Respiratory Exam 2023 with complete solution questions and answers

Lung Structure and Function - Gas exchange > oxygen moves into the blood > CO2 is excreted out of blood - immunity barrier - metabolic organ perfusion movement of blood through lungs - ventilation depends on conducting airways - gas exchange is in alveoli in lungs ventilation movement of air in and out of the lungs - inhale: chest expands - exhale: chest muscles recoil - mismatching ventilation and perfusion > dead air space > shunt Tidal Volume (TV) volume of air inhaled or exhaled in a normal breath - air that moves in and out of lungs during each breath Inspiratory Reserve Volume (IRV) volume of additional air that can be forcibly inhaled after a normal inhalation - max amount of air that you can breathe in Expiratory Reserve Volume (ERV) Amount of air that can be forcefully exhaled after a normal tidal volume exhalation - max amount of air that can be exhaled in excess of normal TV Residual Volume (RV) Amount of air remaining in the lungs after a forced exhalation - about 1200 ml left in lungs after you exhale; increases as you age bc of more trapping of air in lungs at end of exhalation Control of breathing - medulla - CO2 ^ --> medulla --> impulse to diaphragm & chest muscles --> breathing rate ^ - respiratory muscles need continuous input of CNS; if brain dead, can't breathe on own chemoreceptors monitor blood levels of O2, CO2, and pH and adjust based on what body is doing lung receptors monitor breathing patterns and lung function hypoventilation decreased rate or depth of air movement into the lungs - secretions and mucosal edema cause partial blockage of bronchi or alveoli Impaired diffusion Restricted transfer of oxygen and/or carbon dioxide across the alveolar capillary junction Dependent upon: solubility and partial pressure of the gas surface area and thickness of the membrane - oxygen and carbon dioxide pass through the alveoli ventilation/perfusion mismatch occurs when there is a lack of available oxygenated air in the alveoli even though perfusion (blood flow) to the alveoli is adequate or when the alveoli are adequately oxygenated but perfusion to the alveoli is poor or when there is a combination of both poor ventilation and poor perfusion in the alveolar-capillary structures - venous blood entering pulmonary circulation passes through the underventilated areas - arterial HYPOXEMIA Common cold - viral infection of the upper respiratory tract - symptoms: > rhinorrhea (nasal discharge), nasal congestion, cough, sneezing, sore throat, headache, hoarseness, malaise, myalgia > fever common in kids - common viruses: > Rhinovirus, parainfluenza virus, respiratory syncytial virus, coronavirus, adenovirus - usually acute and self-limiting rhinovirus one of a subgroup of viruses that cause the common cold in humans - late fall/early spring parainfluenza A viral infection of the respiratory tract - occurs in kids younger than 3 RSV (respiratory syncytial virus) highly contagious viral respiratory infection, major cause of respiratory illness in young children - in winter and spring in kids younger than 3 drugs for common colds - antihistamines - nasal and systemic decongestants - antitussives - expectorants - mucolytics Sinusitis - inflammation with resulting infection of mucous membranes of one or more paranasal sinuses * SINUS INFECTION - Classifications: acute (1 day-3 weeks), subacute 3 weeks-3 months), chronic (longer than 3 months) - Causes: URIs, viral infections, deviated septum, abuse of nasal decongestants, swimming and diving, smoking, allergies - Treatment: acetaminophen, fluids, rest * if lasts longer than 7-10 days, treat with antibiotics Influenza - one of the most important causes of acute URIs in humans - it is transmitted by aerosol (three or more particles) and direct contact - Types: A, B, C * A & B cause epidemic; C causes mild resp. infections; test for flu A and B; flu A is much worse - Can cause 3 types of infections > uncomplicated URI (common cold) > viral pneumonia > respiratory viral infection followed by a bacterial infection Influenza signs and symptoms; treatment - abrupt onset, profound malaise, abrupt fever and chills, muscle aches, headache, profuse watery discharge, nonproductive cough, sore throat, hypotension , tachypnea - Diagnosis: > based on symptoms > rapid diagnostic test-Respiratory viral panel (A & B only) Treatment: - antiviral drugs: Osetamivir (Tamiflu) and Zanamir (Relenza) - flu vaccine - allow virus to run its course - try to keep in upper resp. tract - antivirals are ineffective if not working after 48 hrs Pneumonia - inflammation of the lung parenchyma (alveoli and bronchioles) - Classification: typical (bacteria that multiply; fluid into alveolar space) and atypical (viral mycoplasma; does