Resp. A+D

NSC 386: Respiratory Assessment and Diagnostics

OBJECTIVES

  • Understand nursing care related to:
    • Respiratory assessment
    • Diagnostics used to identify respiratory issues
    • Screening tests used to identify and diagnose respiratory issues
  • Identify and interpret ABG (Arterial Blood Gas) values

STRUCTURES OF THE RESPIRATORY TRACT

  • Upper Respiratory Tract Components:
    • Nose
    • Mouth
    • Pharynx
    • Epiglottis
    • Larynx
    • Trachea
  • Lower Respiratory Tract Components:
    • Lungs
    • 5 lobes
    • Bronchi
    • Bronchioles
    • Alveoli
    • Surrounded by the pleural sac
    • Diaphragm: The major muscle of respiration, crucial for gas exchange (O2 + CO2).

PHYSIOLOGY OF RESPIRATION

  • Oxygenation: The process of obtaining O2 from the atmospheric air and making it available to the organs and tissues of the body.
  • Ventilation: The processes of inspiration and expiration.
  • Minute Ventilation:
    • Calculated by multiplying tidal volume by respiratory rate.
  • Lung Compliance: The ability of the lungs to expand.
  • Airway Resistance: Any obstruction to airflow during inspiration and/or expiration caused by factors such as foreign objects, secretions, or inflammation (e.g., wheezing).

CONTROL OF VENTILATION

  • Main Drive for Ventilation: Changes in pH and CO2 levels in spinal fluid.
  • Receptors: Located in the heart or arteries that signal the brain with changes in O2 levels.
  • Brain’s Role: Recognizing problems related to changes in ventilation and gas exchange.

ABG VALUES

  • Abbreviations:
    • A = alveolar
    • a = arterial
    • P = partial pressure
    • PO₂ = oxygen partial pressure
    • PCO₂ = carbon dioxide partial pressure
  • Key Values:
    • PO₂ of 158 mm Hg, PaO₂ of 97 mm Hg
    • PACO₂ of 40 mm Hg, PaCO₂ of 40 mm Hg
    • Changes in the partial pressure of gases occur during respiration, affecting O₂ and CO₂ exchange as venous blood flows through the lungs.

PULMONARY CIRCULATION

  • Blood flow from the right pulmonary artery carries oxygen-deficient blood to the lungs.
  • Oxygenated Blood: Collects in the pulmonary vein after passing through the alveoli and is pumped to the heart.

STRUCTURES OF THE RESPIRATORY SYSTEM

  • Anatomy Overview:
    • Right Upper Lobe
    • Right Middle Lobe
    • Right Lower Lobe
    • Left Upper Lobe
    • Left Lower Lobe
    • Important landmarks include the thyroid cartilage, suprasternal notch, and angle of Louis.

