PN 103 8-9

External respiration

alveoli--->

Internal respiration

bloodstream ---->

REGULATION OF OXYGEN

Chemoreceptors Medulla in the brainstem

OXYGENATION IN CHRONIC LUNG DISEAS

-Trapped air impedes oxygen and CO2 exchange

Hypoxemia

low oxygen levels in blood

Hypoxia

blood can't take enough oxygen to tissues

s/sx of hypoxia

--Agitation/anxiety

CAUSES OF IMPAIRED OXYGENATION

-Airway obstruction

ASSESSMENT OF THE RESPIRATORY SYSTEM

-Inspection

INSPECTION

-Symmetry

PALPATION & PERCUSSION

-Excursion

AUSCULTATION

-Normal

eupnea

normal breathing

Hyperventilation

the condition of taking abnormally fast, deep breaths

Tachypnea

rapid breathing

bradypnea

slow breathing

apnea

absence of breathing

Cheyne-Stokes respiration

pattern of breathing characterized by a gradual increase of depth and sometimes rate to a maximum level, followed by a decrease, resulting in apnea

Kussmaul respirations

very deep and rapid respirations

OXYGEN SATURATION

-Pulse oximeter

sputum culture and sensitivity (C&S)

test performed on sputum to determine the presence of pathogenic bacteria

throat culture

Identifies the microbe (bacterium or fungus) causing a throat infection, with results usually available within 2 days

chest x-ray (CXR)

radiographic image of the thoracic cavity (chest film)

bronchoscopy

visual examination of the bronchi

pulmonary function tests

a group of tests that measure volume and flow of air by utilizing a spirometer

IMPAIRED OXYGENATION: NURSING CARE

-Remain calm

NURSING INTERVENTIONS OF THE RESPIRATORY SYSTEM

-Cough, deep breath

Nasal cannula

1-6 L/min- Oxygen into nares- Nasal prongs curve inward

Simple face mask

5-10 L/min - Oxygen into nose and mouth- Gauze may to used under elastic straps above the ears if irritation occurs

Nonbreather Mask

6-15 L/min- Prevents patient from rebreathing exhaled air- Bag shouldn't collapse during inhalation

Venturi mask

24-80%- Can deliver precise percentage of oxygen-Physician order percentage of oxygen. Set dial accordingly

Tracheostomy collar

4-10 L/min- Humidified oxygen which rests over trach- Condensation may build up in tubing. Ensure pooled water doesn't enter tracheostomy

OXYGEN SAFETY PRECAUTIONS

-Remove matches and cigarettes

pharyngeal airways

devices that maintain the patency of the pharyngeal structure

nasopharyngeal airway

a flexible breathing tube inserted through the patient's nostril into the pharynx to help maintain an open airway

endotracheal airway

a device that is positioned in the trachea for the purposes of establishing an airway

tracheostomy

surgical creation of an opening into the trachea through the neck

chest tube

Catheter inserted through the thorax into the chest cavity for removing air or fluid; used after chest or heart surgery or pneumothorax.

defacation

Process of bowel elimination

constipation

hard stools; difficulty passing stools

Diarrhea

several liquid stools per day

Fecal incontinence

Loss of voluntary control of the rectal sphincters

Flatus

gas

PERISTALSIS

-Consists of rhythmic, wavelike movements

PROCESS OF DIGESTION

-Enzymes break down the bolus of food, converting it to chyme

Normal bm

soft, formed, light yellowish brown- dark brown, slight odor

Breastfed babies bm

Bright yellow, pasty, seedy-appearing

Formula/cow's milk fed babies bm

darker yellowish brown or tan colored, more firm and formed

Separate hard lumps, like nuts BM

You're lacking fiber and fluids. Drink more water and chomp on some fruits and veggies.