not have same symptoms; does not evolve the same) Patho: - bacteria invades the lower resp. tract - inflammation occurs in the lungs; inflammatory reaction in the alveoli produces exudate > antigen-antibody response; endotoxins are released > air apces of alveoli become engorged with fluid and RBCs and exudate forms > infiltration of lymphocytes, neutrophils, RBCs, and fibrin leads to cellular infiltration and massive congestion > alveoli become airless Pneumonia S/S - coughing, fatigue, pleuritic pain, dyspnea, chills, fever, elevated WBC, sputum production (rust colored or purulent), lung crackles, pleural rub (raspy breathing), and tachypnea - Chest X-ray: white patchy infiltrates Pneumonia nursing management - medications: antibiotic therapy, antipyretics, bronchodilators, expectorants or drugs to liquefy mucus - increase fluid intake - administer oxygen as needed - monitor resp. rate, depth, and use of accessory muscles - encourage turn, cough, and deep breaths (incentive spirometer) - chest physical therapy Tuberculosis - airborne infection caused by Mycobacterium tuberculosis - Types: primary or secondary - Patho: > organisms enter the lungs and multiply in pulmonary alveoli > enter bloodstream and lymphatic systems; stimulating a cell mediated response > neutrophils and macrophages are released > Bacilli cannot be destroyed but can be isolated; as macrophages eventually contain the infection > sensitized helper T-cells stimulate more macrophages --> boosts ability to kill bacilli, but damages lung tissue > cell-mediated immune response results in development of Gohn focus > Gohn complex Gohn complex TB (inactive phase) Calcium "jail" around mycobacterium granuloma plus regional lymph node swelling, visible on a chest x-ray Tuberculosis diagnosis and nursing management - Chest X-ray - Cultures - TB skin test - CBC - medications include single dose treatment for prevention of exposure and at least 2 antibacterial medications for active cases of disease and resistant strains - direct observational therapy - monitor for hepatotoxicity Tuberculosis Medications - Isoniazid - Ethambutol - Pyrazinamide - Rifampin - educate compliance with these meds; every dose needs to be taken - Rifampin can change urine red-orange color - maintain adequate hydration and nutrition; daily weights - airborne precautions; private and negative pressure rooms - encourage frequent rest periods Pleura - parietal pleura lines the thoracic wall and superior aspect of the diaphragm - visceral pleura covers the lung - pleural cavity or the space between the two layers contains a thin layer of serous fluid Pleuritis (pleurisy) - inflammation of the pleural which is often accompanied by abrupt onset of pain - Causes: viral infections and pneumonia - is common in smokers - S/S: > pain is usually unilateral and abrupt onset which worsens with chest movement (deep breathing and coughing) > pain is described as sharp and stabbing, typically abrupt Pleuritis (pleurisy) treatment - treat underlying cause - treat inflammation, pain, and fever - analgesics and NSAIDs Pleural effusion - abnormal collection of fluid in pleural cavity - hydrothorax: serous fluid - empyema: pus - chylothorax: lymph - hemothorax: blood Signs/symptoms: - dullness to percussion, diminished lung sounds on affected side, hypoxemia, dyspnea are the most common symptoms resulting in increased rate and effort, and breathing pain Pleural effusion Diagnosis and Nursing management - Chest X-ray - Chest ultrasound - CT scan of chest - prepare for thoracentesis which is the aspiration of fluid from the pleural space to allow for re-expansion of the lung - sample of pleural fluid will be obtained for diagnosis - possible chest tube placement if needed - monitor VS and trends, monitor for shortness of breath and worsening symptoms - antipyretics for pain and fever, antibiotics - treat the underlying problem and prevent complications such as atelectasis and pneumothorax pneumothorax - entrance of air into the pleural cavity, resulting in complete or partial collapse of the lung - Types: > spontaneous: primary and secondary > traumatic: open or "sucking chest wound" > Tension > Iatrogenic > Hemothorax Pneumothorax S/S, diagnosis, and nursing management S/S: - severe shortness of breath, sharp and intense pain of the affected side that may worsen on inspiration, absence of breath sounds, distension on one side of chest, tachypnea, hypoxemia, cyanosis, anxiety, and diaphoresis Diagnosis: - Chest X-ray - ABGs - Pulse Ox Nursing Management: - in small spontaneously pneumothoraces, the air usually is reabsorbed and observation is needed with chest XR follow up - supplemental oxygen may be needed - large pneumothorax; air is removed by a needle aspiration (thoracentesis) or a closed