Chapter 25

$Table 25.1, 25.2 (early and late signs)$
- 25.1: Manifestations of Inadequate Oxygenation

	Early	Late
Central Nervous System	Unexplained apprehension, unexplained restlessness or irritability, unexplained confusion or lethargy	Unexplained confusion or lethargy, combativeness, coma
Respiratory	Tachypnea, Dyspnea on exertion	Dyspnea at rest, use of accessory muscles, retraction of intercostal spaces or inspiration, pause for breath between sentences, words
Cardiovascular	tachycardia, mild hypertension, dysrhythmia	dysrhythmia, hypotension, cyanosis, cool, clammy, skin
Other	Diaphoresis, decreased urine output, unexplained fatigue	Diaphoresis, decreased urine output, unexplained fatigue

$Gerontologic assessment differences$
- Structural changes
- reduced chest expansion and functional alveoli
- calcification of costal cartilage, which can interfere with chest expansion
- outward curvature of the spine, chest appear barrel-shaped, may use accessory muscles to breather
- muscle strength declines, harder to inflate
- alveoli become less elastic→ more inspired air is distributed and ventilation is less well matched (lower PaO2)
- Defense mechanisms
- reduced immune function
- the decline in cell-mediated and humoral immunity
- alveolar macrophages less effective, less functional Celia, mucous membranes drier, retained mucous predisposes to respiratory infections
- swallowing slower, reduced sensation in the pharynx, greater risk for aspiration
- Respiratory control
- more gradual responses to changes in oxygen and carbon dioxide levels
- PaO2 may drop to slightly lower than normal level, and paCO2 may rise before respiratory rate changes
- Table 25-2 Gerontologic Assessment Differences

	Changes	The difference in Assessment Findings
Structure	Chest wall stiffening, costal cartilage calcification, increased AP diameter, decreased elastic recoil, decreased chest wall compliance, decreased functioning alveoli, decreased respiratory muscle strength	Barrel chest appearance, kyphotic posture, decreased chest wall movement, decreased deep breathing, decreased cough effectiveness, decreased vital capacity, increased residual volume, increased functional residual capacity, decreased breath sounds, particularly at lung bases, decreased PaO2 and SaO2, normal pH and PaCO2
Defense Mechanisms	decreased cell-mediated immunity decreased specific antibodies, decreased cilia function, decreased cough force, decreased alveolar macrophage function, decreased sensation in the pharynx	decreased cough effectiveness, decreased secretion clearance, thickened mucus, increased risk for upper respiratory aspiration, infection, influenza, pneumonia, respiratory infections may be more severe and last longer
Respiratory Control	decreased response to hypoxemia and decreased response to hypercapnia	slight decrease in PaO2, increase in PaCO2 before respiratory rate changes, decreased ability to maintain acid-base balance, significant hypoxemia or hypercapnia may develop from relatively small incidents, retained secretions, excessive sedation, or positioning that impaired chest expansion may substantially change PaO2 and SaO2

$Table 25-8 Assessment abnormalities$
- Inspection
- appearance: position, evidence of respiratory distress
- Shape, symmetry, and movement
  - normal AP diameter: 1:2
- Respiratory rate, depth, and rhythm
  - normal:12-20
  - Kussmaul: rapid, deep, breathing
  - Cheyenne-Stokes: abnormal respirations y alternating periods of apnea and deep, rapid breathing
- Skin and nails: cyanosis, clubbing
  - hypoxemia
  - long standing hypoxemia
- Palpation
- Tracheal position
- Expansion
- Fremitus
- Percussion
- Auscultation
- Abnormal/adventitious breath sounds
  - Crackles
  - fine
  - coarse
  - Wheezes
  - Stridor
  - Pleural Fiction rub
- Abnormal voice sounds
  - egophany
  - Bronchophony
  - Whispered pectoriloquy
- Table 28-8: Chest Examination Findings in Respiratory Problems

