respiratory 1

• asthma
• atelectasis
• brain trauma
• bronchitis
• bronchietasis
• CNS depressants
• emphysema
• hypoventilation
• pulmonary edema
• pneumonia
• PE

• fever
• hyperventilation
• hypoxia
• hysteria
• overventilation by mechanical ventilator
• pain

• DM or Diabetic Ketoacidosis
• excessive ingestion of acetylsalicylic acid (aspirin)
• high fat diet
• insufficient metabolism of carbohydrates
• malnutrition
• renal insufficiency or renal failure
• severe diarrhea

• diuretics
• excessive vomiting or gastrointestinal suctioning
• hyperaldosteronism
• ingestion of and/or infusion of excess sodium bicarbonate
• massive transfusion of whole blood

• neuro-drowsiness, disorientation, dizziness, headache, coma
• cardiovascualr-dec. BP, ventricular fibrillation r/t hyperkalemia from compensation, warm flushed skin r/t peripheral vasodilation
• GI-no significant findings
• respiratory-hypoventilation with hypooxia (lungs are unable to compensate when there is a respiratoy problem)
• neuromuscular-seizures

• neuro-drowsiness, confusion, headache, coma
• cardiovascular-dec. BP, dysrhythmias r/t hyperkalemia from compensation, warm flushed skin r/t peripheral vasodilation
• GI-N/V, diarrhea, abd pain
• neuromuscular-no significant findings
• respiratory-deep rapid respiraoty rate (compensatiing action by lungs)

• neuro-lethargy, light headedness, confusion
• cardiovascular-tachycardia, dysrhythmias r/t hypokalemia from compensation
• GI-N/V, epigastric pain
• neuromuscular-tetany, numbness, tingling in the extremities, hyperreflexia, seizures
• respiratory-hyperventilation (lungs are unable to compensate when there is a respiratory problem)

• neuro-drowsiness, dizziness, nervousness, confusion
• cardiovascular-tachycardia, dysrhythmias r/t hypokalemia from compensation
• GI-N/V, anorexia
• neuromuscualr-tremors, hypertonic muscles, muscle cramps, tetany, tingling of fingers and toes, seizures
• respiratory-hypoventilation (compensating action by lungs)

• occurs when there is an excess buildup of CO2 in the blood
• most common acid/base imbalance

• occurs secondary to problems that cause hypoventilation
• CNS depression (head injury, sedatives, anesthesia)
• increased reistance-aspiration, broncho and laryngospasm, prolonged narrowing of airway (asthma, airway edema)
• loss of lung surface-atelectasis, COPD, pneumonia, pneumothorax, chronic pulmonary diseases
• neuromuscular diseases-Guillain-Barre, myasthenia gravis
• mechanical ventilation-inc retention on CO2

• dyspnea, hypoventilation
• hypoxia
• restlessness progressing to lethargy
• drowsiness, confusion, coma
• trachycardia, tachypnea
• dysrhythmias associated with hypoxia, hyperkalemia
• seizures
• diaphoresis-skin may appear flushed and feel warm
• hypercapnia-inc. CO2, this will cause cerebral vasodilation and cause IICP

• pH is less than 7.35
• PCO2 is greater then 45
• HCO3 may be normal or increased b/c of compensation
• compensation from renal system is slow
• urine pH is less than 6

• even though oxygen doesn't play a part in acid/base balance, acidosis will occur when the pt doesn't have adequate gas exchange.
• respiratory depression from whatever cause will precipitate hypoxia (too little O2) and hypercapnia (too much CO2).
• excess CO2 causes this

• bronchodilators
• if on a ventilator the Dr. may order an inc. in tidal volume to facilitate maximum volume and gas exchage to inc. expiration of CO2
• correct the precipitating cause of hypoxia or respiratory problem if possible

