118 unit2 2025

UNIT 2 REVIEW

Respiratory Patterns

  • Eupnea: Normal breathing pattern.
  • Assess Breathing Patterns:
    • Tachypnea: Increased respiratory rate.
    • Bradypnea: Decreased respiratory rate.
    • Dyspnea: Difficulty in breathing.
    • Orthopnea: Difficulty in breathing when lying flat.
    • Apnea: Temporary cessation of breathing.
    • Kussmaul's Respirations: Deep, labored breathing typically associated with metabolic acidosis.
    • Biot's Respirations: Irregular breathing pattern with periods of apnea.
    • Cheyne-Stokes Respirations: Cycles of apnea followed by gradual increases in the depth of breathing.
    • Stridor: Harsh, high-pitched sound on inhalation indicating airway obstruction. EMERGENCY.

Auscultating Lung Sounds

  • Auscultation Process:
    • Systematic Approach: Start just above the clavicle down to below the xiphoid process; both anteriorly and posteriorly along the chest wall.
    • Instructions: Patient should take slow, deep breaths through an open mouth.
  • Normal Lung Sounds:
    • Bronchial: Located over the trachea.
    • Broncho-vesicular: Located over the sternum in front and between the clavicles posteriorly.
    • Vesicular: Heard over lower lung fields.

Abnormal Lung Sounds

  • Adventitious Lung Sounds:
    • Rales (Crackles): Fine crackling sounds, often indicating fluid in the airways.
    • Rhonchi: Low-pitched wheezing sounds from blocked airways.
    • Wheezes: High-pitched sounds due to narrowed airways.
    • Stridor: Indicates upper airway obstruction, requiring immediate intervention.
    • Pleural Friction Rub: Sound from inflamed pleurae rubbing against each other.
    • Grunting: Indicates severe respiratory distress.

Diagnostic Tests - Peak Flow

  • Peak Flow Meter: Measures the amount of air exhaled with force. Utilized for asthma patients to monitor their condition by detecting subtle changes.
    • Color Coded System:
    • Green: All clear.
    • Yellow: Caution; take bronchodilator.
    • Red: Severe reduction in peak flow; emergency department visit required.

Nursing Interventions

  • Incentive Spirometer Usage:

    • Helps facilitate sustained, slow deep breaths and prevent/reverse atelectasis when used regularly.
    • Assists in liquefying and loosening secretions to prevent pneumonia.

  • Health Teaching/Education:

    • Weight Reduction: Low sodium and cholesterol diets, regular exercise, stress reduction, and occupational safety.
    • Vaccines: Administration of influenza and pneumonia vaccines.
    • Infection Control: Teach about limiting exposure to crowds and implementing proper hygiene.

Management and Etiology of Respiratory Conditions

  • Hypercarbia: Excess of CO2 in blood, often due to hypoventilation associated with conditions like COPD and sleep apnea.
  • Hypocarbia: Low level of CO2 in blood due to hyperventilation which creates a stimulating effect.

Assessment Techniques in Respiratory Conditions

  • Clubbed Fingers: Distorted angle of the nail bed associated with chronic hypoxemia.
  • Cyanosis: Blue coloration of skin and mucous membranes indicating low oxygen levels in the blood.

Hypoxia Interventions

  • Rapid Assessment Includes:
    • High-fowler's position for comfort.
    • Counting respirations.
    • Using pulse oximetry.
    • Applying oxygen if pulse ox < 90%.
    • Checking vital signs and listening to lung sounds for abnormalities.

COPD and Chronic Bronchitis

  • Definition: Inflammation and hypersecretion of mucus in bronchi/bronchioles leading to airway obstruction.
  • Etiology:
    • Primarily due to smoking (90% of cases).
    • Occupational exposures, air pollution, asthma, cystic fibrosis.
  • Signs & Symptoms:
    • Chronic cough, thick sputum, rhonchi, wheezing, hypoxemia, cyanosis, tachycardia, tachypnea, dyspnea, peripheral edema, orthopnea.

Central Nervous System (CNS) Stimulation to Breathe

  • Normal Regulation: Increased CO2 levels signal the brain to stimulate breathing, whereas COPD presents decreased sensory input from O2 levels.

Obstructive Sleep Apnea (OSA)

  • Condition: Blocked airway during sleep, impacting oxygenation.
  • Interventions:
    • Assess symptoms and teach side-lying positioning during sleep to avoid airway blockage, maintain weight loss, and employ CPAP therapy when necessary.

Laboratory Tests for Heart Failure

  • BNP Natriuretic Peptides: Indicator for congestive heart failure (CHF).
    • Released by the left ventricle due to stretching caused by fluid buildup. Elevations in BNP correlate with the severity of CHF.

Nursing Interventions for Cardiovascular Disease

  • Patient EducationFocus:
    • Diet, weight loss, exercise, and awareness of modifiable/non-modifiable risk factors (e.g., smoking cessation).
  • Promote venous return and circulation while managing anxiety and preventing clot formation through medication administration.

Heart Failure Concepts

  • Pathophysiology: The heart loses efficiency, leading to systemic and pulmonary edema, resultant fatigue, and organ dysfunction.
    • Right-Sided Heart Failure: Insufficient blood pumped to lungs, resulting in peripheral vein backup.
    • Left-Sided Heart Failure: Inadequate blood pumped to body, causing lung backups.

Peripheral Venous Disease (PVD)

  • Management Strategies:
    • Encourage ambulation and leg elevation.
    • Use compression stockings and instruct against crossing legs to improve venous return.

Transfusion Preparation & Reactions

  • Preparation Steps:
    • Signed consent, type & cross every 72 hours, check vital signs before infusion.
    • Use 18-20 gauge IV access, and administer medications like acetaminophen and diphenhydramine if ordered.
  • Reactions to Watch For:
    • Febrile, Allergic, Bacterial, Hemolytic, Circulatory Overload Reactions: Management includes stopping the transfusion, notifying providers, and administering appropriate medications as needed.

Complications Related to Intravenous Therapy

  • Infiltration, Phlebitis, Thrombophlebitis, and Extravasation: All require immediate attention and specific nursing interventions.
    • Cold or warm compress application depending on the complication.

Electrolyte Regulation

  • Potassium (K+): Vital for muscle contraction and cardiac rhythm regulation (Normal range: 3.5 - 5.0 mEq/L).
  • Magnesium (Mg2+): Involved in nerve and muscle electrical activity; necessary for protein synthesis.
    • Normal levels: 1.6 - 2.1 mEq/L.
  • Calcium Regulation: Trousseau's and Chvostek's signs indicate hypocalcemia, compelling further investigation and potential treatment.