prevent infection; cuff use helps prevent fluid aspiration and should be managed at < __ cm H2O.

25 cm H2O

Noninvasive ventilation options include __ and , which provide positive pressure support.

CPAP (continuous) and BiPAP (bi-level)

Endotracheal intubation is indicated when Glasgow Coma Scale (GCS) is less than __; document tube size at lip.

8 (less than 8)

Oxygen delivery devices: Nasal cannula delivers **** L/min and **% O2; simple mask delivers 6-8 L/min and 40-60% O2.

1-6 L/min; 23-42% O2 (nasal cannula); 6-8 L/min; 40-60% O2 (mask)

Venturi masks provide fixed concentrations of oxygen at __% (examples: 24-40%).

Fixed, typically in the 24-40% range depending on color attachment.

Capnography measures __ and is used for early detection of respiratory depression.

End-tidal CO2 (EtCO2)

The Glasgow Coma Scale assesses __, __, and __.

Eye opening, verbal response, motor response

Breath sounds: Normal vesicular sounds are __ and are heard best peripherally; bronchial sounds are louder and heard over the trachea.

Soft, low-pitched; bronchial sounds are loud and harsh over the trachea

Adventitious lung sounds include **** (crackles), ** (wheezes), and __ (rhonchi).

Crackles (rales); wheezes; rhonchi

Incentive spirometry instruction: perform **** breaths per hour while awake and ** hold each breath.

10 breaths per hour; hold for 3-5 seconds

Chest physiotherapy components include postural drainage, percussion, and __.

Vibration

Bronchodilators, corticosteroids, mucolytics/expectorants, and antibiotics are examples of used in respiratory care.

Medications

Bronchophony, egophony, and whispered pectoriloquy are bedside tests for identifying __.

Lung consolidation (e.g., pneumonia)

Bronchoscopy is used to visualize airways and may obtain __ or biopsy samples.

Tissue samples or secretions

Thoracentesis is performed to obtain specimens for analysis and relieve compression; it may be followed by __ if needed.

Medication instillation or diagnostic analysis; relieve lung compression

Capnography waveform monitoring includes Phases 1-3; sudden loss of waveform may indicate ETT displacement or disconnection.

True

The pediatric signs of respiratory distress include nasal flaring, head bobbing, chest retractions, and use of __ muscles.

Accessory

A patient with COPD requiring low-flow oxygen should avoid high-flow to prevent CO2 narcosis and maintain saturation above __%.

90%

Vital signs interpretation for adults: SpO2 95-100%; respiratory rate 12-20/min; assess for symmetrical chest rise.

Baseline respiratory assessment indicators

A chest tube system should be kept below the level of insertion and __ should be performed only briefly to assess for air leaks.

Clamping

A patient with acute asthma attack may present with chest __ as the patient uses chest muscles to breathe.

Sucking in (retractions)

Oxygen therapy safety: ensure humidification and monitor patency of nares; check for skin integrity and comfort.

Oxygen delivery safety measures

Postural drainage positions vary; typical sessions last **** minutes and are done ** times per day before meals.

10-15 minutes; 2-4 times a day