• Semi-Fowler's to facilitate ventilation
• suction PRN to remove excess mucus
• have artififcial airway available
• assess patency of airway-resp. rate, breath sounds
• assess for tachycardia, secondary to hypoxia
• maintain calm reassuring attitude (pt is restless and anxious)
• teach to use incentive spirometer
• turn, cough, and deep breathe
• monitor for bradypnea (less than 12 bpm)
• initiate seizure precautions
• assess medications (may need to dec. sedation)
• encourage ambulation (assess response to activity, stop with increased SOB and tachycardia)

Due to low circulation CO2 levels in the bloodfrom hyperventilation secondary to hypoxia, PE, pain, anxiety, pregnancy, or alveolar hyperventilation as seen in clients with a ventilator with high tidal volume and increased respiratory rate

• causes:
• hyperventilation (anxiety, hysteria)
• hyperventilation cuased by:
• -fever
• -hypoxia
• -pain
• -pulmonary d/os
• CNS problems

• hallmark sign is hyperventilation (hypernea)
• client may say that they feel light-headed
• arrythmias-tachycardia (potassium may be low)
• anxiety
• epigastric pain, nausea
• tetany, seizures, parasthesias in toes and fingers

• pH is greater than 7.45
• PCO2 is less than 35
• HCO3 may be normal or less than 20 if compensating
• pH urine is greater than 6

• may need antianxiety like Ativan
• Dr. may order a dec. in rate of tidal volume if client is on a ventilator

• identify and correct the precipitating cause
• monitor ABGs
• check for presence of dec. potassium, monitor for dysrhythmias
• try to relax/calm pt relaxation techniques and guided imagery
• breathing in a sac or rebreathing mask to increase retention of CO2
• reduce environmental noise/stimuli
• encourage pt to slow their breathing
• if having pain, treat with analgesics
• if fever, treat with antipyretics

• result of excess acid production in body or rapid excreation of bicarbonate from the body
• metabolic system is the primary problem, respiraoty system compensates
• causes:
• lactic acidosis (shock, respiratory, or cardiac arrest)
• renal failure
• liver failure
• severe diarrhea
• vomiting
• salycilate toxicity
• starvation
• GI fistulas

• Kussmal respirations (deep rapid respirations)
• confusion, disorientation progressing to coma
• headach, lethargy
• hypotension
• arrythmia changes secondary to hyperkalemia associated with diabetic ketoacidosis
• warm to hot, flushed skin
• abd pain

• pH less then 7.35
• HCO3 less than 22
• PCO2 may be normal or resp. compensation may occur causing a dec. in PCO2 level
• urine pH is less than 6

• IV bicarb if arterial level is less than 21 or plasma venous bicarb is less than 20
• check ABGs frequently
• correct precipitating cause of acidosis

• fluid replacement 0.9% or 0.45% NaCl given for hydration therapy
• antidiarrheals if having excessive diarrhea
• assess skin turgor, urine, and weight for hydration status

• identify and tx cause
• determine hx of precipitaing cause (DM, ETOH, renal disease, excessive GI fluid loss, lactic acidosis)
• assess BUN, CRT for renal function
• AST and ALT for liver function
• E-Lytes (K+ many inc., can fluctuate with tx)
• blood sugar
• ABGs check pH if less than 7.35 and HCO3 less than 22
• VS including temp and wt
• if a result of DKA-give insulin, watch for hypokalemia during administration b/c it moves K+ into the cells
• antiemetics for vomiting

• occurs as a result of a loss of acid or a dec. in bicarb
• the lings compensate by an inc. in respirations to inc. CO2 by taking fewer and longer breaths
• kidneys also compensate by excreating bicarb
• causes:
• loss of stomach acid through suctioning or vomiting
• excess alkali intake-antacids, bicarbonate
• GI fistulas
• adrenal disease-Cushing's, aldosteronism
• diuretic therapy (especially Diamox)

• nervousness, dizziness
• cardiac irritability- dec. K+, ventricular dysrhythmias, tachycardia
• N/V
• parasthesias in fingers and toes
• tetany, muscle cramps-late signs
• hypoventilation
• assess hydration status-tend to be dehydrated

• pH greater than 7.45
• PCO2 normal or may be inc. b/c of compensating
• HCO3 greater than 26
• urine PH greater than 6