Problem	Inspection	Palpation	Percussion	Auscultation
Asthma exacerbation	Prolonged expiration, tripod position, pursed lips	decreased movement	hyper-resonance	Wheezes, decreased breath sounds ominous sign (severely decreased air movement)
Atelectasis	No change unless involves entire segment, lobe	if small, no change; if large, decreased movement, decreased fremitus	Dull over affected area	fine crackles (may disappear with deep breaths), absent sounds if large
COPD	Barrel chest, cyanosis, tripod position, use of accessory muscles	decreased movement	hyperresonant or dull if consolidation	crackles, wheezes, distant breath sounds
Pleural Effusion	Tachypnea, use of accessory muscles	increased movement, increased fremitus above effusion, absent fremitus over effusion	dull	decreased or absent over effusion, ego-phony, above effusion
Pneumonia	Tachypnea, use of accessory muscles, duskiness or cyanosis	increased fremitus over the affected area	dull over affected areas	Early: bronchial sounds, Later: fine and/or coarse crackles, egophony, whispered pectoriloquy
Pulmonary Edema	Tachypnea, labored respirations, cyanosis, pink-tinged sputum	decreased movement or normal movement	dull or normal depending on the amount of fluid	fine or coarse crackles
Pulmonary Fibrosis	tachypnea	decreased movement	normal	crackles or sounds like velcro being pulled apart

$Diagnostic studies H/H, ABG’s, Oximetry, sputum cultures, AFB, CXR, CT, MRI, V/Q scan,$ \n $angiogram, Bronchoscopy, biopsy, thoracentesis, Pulmonary function test (focus on$ \n $nursing responsibilities and assessments)$
- Pulse ox → SpO2: 94-99
- SpO2: saturation of hemoglobin
- During: assess for factors that can alter (nail polish, motion, cold extremities, dark skin color, anemia)
- Arterial Blood Gases (ABGs)
- oxygenation status and acid-base balance
- arterial puncture or arterial catheter
- normal PaO2 decreases with age
- Nursing responsibilities: avoid change in O2 therapy and interventions, assist with positioning, apply pressure to radial artery at least 5 minutes after
- CO2 monitoring (capnography)
- early warning of change in cardiac output or O2 delivery to tissues
- See table 25-12
- Sputum Studies (Table 25-13)
- color, volume, viscosity, and presence or absence of blood → expectoration, tracheal suction, bronchoscopy
- Nursing responsibility:
  - during: obtain in early morning after mouth care because secretions collect during night, have patient cough deeply and expectorate, if unsuccessful, increase oral fluid intake unless fluids are restricted, if cannot produce specimens, bronchoscopy may be needed
  - after: send specimen promptly for analysis
- Skin tests: intradermal injection
- allergies
- TB
- to prevent false negative reaction, ensure that injection is intradermal and not subcutaneous . After injection, circle site and tell patient not to remove marks. When charting administration, draw diagram of forearm and hand, and label injection site. When reading test, make sure to have good light, do not measure reddened flat areas.
- Bronchoscopy
- direct visualization of bronchi through scope
- Nursing: verify consent; NPO; sedated
- After: NPO until gag returns; monitor for hemorrhage or pneumothorax
- Lung Biopsy (Table 25-15) → verify consent
- monitor for distress q 4 hours, pneumothorax, or bleeding; obtain chest x-ray; incision or chest tube care; monitor breath sounds; encourage deep breathing
- Thoracentesis
- Needle inserted through the chest wall to obtain specimens, remove pleural fluid, or instill the medication
- Nursing:
  - before: verify consent, explain the procedure
  - During: position and monitor
  - After: monitor breath sounds and for hypoxia and pneumothorax; chest tube
- Pulmonary Function Tests (PFT’s)
- Measures lung volumes and airflow
- Diagnose and monitor disease progression; evaluate treatment; determine disability
- Spirometer and computer calculate values; coaching from trained personnel
  - at home: peak flow meter
- Tables 25-16 and 26-17 in textbook
- Radiology
- no metal, check pregnancy
- chest Xray: most common
- Computed Tomography (CT)
  - nursing: check allergy to contrast/iodine.shell fish; renal function; encourage hydration before and after; feel warm and flushed with injection, drink fluids
- Magnetic resonance imaging (MRI)
  - nursing: screen for/remove all metal; check implantable devices; address claustrophobia (sedation)
- VQ scan
  - same responsibility as chest xray
- Pulmonary angiogram
  - Nursing: contrast media precautions, fast 6-12 hr before. pressure dressing to injection site; monitor distal circulation
- Position emission tomography (PET)
  - Nursing: NPO prior; monitor glucose levels; encourage fluids
  - glucose must be between 60-140