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What factors affect oxygentation/
1. Physiological
- -Decreased oxygen carrying capacity(anemia, inhalation of toxins)
- -Decreased inspired oxygen
- upper/lower resp. obstruction...pneumonia, COPD)
- - Hypovolemia
- shock, severe dehydration
- - Increased metabolic rate
- (exercise, fever...etc.)
- 2. Conditions affecting chest wall movement
- -pregnancy
- - obesity
- -muscular abnormalities
- - trauma
- - neuromuscular disease (MS, MD)
- - CNS alterations (opiades, drug overdose)
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Define hyperventilation?
Ventilation in excess of that required to eliminate CO2 produced by cellular metabolism
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Define Hypoventilation?
Alveolar ventilation inadequate to meet the body's oxygen demand or to eliminate sufficient CO2
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Define Hypoxia? Late stage of Hypoxia with discoloration of the skin, mucous membranes or capillary beds is called?
Inadequate tissue oxygenation at the cellular level. Cyanosis
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Causes of hypoxia may include?
- 1. decreased hemoglobin level and lowered oxygen-carrying capcity of the blood
- 2. diminished concentration of inspired oxygen (high altitudes)
- 3. inability of the tissues to extract oxygen from the blood (cyanide poisoning)
- 4. decreased diffusion of oxygen from the alveoli to the blood (pneumonia)
- 5. poor tissue perfusion with oxygenated blood (shock)
- 6. impaired ventilation (multiple fractures or chest trauma)
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Clinical S/Sx of hypoxia? Name some vital signs you might see changed?
- apprehension
- restlessness
- inability to concentrate
- declining level of consciousness
- dizziness
- behavioral changes
- Client may be unable to lay down and will appear fatigued and agitated
- Vital sign changes:
- increased pulse rate
- increased rate/depth of respiration
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What are S/Sx of hyperventilation? What nursing treatment should be implemented?
Fever, anxiety, infections, drugs (aspirin overdose), hypoxia associated with pulmonary embolus or shock. Treatment requires improving tissue oxygenation, restoring ventilatory functions, acid-base balance, and treating underlying cause.
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What are S/Sx of hypoventilation? What nursing treatment should be implemented?
mental status changes, dysrhythmias, potential cardiac arrest. Treament requires imprvoing tissue oxygenation, resotring ventilatory function, treating underlying cause, achieveing acid-base balance.
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A client with diabetes, who had gone into diabetic ketoacidosis produces large amounts of metabolic acids. How does the body try to compensate?
The respiratory system tries to correct the acid-base balance by overbreathing. Ventilation increases to recue the amoung of carbon dioxide available to form carbonic acid.
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How does a nurse assess oxygentation?
- Pain - overbreathing, grabbing at chest?
- Dyspnea - clinical sign of hypoxia
- Wheezing - asthma, restricted breathing
- Resp. infections - freq./duration?
- Health risks - hereditary? work related?
- Smoking - self/2nd hand
- Cough - forceful expulsion of air?
- Environmental exposure
- Allergies - airborne, mold, etc.
- medications - OTC, drug interactions
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When facilitating dyspnea management, what is the goal?
- Ensure...
- Airway is maintained
- - broncodilators
- - oxygen therapy (exercise)
- - physical tech. (exercise conditioning, breathing tech, cough control)
- - psychosocial tech. (relaxation, biofeedback, meditation)
- Mobilization of pulmonary secretions
- -achieve a normal airway by clearing of secretions
- Humidification
- -adding water to gas, clients above 4L O2 therapy
- Nebulization
- -add moisture to inspired air
- Chest physiotherapy
- -postural drainage
- - chest percussion
- - vibration
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This airway suctioning is used when the client can cough effectively but is unable to clear secretions?
oropharyngeal and nasopharyngeal
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This airway suctioning is used when the client is unable to manage secretions by coughing?
Orotracheal and nasotracheal
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This airway suctioning is used to create an artifical airway?
Tracheal; patients who are intubated
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This is an abnormal condition in which the client uses multiple pillows when lying down or must sit with the arms elevated and leaning forward to breathe?
Orthopnea
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This is a clinical sign of hypoxia associated with exaggerated repiratory effort, use of the accessory muscles of repiration, nasal flaring, and marked increased in the rate and depth of respirations?
hypoxia
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If a client produces more that 30mL of sputum per day or has evidence of atelectasis by chest x-ray, what type of dyspnea management might a nurse choose?
Chest physiotherapy; rationale= these therapies mobilize pulmonary secretions and after therapy is complete it is usually followed by a productive coughing and sutioning of the client
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This is the simplest artifical airway used to prevent obstruction of the trachea by keeping tongue from obstructing airway?
Oral airway
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This type of artifical airway puts the client at high risk for infection and airway injury. It should only be used for short-term to ventilate, relieve upper airway and protect client against aspiration?
Endotracheal airway
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This type of artificial airway is typically used on long-term, unconsious clients either in a coma, a traumatic spinal accident or head trauma...etc. by placing a surgical incision made in the trachea to assist client in breathing?
Tracheostomy
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What is the most effective positioning a nurse can place a client in to promote and maintain lung expansion/
45 degree semi-fowlers
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What is a cost-effective way to promote and maintain lung expanison in a oxygen compromised client?
Positioning changes; reduces pulmonary stasis, maintains ventilation and oxygenation
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A client is post-operative, sent back to the med-surg floor on 2L of O2 with a nasal cannula with the goal to go home 3 days after surgery IF he can keep his stats at 95% or higher without the oxygen. What lung expantion technique will a nurse encourage the client to perform multiple times throughout the day/
The incentive spirometer; it encourages voluntary deep breathing by providing visual feedback to clients about inspiratory volume
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Why might a client receive a chest tube?