• administer Diamox to inc. excretion of bicarbonate
• inatke of bicarb should be stopped
• replacement of balanced fluids for pts with GI suctioning, intestinal fistulas, or both

• determine underlying cause
• assess for hx of precipitaing cause-GI fistulas, suctioning, vomiting
• moniotr ABGs
• monitor K+ values (hypokalemia usually occurs, but levels will increase with tx of alkalosis)
• assess for dysrhythmias-tachycardia and dysrhythmias r/t dec. K+
• monitor respirations-may see bradypnea
• if taking Digoxin, monitor labs, toxicity occurs when serum level is greater than 2.4 ng/ml
• give antiemetics to control n/v
• assess for parasthesias of toes and fingers

• pH=7.4
• PaCO2=40
• HCO3=24

• note:
• pH greater than 7.4=alkalosis
• pH less than 7.4=acidosis
• pH of 7.4=normal

metabolic acidosis

body's bicarb level drops from direct bicarb loss or gains of acids like lactic or ketones

metabolic alkalosis

occurs when the body gains too much bicarb

respiratory acidosis

occurs when the pt hypoventilates and retains too much CO2

respiratory alkalosis

occurs when pt hyperventilates and "blows off" too much CO2

resp. acidosis

resp. alkalosis

met. acidosis

met. alkalosis

resp. acidosis

resp. alkalosis

met. alkalosis

• to relaease normal negative pressure in the pleaural space by removing
• -air (pneumothorax)
• -blood (hemothorax)
• -air and blood (hemopneumothroax)

promotes and facilitates lung re-expansion

dry suction

• air in the pleaural cavity resulting in lung collapse
• causes:
• ruptured bleb (COPD)
• thoracentesis>>trauma>>secondary infection

• dx:
• CRX
• ABGs

• tx:
• chest tube

• dyspnea
• anxirty
• tachycardia
• pleural pain
• assymetrical chest wall expansion
• * dec. breath sounds

• ruptured bleb, idiopathic
• sudden onset of air in pleural space and lung deflation

• s/s:
• chest discomfort, diminished/absent breath sounds

• intervention:
• less than 15% monitor, more than 15% chest tube, deep breathing, incentive spirometry

• blunt or penetrating trauma
• air enters on inspiration and cannot escape
• wound creates a one-way valve

• s/s:
• severe pain with breathing, cyanosis, dyspnea, air hunger, restlessness, diminished breath sounds, assymmetry with breathing, hypotension, tachycardia, tracheal deviation, mediastinal shift, JVD

• intervention:
• chest tube or thoracentesis to release trapped air, check PMI for mediastinal shift

• penetrating chest trauma
• open pathway, air passes freely in and out of cavity
• partial or total liunf collapse

• s/s:
• mediastinal shift possible
• dyspnea, sucking/hissing sound of wound
• tachycardia
• hypotension
• cyanosis
• dec. breath sounds
• airhunger
• JVD
• crepitus

• intervention:
• cover wound with a taped 3 sided vasoline gauze, bear down/valsalva maneuver, w/o chest tube a tension pneumothorax could occur, turn on affected side to splint

• blunt or penetrating trauma in pleural cavity
• partial or total lung collapse
• mediastinal shift possible

• s/s:
• dyspnea, chest tightness, diminished breath sounds, hemoptosis, bruising on chest (eccymosis)

• intervention:
• thoracentsis, chest tube, monitor fluid status, replace fluids, blood

• blunt chest trauma
• ribs broken in 2 or more places-side/close to sternum
• chest stability is los-paradoxical chest movement

• s/s:
• diminished breath sounds, hypotension, tachycardia, cyanosis, crepitus, paradoxical chest movement

• intervention:
• stabilize ribs, turn on affected side, be careful of spinal injuries/car accidents

compression of aorta, dec. CO, dec. BP, misplaced trachea

• interventions:
• check apical pulse-PMI, moves mark on chest to monitor changes/movement

