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NUR 230 EXAM 2- RESPIRATORY (Dr. Layne Kahoot=scubanurse41)
ASSESSMENT OF RESPIRATORY (10 questions)
Pleura & Pleural Space
- Lungs are covered by visceral pleura
- Chest is covered by parietal pleura
- The pleural space
o Between the parietal pleura & visceral pleura
There is 10-15 mL of pleural fluid in this space
o Empyema
Infection in the pleural space
o Pleural effusion
An overproduction of pleural fluid in the pleural space
SOB, anxiety, crackles, diminished breath sounds
o If there is not enough fluid in the pleural space:
Creates friction which causes a pleural friction rub
Also causes pleurisy
Extreme pain on inspiration
Dx based on s/s, not diagnostics
Smoking
- Nicotine is CNS stimulant
o The effects last 1-2 hrs. Before w/draw s/s occur
Tiredness, irritability, & anxiety
- Causes
o Lung disease, CV disease, lung & other cancers, & many others
- Pack years calculation
o # of packs smoked per day x the # of years they smoked
This does not include time stopped smoking
- Smoking cessation
o Nicotine replacement therapy
Patches, lozenges, gum
Increase chance of pt quitting & relieves w/drawl s/s
o Non-nicotine products
Varenicline
Bupropion
o Programs
Hypnosis, acupuncture, behavioral interventions, aversion therapy, support groups,
individual therapy, & self-help options
- The 5 As for Users Who Want to Quit
o Ask: Identify all tobacco users at every contact
o Advise: Strongly urge all tobacco users to quit
o Assess: Determine willingness to make a quit attempt
o Assist: Develop a plan with the patient to help the patient quit (e.g., counseling, medication)
o Arrange: Schedule follow-up contact
- The 5 Rs for Users Unwilling to Quit
, 2
o Relevance: Ask the patient to say why quitting is personally relevant (e.g., health)
o Risks: Ask the patient to identify his/her potential risks/consequences of tobacco use
o Rewards: Ask the patient to relate potential benefits of stopping tobacco use
o Roadblocks: Ask patient to identify barriers or impediments to quitting
o Repetition: Repeat process every clinic visit
Assessments
- Inspection
o Look for cyanosis
Central or peripheral
If a darker skin tone, look at oral mucosa & nailbeds
o Clubbing
Seen with long term hypoxia
o Sores, lesions, masses
o Hydration status
o Symmetrical breathing (COPD pt have a barrel chest)
o Assess LOC/orientation
Abnormalities may indicate hypoxia
o Assess speech
Pt in resp. Distress may have difficulty speaking d/t SOB
- Auscultation
o Should compare sounds between right & left lungs on inspiration & expiration
Make sure pt does not become dizzy or lightheaded during this procedure
o Assess lung sounds
- Elderly changes
o May present w/atypical s/s
Confusion, restless, agitated
WBC & temp will not elevate like a normal adult
Lung Sounds
- Fine crackles (rales)
o Rubbing hair follicles together on inspiration
d/t inflation of previously deflated lung tissue
- Coarse crackles (rales)
o Popping/coarse/bubbling sound on inspiration or expiration
d/t fluid or secretions in lower airways
- Rhonchi
o Snoring on inspiration or expiration
d/t obstruction, sputum, or secretions in upper airway
o May clear w/cough/suction
- Wheezing
o Squeaky musical instrument on inspiration or expiration
d/t bronchoconstriction & inflammation
- Stridor
o High-pitched sound on inspiration
d/t airway obstruction of throat/upper airway/spasms of airway
, 3
- Pleural friction rub
o Grating/squeaking on inspiration & expiration
d/t inflammation/decrease fluid in pleural space
- Tactile fremitus (vibration intensity)- place hands on the patient’s posterior thorax and having the patient
say “ninety-nine.”
Dyspnea
- This is a subjective finding and needs immediate intervention if pt complains of:
o Trouble speaking (do not try to ask them questions, need to stabilize pt first)
o Use of accessory muscles
o Retractions
o Adventitious lung sounds
o Increased RR
o Pulse ox reading low based on pt baseline
o Abnormal percussion sounds
o Cyanosis
o LOC change
- Do a focused resp. Assessment (breath sounds, VS, skin color change, etc.)