RESPIRATORY ASSESSMENT

VITAL SIGNS
  • Respiratory Rate: Normal for adults is _.
  • Oxygen Saturation: Percentage of hemoglobin saturated with oxygen.
    • Normal saturation is greater than %.
    • Intervention needed if saturation falls below %.
  • Compensation Indicators:
    • Heart Rate (HR) and Respiratory Rate (RR) assessments to gauge the respiratory status.
RESPIRATORY DISTRESS
  • Symptoms of respiratory distress include:
    • Shortness of breath
    • Rapid, shallow breathing
    • Wheezing or gasping
    • Coughing
    • Chest pain or tightness
    • Cyanosis (bluish lips or skin)
    • Confusion or disorientation
CAPNOGRAPHY: END-TIDAL CO2 (ETCO2)
  • Definition: The amount of CO2 at the end of expiration.
  • Normal Range: 35-45 mmHg
  • Significance: Indicates immediate CO2 levels and gas exchange efficiency, especially critical for patients on opioids or other respiratory depressants.
    • Hypoventilation leads to CO2 retention.
INSPECTION
  • General Survey: Assess for respiratory effort, posture, color, and level of consciousness (LOC).
  • Look for signs such as:
    • Use of accessory muscles
    • Cyanosis or pallor
    • Tripod position indicating difficulty breathing
INSPECTION FINDINGS
  • Accessory Muscle Use: Pulling in of neck and shoulder muscles; indicates severe respiratory distress.
  • Clubbing: Increased depth and bulk of distal fingers; may indicate chronic hypoxemia or lung disease.
  • Cyanosis: Bluish skin coloration indicative of low O2 transfer.
  • Kussmaul Respirations: Regular, rapid, deep breaths associated with metabolic acidosis.
  • Pursed-Lip Breathing: Technique to slow expiration; indicates increased respiratory distress in conditions such as COPD.
  • Tachypnea: Respiratory rate >20 breaths/min; indicates various issues like fever or anxiety.
INSPECTION AND PALPATION
  • Inspection of Neck and Chest: Check for symmetry, use of accessory muscles, and deformities.
    • Trachea should be midline.
    • Respiratory Excursion: Observe for out of defined limits, indicating potential issues.
  • Altered Chest Movement:
    • Unequal Movement: May indicate atelectasis or pneumothorax.
    • Tracheal Deviation: Left/right movement deviation indicates a medical emergency when caused by tension pneumothorax.
AUSCULTATION
  • Breath Sound Types:
    • Absent Breath Sounds: May suggest pneumothorax or large atelectasis.
    • Coarse Crackles: Indicate excess fluid in lungs; heard with pulmonary edema or severe congestion.
    • Fine Crackles: Suggest interstitial edema or pneumonia; heard before the end of inspiration.
    • Pleural Friction Rub: Grating sound due to inflamed pleural surfaces.
    • Stridor: Continuous crowing sound indicates upper airway obstruction.
    • Wheezes: Indicates bronchospasm or airway obstruction; audibly more pronounced during expiration.
SCREENING AND DIAGNOSTIC TESTS

  • Sputum Studies:

    • Methods of collection: Coughing up, expectoration, suctioning, bronchoscopy.
    • Analyze sputum based on color (white, green, red, brown) for diagnostic clues to infection types.
    • Culture and Sensitivity Testing (C&S): Diagnostic test for infections; results available in 48-72 hours.
    • Gram Stain: Classifies bacteria into gram-negative and gram-positive types to guide initial therapy.

  • Bronchoscopy:

    • Procedure to visualize bronchi via a fiberoptic tube.
    • Purpose: Biopsy, obtain specimens, remove obstructions like mucous plugs.
NURSING CARE FOR BRONCHOSCOPY
  • NPO for hours prior.
  • Monitor sedation and respiratory status post-procedure.
    • Normal blood tinged mucus occurs but should be monitored for excessive bleeding.
NURSING CARE FOR LUNG BIOPSY
  • Monitor for bleeding and respiratory status.
  • Percutaneous Biopsy: Monitor dressing and perform chest x-ray to check for complications like pneumothorax.
THORACENTESIS
  • Procedure: Insertion of a large bore needle into pleural space.
    • Common reasons: Removal of pleural effusion, fluid, or blood.
NURSING CARE FOR THORACENTESIS
  • Position patients upright and prepare to monitor vital signs continuously.
  • Post-procedure care includes monitoring breath sounds for hypoxia or pneumothorax.
PULMONARY FUNCTION TEST (PFT)
  • Purpose: Diagnosing diseases like asthma and COPD; assessing disability and response to bronchodilators.
  • Nursing Care: Ensure no eating beforehand, avoid inhaled bronchodilators before testing.
6-MINUTE WALK TEST
  • Used to determine need for home oxygen therapy; measures oxygen saturation during ambulation.
    • Nursing Care: Monitor for signs of stress in the patient's respiratory condition.
RADIOLOGIC TESTS
  • Chest X-ray: Used for screening and diagnosing respiratory system changes.
    • Important considerations: patient preparation and recognition of diagnostic limits.
  • Ventilation-Perfusion (V/Q) Scan: Assesses lung ventilation and perfusion; commonly used for diagnosing pulmonary embolisms.
  • Positron Emission Tomography (PET) Scan: Distinguishes between benign and malignant tumors based on glucose metabolism in cells; care considerations include NPO status before testing.
LEARNING CHECK
  • Example Scenario: Assessment after bronchoscopy indicating aspiration risk. If the patient coughs after drinking water, monitor for further issues like bleeding or changes in respiratory status.