• oxygen-suction available
• premedicate-local anesthetic
• positioning

• position-semi-fowler's to high fowler's for air, high-fowler's for blood
• encourage CDD to help push things out and expand lung drainage
• incentive spirometry
• monitor drainage-use date and time as a marker
• *over 100 ml/hr is excessive
• anterior-little to no drainage (air)
• posterior-100-300 ml during 1st 2 hrs post-op thoracotomy, then dec., 500-1000 ml in 1st 24 hrs
• check for crepitus/sq empysema
• check for tubing kinks

• check chest tube drainage system connections
• observe for fluctuation in water seal chamber (intermittent tidaling) should happen with respirations
• observe for air leak (constant bubbling)
• dry suction-the higher the # in air leak. the greater the leak
• check CT dressing-vasoline gauze and 4 X 4s/ABD air occlusive dressing
• removing chest tube:
• medicate prior to removal
• positon on side/sitting up
• ask pt to hold breath or exhale while removed
• apply air occlusive drsg (vasoline gauze 4x4s)

• over 100 ml drainage
• rapid, shallow respiration
• cyanosis
• chest tube comes out
• drastic change in VS
• constant bubbling

• high apical and anterior-air
• low posterior or lateral-blood
• mediastinal (below sternum)-blood or air used in cardiac surgery

• allows air to escape with expiration
• prevents air from coming into lungs with inspiration

use sterile water or normal saline

• wet suction
• -if suction is applied, fill chamber to the 20 cm level

• dry suction
• -uses a dial to set the suction control (20 cm mark)
• no fluid, quieter, connections must stay together, tape, clamp, ect.
• Pleur-evac systems-water seal and suction control chamber will turn blue when filled

• tape all connections
• position chest tube system below pts chest
• dependant loops in tubung inc. resistance to drainage
• extra tubing should be coiled in bed and draped along side of bed

• look for:
• kinks
• leaks in tube
• lung could be re-expanded
• is suction working?

• constant bubbling in the water seal chamner
• dry-air leak indicator (bubbling)

• systemic brief clamping of drainage tube with padded clamp (hemostats)
• clamp close to occlusive dressing
• if bubbling stops-leak is btwn pt and clamp
• tx-change dressing
• if bubbling doesn't stop-leak is btwn clamp and drainage collector
• tx-change tubing

• stand it back up
• have the pt couph and deep breathe

• change system-RUN
• place tubing in sterile water

• in suction control chamber-refill
• in water seal chamber-refill

• controversial
• milking prevents tube from being plugged with clots/fibrin, but it increases intrapleural pressure which can cause trauma

new tubes are defibrinogenated so it's unlikely to clot and have a coating that makes them nonthrombogenic

• acid/base
• oxygen-O2 sat
• ventilation

• 02 level
• HGB
• BP-if decreased not perfusing

lose CO2, so it causes resp. alkalosis

retain CO2 so it causes acidosis

Biots respirations

Cheyne-Stokes respirations

Kussmal respirations

15-20 min

e.g. suctioning

safety:hold pressure

pH

PCO2

PO2

HCO3

O2 sat

bradypnea

tachypnea

oxyhemaglobin

• oxygen in blood
• shows is pt is getting adequate oxygentation

• ratio of PRBC in blood volume
• 3X's Hgb

• too many rbc's
• can occur from COPD-chronic hypoxemia
• slows blood flow
• pt is red

• O2 sat-how well you're perfusing
• amount of O2 in blood
• normal range is 95-100%

lungs

kidneys-3-5 days

involves renal excretion of HCO3

less oxygen delivered to tissues

can be caused by hypoventilation (retaining CO2)

purpose of thoracentesis

• obtain CRX
• sit ip
• comfort pt
• may sedate

• watch resp.
• pain
• vertigo
• tightness
• uncontrollable pulse
• *lung sounds
• assymetry of chest
• diminished so after they should have relaxed breathing and can take a deep breath

• pneumothorax
• infection
• sq emphysema
• cardiac distress

• agitation
• rapid respirations
• pallor
• anxiety
• sitting on bedside table
• cyanosis
• difficultly speaking

• know if it's worsening
• assess right away