Pulmonary Function Test (PFT)
- Determines lung function & breathing difficulties
o If pt is a smoker, teach to not smoke 6-8 hrs. before test
o If pt uses inhaler, teach to w/hold 4-6 hrs. before test
Arterial Blood Gas (ABG)
- Before obtaining specimen, the nurse should assess pt pulses
o If radial artery selected
Perform Allen’s test to check for adequate ulnar circulation
Occlude blood flow in radial & ulnar artery, then release the ulnar artery
and observe the color of the palm on that side
- Right after procedure
o Hold direct pressure over site for at least 5 mins, 20 mins for pt on anticoags
- Complications
o Hematoma
Occurs when blood accumulates under skin at puncture site
Apply pressure until hemostasis is achieved then put pressure bandage on
o Air embolism
Place pt flat or in Trendelenburg
Have pt do Valsalva maneuver
Monitor sudden SOB, decrease SaO2 levels, chest pain, anxiety, & air hunger
- pH= 7.35-7.45
- CO2= 45-35
- HCO3= 21-28
- If pH is abnormal and either the CO2 or HCO3 abnormal (not both) = uncompensated
- If pH remains abnormal, both CO2 and HCO3 are abnormal = partial compensation (all abnormal)
- If pH returns to normal, both CO2 and HCO3 are abnormal = full compensation
, 4
Capnography
- Continuously monitors PaCO2 during inhalation & expiration & gives a written tracing
Capnometry
- Measures amount of CO2 exhaled w/out a continuous tracing
o The most valuable reading is the end tidal CO2
Normal is 2-5 mmHg less than PaCO2 reading
This can detect resp. distress before pt has s/s
Sputum Analysis
- Checks for microorganisms &/or abnormal cell growth
o If organism identified, sensitivity test is performed to see what antibiotic therapy is needed
o If abnormal cells identified, test to see if malignant or nonmalignant
- Performed 2 ways
o Pt asked to cough & expel into sterile collection device
Pt should rinse mouth before to limit contamination of normal mouth flora in
culture
Needs collected as early in morning as possible because secretions accumulate at
night
Pt should deeply inspire & expire, w/the pt coughing during expiration
o Pt w/ETT/trach will get this collected via suctioning airway w/in line suction device &
placing contents in sterile device
Skin Tests
- Can test allergic reactions or exposure to TB bacilli or fungi
- Nursing responsibilities
o Prevent false negative reaction by giving injection intradermal instead of SUBQ
o Circle site after injection & tell pt not to remove marks
- TB (Mantoux)
o Reads induration
Skin raised & is palpated to measure
Positive if > 10 mm
o Redness is not a positive test
CXR
- Pt needs to remove all jewelry
- Female pt should remove bra
- Nurse/tech should drape all body areas not being x-rayed in lead shield to minimize radiation exposure
- Assess for pregnancy before test
o If pt is pregnant, they will need shielded
Bronchoscopy
NUR 230 EXAM 2- RESPIRATORY (Dr. Layne Kahoot=scubanurse41)
ASSESSMENT OF RESPIRATORY (10 questions)
Pleura & Pleural Space
- Lungs are covered by visceral pleura
- Chest is covered by parietal pleura
- The pleural space
o Between the parietal pleura & visceral pleura
There is 10-15 mL of pleural fluid in this space
o Empyema
Infection in the pleural space
o Pleural effusion
An overproduction of pleural fluid in the pleural space
SOB, anxiety, crackles, diminished breath sounds
o If there is not enough fluid in the pleural space:
Creates friction which causes a pleural friction rub
Also causes pleurisy
Extreme pain on inspiration
Dx based on s/s, not diagnostics
Smoking
- Nicotine is CNS stimulant
o The effects last 1-2 hrs. Before w/draw s/s occur
Tiredness, irritability, & anxiety
- Causes
o Lung disease, CV disease, lung & other cancers, & many others
- Pack years calculation
o # of packs smoked per day x the # of years they smoked
This does not include time stopped smoking
- Smoking cessation
o Nicotine replacement therapy
Patches, lozenges, gum
Increase chance of pt quitting & relieves w/drawl s/s
o Non-nicotine products
Varenicline
Bupropion
o Programs
Hypnosis, acupuncture, behavioral interventions, aversion therapy, support groups,
individual therapy, & self-help options
- The 5 As for Users Who Want to Quit
o Ask: Identify all tobacco users at every contact
o Advise: Strongly urge all tobacco users to quit
o Assess: Determine willingness to make a quit attempt
o Assist: Develop a plan with the patient to help the patient quit (e.g., counseling, medication)
o Arrange: Schedule follow-up contact
- The 5 Rs for Users Unwilling to Quit
, 2
o Relevance: Ask the patient to say why quitting is personally relevant (e.g., health)
o Risks: Ask the patient to identify his/her potential risks/consequences of tobacco use
o Rewards: Ask the patient to relate potential benefits of stopping tobacco use
o Roadblocks: Ask patient to identify barriers or impediments to quitting
o Repetition: Repeat process every clinic visit
Assessments
- Inspection
o Look for cyanosis
Central or peripheral
If a darker skin tone, look at oral mucosa & nailbeds
o Clubbing
Seen with long term hypoxia
o Sores, lesions, masses
o Hydration status
o Symmetrical breathing (COPD pt have a barrel chest)
o Assess LOC/orientation
Abnormalities may indicate hypoxia
o Assess speech
Pt in resp. Distress may have difficulty speaking d/t SOB
- Auscultation
o Should compare sounds between right & left lungs on inspiration & expiration
Make sure pt does not become dizzy or lightheaded during this procedure
o Assess lung sounds
- Elderly changes
o May present w/atypical s/s
Confusion, restless, agitated
WBC & temp will not elevate like a normal adult
Lung Sounds
- Fine crackles (rales)
o Rubbing hair follicles together on inspiration
d/t inflation of previously deflated lung tissue
- Coarse crackles (rales)
o Popping/coarse/bubbling sound on inspiration or expiration
d/t fluid or secretions in lower airways
- Rhonchi
o Snoring on inspiration or expiration
d/t obstruction, sputum, or secretions in upper airway
o May clear w/cough/suction
- Wheezing
o Squeaky musical instrument on inspiration or expiration
d/t bronchoconstriction & inflammation
- Stridor
o High-pitched sound on inspiration
d/t airway obstruction of throat/upper airway/spasms of airway
, 3
- Pleural friction rub
o Grating/squeaking on inspiration & expiration
d/t inflammation/decrease fluid in pleural space
- Tactile fremitus (vibration intensity)- place hands on the patient’s posterior thorax and having the patient
say “ninety-nine.”