drainage system is used with or without suction atelectasis - collapse of alveoli in lungs > perfusion occurs without ventilation - classifications: primary and secondary Atelectasis S/S and treatment - tachypnea, tachycardia, dyspnea, cyanosis, hypoxemia, diminished chest expansion, absence of breath sounds, intercostal retractions Diagnosis: - based on s/s - chet x-ray Nursing Management: - prevention is key: deep breathing exercises and early mobilization - administer oxygen if needed - body position to help with chest expansion Reactive airway disease a term used to describe any condition that causes hyperreactive bronchioles and bronchospasm; asthma - the term is used when asthma is suspected but not confirmed as a specific diagnosis asthma - chronic inflammatory airway disorder resulting in reversible bronchoconstriction and air hunger in response to triggers from a variety of sources Patho: - affects the bronchial airways and causes mucosal edema, secretion of mucous, and inflammation of the airway - inflammatory process - allergen binds to immunoglobulin E (IgE) antibodies extrinsic asthma allergic asthma; environmental allergens - caused by hypersensitivity intrinsic asthma Not an allergic reaction Usually presents after age 35 years Triggers: upper respiratory infections, air pollution, emotional stress, smoke, exercise, and cold exposure - usually from an unknown source status asthmaticus a prolonged, extremely severe, life-threatening asthma attack bronchospasm a contraction of the smooth muscle in the walls of the bronchi and bronchioles that tighten and squeeze the airway shut asthma assessment - inspiratory and expiratory wheezes, audible wheezing, sitting upright, leaning forward, and using accessory muscles to breathe Diagnostic tests: - Pulmonary Function Tests Pulmonary Function Test - Forced vital capacity - Forced expiratory volume - Peak expiratory flow rate forced vital capacity the maximum amount of air that can be removed from the lungs during forced expiration forced expiratory volume amount of gas expelled during specific time intervals of FVC - single most useful test of lung function peak expiratory flow rate measurement of how fast a person can exhale using a small handheld device to monitor treatment in asthma or COPD - done using a peak flow meter Asthma Classification Intermittent Mild persistent Moderate persistent Severe persistent Intermittent Asthma Symptoms occur 2 or less times a week, nighttime symptoms are two or fewer times a month, no interference with normal activity mild persistent asthma Symptoms occur >2x/wk, but not daily 3-4 nighttime awakenings a month moderate persistent asthma Daily symptoms occur w/ exacerbations 2x/wk Nighttime awakenings >1 time a week, but not nightly severe persistent asthma Symptoms occur continually, along w/ frequent exacerbations that limit physical activity & QOL nighttime awakenings often 7 times a week Nursing management of asthma - teach about medications - explain differences between rescue inhalers and maintenance inhalers - teach how to identify what triggers will induce an asthma attack (i.e. exercise, smoking, pets, and avoiding triggers) - flu vaccines recommended yearly desired results of asthma - relief of wheezing - lung sounds clear as auscultation - oxygen saturations about 95% - RR 12-20 breaths per minute - low dyspnea rating scale chronic obstructive pulmonary disease (COPD) - a group of respiratory disorders characterized by chronic and recurrent obstruction of airflow in the pulmonary airways - hypercapnia is typical along with hypoxemia - emphysema - enlargement of air spaces and destruction of lung tissue COPD assessment - usually starts in patients 50-60 y/o S/S: cough, sputum production, SOB - Late signs: recurrent history of respiratory infections and chronic resp. failure Diagnostic tests: - ABGs, FEV1, Chest X-ray COPD nursing management - Medications > Bronchodilators > Anticholinergics (Spiriva) > Steroids or anti-inflammatory drugs COPD medication management Bronchodilators: - Beta-2 adrenergic agonists - Xanthines Anti-inflammatory agents: - inhaled steroids - inhaled non steroids - Leukotriene modifiers Med. Admin. - MDI, dry powder inhaler, nebulizer Short-acting - bronchodilators, beta-2 agonists, anticholinergics Long-acting - anti inflammatory, inhaled and oral corticosteroids, inhaled non steroids, leukotriene modifiers, long acting beta-2 agonists, xanthines Metered Dose Inhaler - small hand held pressurized device that delivers a measured dose of the drug with activation - usually 1-2 puffs - interval of at least 1 min between puffs - patient needs to inhale prior to activating device - to check the canister: place in water, if the canister stays under water, the canister is full, if it floats, it