Common after surgery and chest trauma and for pneumothorax (air in the pleural space) and hemothorax (blood/liquid in the pleural space).
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What should a nurse keep in mind when transporting a client with a chest tube?
- 1. clamping a chest tube is not recommended- it can reulst in a possible tension pneumothorax - life-threatening event!
- 2. Always keep the chest drainage device BELOW the clients chest
- 3. If tubind disconnects from unit, instruct client to exhale as mush as possible and cough - this maneuver rids pleural space of as much air as possible
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Should you milk a chest tube as it is draining?
NEVER milk a chest tube
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When a doctor orders a complete blood count (CBC) what is he looking for?
A CBC determines the number and type of RBC and WBC per cubic millimeter of blood
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What is a cardiac enzyme test?
Cariopulmonary Blood test
- 1. tests for creatine kinase (CK) values - which helps diagnose acute myocardial infarcts
- 2. tests for troponin valuesn -
- - values will be elevated in a cardiac event
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What is a serum electrolyte blood test?
- Cardiopulmonary Blood test
- Test potassium levels (norm=3.5-5mEq/L)
clients on diuretic therapy are at risk for hypokalemia (low potassium). Clients receiving angiotensin-converting enzyme (ACE) inhibitors are at risk for hyperkalemia (elevated potassium)...this test monitors the K+ levels
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What is a cholesterol test for What factors might affect a persons cholesterol levels?
To test fasting cholesterol, low-density lipoproteins (LDL's) and high-density lipoproteins (HDL's) and a clients triglycerides
Affect: obesity, smoking, diabetes, lack of regular exercise, beta-adrenergic blocking agents, high fatty-acid intake diet
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The best cardiopulmonary diagnostic blood test/indicator for myocardial damage would be?
Cardiac enzyme test - troponin levels
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This is a portable ECG worn by the client. The test produces a continous ECG tracing over a period of time...client keeps a diary of activity noting experience while wearing this portable unit. This unit is called a_________?
Holter monitor
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An ECG stress test (monitor heart while client walks on treadmill) with the addition of thallium-201 injected IV watching the coronary blood flow changes with increased activity is what kind of cardiac functioning test?
Thallium stress test
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A nurse should encourage a client with COPD, upper/lower respiratory infections, and postopperative clients to dep breathe and cough at least how many times a day?
Every 2 hours while awake; this helps clear sputum and expectorated the sputum
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When would a cascade cough be used?
It is a technique used with clients who have large volumes of sputum (such as....). Instruct client to slow, deep breath and hold for 2 seconds while contracting expiratory muscles. Then throught exhalation perform a series of coughs - tech. promotes airway clearance and patent airway
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When should a huff cough be used?
Stimulates a natural cough and is generally used for clearing central airways
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When should a quad cough be used?
Typically for clients without abdominal muscle contraol (spinal cord injury clients, GI clients)...while client breathes out with maximal expiratory effort the client or nurse pushes inward and upward on the abdominal muscles toward the diaphragm causing a cough
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When you want to prevent alvelolar collapse or control SOB (as in a COPD patient) a nurse may instruct the client to use this type of breathing?
Pursed-lip breathing; helps client gain control of the exhalation phase so that it is longer than inhalation...helps to increase oxygen saturation
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Fever increases the tissues' need for oxygen and as a result:
1. metabloic demands decrease
2. blood glucose stores stabilize
3. carbon dioxide production increases
4. carbon dioxide production decreases
3. carbon dioxide production increases
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Conditions such as shock and severe dehydration resulting from extracellular fluid loss and reduced circulating blood volume cause:
1. hypoxia
2. hypovolemia
3. hypervolemia
4. uncontrolled bleeding
2. hypovolemia
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Left-sided heart failure causes:
1. increased cardiac output
2. lowered cardiac pressures
3. decreased functioning of the left atrium
4. decreased functioning of the left ventricle
4. decreased functinoing of the left vent.
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Clients with chest tubes are at risk for tension pneumothorax. Some of the symptoms of a tension pneumothorax include (choose all that apply):
1. increased heart rate
2. decreased heart rate
3. increased resp. rate
4. increased blood pressure
5. decreased blood pressure
asymmetrical chest wall movement
2,3,5,6
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A suddent cesation of CO and circulation with permanent heart, brain, and tissue damage occuring within 4-6 minutes is what? What is the purpose of CPR?
Cardiac arrest...to circulate oxygenated blood to the brain and prevent tissue damage
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AHA suggest that defibrillation occur within the first _____min. of an in-hospital cardiac arrest and within______min in an out-of-hospital arrest to help save lives?
3 min / 5 min
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Define sinus tachycardia?
- regular rhythm
- 100-180 beats/min
- rate increase is normal in exercise, fever, pump failure, hyperthyroidism, and certain druges (caffeine, nitrates, epinephrine, nicotine)
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Define sinus bradycardia?
- regular rhythm
- less than 60 beats/min
- rate decrease is normal response to sleep or in well-conditioned athelets
- diminished blood flow to SA node
- vagal stimulation
- hypothyroidism
- increased intracrainial pressure
- pharmalogical agents (digoxin, prpranolol)
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What is atrial fibrillation (A-fib)? Caused by?
Chaotic, irregular atrial activity resulting in an irregular ventricaul response. Irregular ventricular response resulting in an irregular cardiac rate and rhythm. The conducation of the multiple atrial impulses across the AV node determines the rate.
Caused by again, calcification of the SA node, or changes in myocardial blood supply
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You have a 70 year-old man who has a chaotic, irregular atrial activity resulting in irregular ventricular response...you might suggest the client's dysrhythmia to be?
A-fib
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