Dyspnea
- This is a subjective finding and needs immediate intervention if pt complains of:
o Trouble speaking (do not try to ask them questions, need to stabilize pt first)
o Use of accessory muscles
o Retractions
o Adventitious lung sounds
o Increased RR
o Pulse ox reading low based on pt baseline
o Abnormal percussion sounds
o Cyanosis
o LOC change
- Do a focused resp. Assessment (breath sounds, VS, skin color change, etc.)
Pulmonary Function Test (PFT)
- Determines lung function & breathing difficulties
o If pt is a smoker, teach to not smoke 6-8 hrs. before test
o If pt uses inhaler, teach to w/hold 4-6 hrs. before test
Arterial Blood Gas (ABG)
- Before obtaining specimen, the nurse should assess pt pulses
o If radial artery selected
Perform Allen’s test to check for adequate ulnar circulation
Occlude blood flow in radial & ulnar artery, then release the ulnar artery
and observe the color of the palm on that side
- Right after procedure
o Hold direct pressure over site for at least 5 mins, 20 mins for pt on anticoags
- Complications
o Hematoma
Occurs when blood accumulates under skin at puncture site
Apply pressure until hemostasis is achieved then put pressure bandage on
o Air embolism
Place pt flat or in Trendelenburg
Have pt do Valsalva maneuver
Monitor sudden SOB, decrease SaO2 levels, chest pain, anxiety, & air hunger
- pH= 7.35-7.45
- CO2= 45-35
- HCO3= 21-28
- If pH is abnormal and either the CO2 or HCO3 abnormal (not both) = uncompensated
- If pH remains abnormal, both CO2 and HCO3 are abnormal = partial compensation (all abnormal)
- If pH returns to normal, both CO2 and HCO3 are abnormal = full compensation
, 4
Capnography
- Continuously monitors PaCO2 during inhalation & expiration & gives a written tracing
Capnometry
- Measures amount of CO2 exhaled w/out a continuous tracing
o The most valuable reading is the end tidal CO2
Normal is 2-5 mmHg less than PaCO2 reading
This can detect resp. distress before pt has s/s
Sputum Analysis
- Checks for microorganisms &/or abnormal cell growth
o If organism identified, sensitivity test is performed to see what antibiotic therapy is needed
o If abnormal cells identified, test to see if malignant or nonmalignant
- Performed 2 ways
o Pt asked to cough & expel into sterile collection device
Pt should rinse mouth before to limit contamination of normal mouth flora in
culture
Needs collected as early in morning as possible because secretions accumulate at
night
Pt should deeply inspire & expire, w/the pt coughing during expiration
o Pt w/ETT/trach will get this collected via suctioning airway w/in line suction device &
placing contents in sterile device
Skin Tests
- Can test allergic reactions or exposure to TB bacilli or fungi
- Nursing responsibilities
o Prevent false negative reaction by giving injection intradermal instead of SUBQ
o Circle site after injection & tell pt not to remove marks
- TB (Mantoux)
o Reads induration
Skin raised & is palpated to measure
Positive if > 10 mm
o Redness is not a positive test
CXR
- Pt needs to remove all jewelry
- Female pt should remove bra
- Nurse/tech should drape all body areas not being x-rayed in lead shield to minimize radiation exposure
- Assess for pregnancy before test
o If pt is pregnant, they will need shielded
Bronchoscopy