Sausage-shaped but lumpy bm

Not as serious as separate hard lumps, but you need to load up on fluids and fiber

Sausage-shaped but with cracks on surface bm

This is normal, but the cracks mean you could still up your intake of water

Sausage shaped smooth and soft bm

Optimal poop. You're doing fine

Soft blobs with clear cut edges bm

Not too bad. Pretty normal if you're pooping multiple times a day

Fluffy pieces with ragged edges, a mushy stool bm

You're on the edge of normal. This type of poop is on its way to becoming diarrhea

Watery-solid pieces, all liquid bm

You're having diarrhea. This is probably caused by some sort of infection and diarrhea is your body's way of cleaning it out. Make sure you drink lots of liquid to replace the liquids you lost otherwise you might find yourself dehydrated

Soft and sticks to the side of the toilet bowl bm

Presence of too much oil, which could mean your body isn't absorbing fats properly. Diseases like chronic pancreatitis prevent your body from properly absorbing fat.

brown bm

You're fine. Poop is naturally brown due to the bile produced in your liver

black bm

It could mean that you're bleeding internally due to an ulcer or cancer. Sine vitamins containing iron or bismuth subsalicylate could cause black poop too. Pay attention if it's sticky, and see a doc if you're worried

green bm

food may be moving through your large intestine too quickly. Or you could've eaten lots of leafy green veggies good for coloring

Light colored, white, or clay colored bm

If it's not what you're normally seeing, it could mean a bile duct obstruction. Some meds could cause this too. See a doc.

yellow bm

Greasy, foul smelling, yellow poop indicates excess fat, which could be due to malabsorption disorder like celiac disease

bloody stained or red bm

Blood in your poop could be a symptom of cancer. Always see a doc right away if you have blood in your stool.

spinach

Greenish black streaks bm

beets

reddish bm

Iron supplements and Pepto bismol

black, non-tarry, no odor bm

Antacids and barium

white bm

FACTORS AFFECTING ELIMINATION

-Change in activity level

Guaiac test (occult blood test)

tests for the presence of blood in stool

Culture and sensitivity (C&S)

Identifies microorganisms infection the stool and the antibiotics that will kill the microorganisms

Ova and parasite test (O&P)

Tests for the presence of parasitic worms and their eggs

PROMOTING BOWEL FUNCTION

-Increase physical activity

ALTERATIONS IN ELIMINATION

-Constipation

HEALTH RELATED TO DIARRHEA

-Caused by:

HEALTH RELATED TO CONSTIPATION

-Decrease in physical activity and bedrest

ENEMAS

-Purpose: stimulate the bowel and encourages peristalsis which will result in stool.

SOLUTUONS USED FOR ENEMAS

-Tap water

CONTRAINDICATION FOR ENEMAS

-Rectal surgery

COMPLICATIONS OF ENEMAS

-Fluid and electrolyte issues

VAGAL RESPONSE

-Place the patient in a supine position or Trendelenburg

NORMAL URINARY ELIMINATION

-Void/micturate

oliguria

Decreased urine output

polyuria

excessive urination

anuria

absence of urine

Normal pH of urine

4.5-8.0

Normal specific gravity of urine

1.010-1.029

ABNORMAL URINE

-Red or white blood cells (hematuria)

urinanalysis

Microscopic and chemical examination of a fresh urine sample

Timed urinary collection

Urine tests: This collects all the urine produced within the 24 hour collection time with a final voiding at 24 hours later.

Raegent urine testing

Urinalysis provide tests for Glucose, Bilirubin, Ketone (acetoacetic acid), Specific Gravity, Blood, pH, Protein, Urobilinogen, Nitrite and Leukocytes in urine.

Straining urine

The purpose is to stream out kidney stones (renal calculi).

urinary retention

inability to empty the bladder

residual urine

urine that remains in the bladder after urination

nocturia

excessive urination at night

Cause of alteration in urination

--Kidney stones

TREATMENT FOR RETENTION

-Bladder scanning

MANAGING INCONTINENCE

-Bladder training

urge incontinence

state in which a person experiences involuntary passage of urine that occurs soon after a strong sense of urgency to void

stress incontinence

the inability to control the voiding of urine under physical stress such as running, sneezing, laughing, or coughing

overflow incontinence

involuntary loss of urine associated with overdistention and overflow of the bladder

functional incontinence

the person has bladder control but cannot use the toilet in time