is empty - store at room temp Administering MDI Hold inhaler upright with the mouthpiece at the Botton and shake it Tilt your head back slightly and breathe out fully Place the inhaler with the mouthpiece in the position that is correct for the patient. Close lips around the inhaler or hold it 1-2 inches from open mouth Prior to pressing down on the inhaler to release the medication, start to breathe in Breathe in slowly and steadily, take 3-5 seconds for each breath Hold your breath for 10 seconds to allow the medication to settle in your lungs Breathe out slowly Repeat puffs as directed If a steroid is used, rinse the mouth after use Dry Powdered Inhaler (DPI) Use to deliver the drug in the form of a dry, micronized powder directly to the lungs No propellant is needed Breath activated Don't require the hand-lung coordination Nebulizer Small machine used to convert an anti-asthma drug solution into mist Can be done through a face mask or mouth piece held between the teeth Nebulizers take several minutes to deliver the same amount of drug contained in 1 puff of an inhaler Should be cleaned daily and rinsed with water after each treatment and allowed to air dry after loosely covering it with a clean paper towel Pulmonary embolism - Blockage of pulmonary artery (PA) by an embolus Pathophysiology: - A portion of thrombus dislodges and travels through venous circulation through the right side of the heart and enters the PA - A blocked PA causes decreased blood flow to the lungs and can result in infarction to the lung tissue - Embolus may block the entire PA or may block smaller branches of the pulmonary circulation, causing pulmonary infarcts - PE leads to ventilation without perfusion (alveolar dead space is increased) - The right side of the heart is unable to pump sufficiently > Decreased oxygenation of brain and other vital organs Pulmonary embolism S/S - Tachypnea, tachycardia, hypotension, sudden acute dyspnea with extreme anxiety, chest or pleuritic pain, abnormal lung sounds (wheezes, decrease breath sounds or crackles), hypoxemia - Large clots may cause: pulmonary HTN, shock, right sided heart failure or sudden respiratory arrest Pulmonary Embolism Nursing management Medications: - Anticoagulants (Heparin, warfarin (Coumadin)) - Low molecular weight heparins (Lovenox) - Thrombolytic therapy - Avoid prolonged bed rest or sitting - Immediate ambulation may be allowed depending on clot location and size - Apply anti embolism stocking or sequential compression devices (SCDs) - Monitor VS, respiratory status, LOC, skin color, and mental status - Monitor labs and assess for bleeding if on anticoagulant therapy Pulmonary Hypertension - Elevated pressures in PA, usually resulting from cardiac or cardiac disease - Resting PA means pressure >25mmHg Classifications: - Primary - Secondary Cor Pulmonale: - Right ventricular hypertrophy and failure result from long-term pulmonary HTN Pulmonary Hypertension S/S Venous congestion, peripheral edema, SOB, and productive Nursing Management: - Medications: > Calcium channel blockers > Direct vasodilators > Ace inhibitors > Diuretics and digoxin if for Cor pulmonale occurs Acute Respiratory Distress Syndrome - A clinical syndrome that is characterized by severe dyspnea of rapid onset, hypoxemia, and pulmonary infiltrates Causes: - Aspiration (near drowning); drugs, toxins, therapeutic agents (Heroin, radiation, breathing high concentrations of oxygen); infections (septicemia); trauma/shock (burns, chest trauma, fat embolism), and multiple blood transfusions Pathophysiology: - Diffuse epithelial cell injury - Increase permeability of the alveolar capillary membrane - Lungs stiffen and become difficult to inflate - Increased shunting of blood, impaired gas exchange, and hypoxemia - Alveolar collapse Acute Respiratory Distress Syndrome S/S - Rapid onset, usually 12-18 hours of initiating event of respiratory distress - Increased respiratory rate - Signs of respiratory failure; hypoxemia, multiple organ failure (particularly renal, GI, CV, and CNS) Respiratory Failure - An inability of the lungs to maintain adequate oxygenation and is usually manifested by hypoxemia, hypercapnia, and respiratory acidosis Classifications: - Acute (ARF) - Chronic (CRF) Two types: - Hypoxemia respiratory failure - Hypercapnic/Hypoxemic respiratory failure Respiratory Failure S/S - Hypoxemia and hypercapnia, dyspnea, neurological changes (restlessness, apprehension, impaired judgement, and motor skills), cyanosis, diaphoresis, cool skin, tachycardia, HTN, and tachypnea Nursing Management: - Treat underlying cause - Bronchodilators, corticosteroids, antibiotics if infection exists - Benzodiazepines - Neuromuscular blocking agents - Administer oxygen as needed or maintain ventilation - Monitor pulse ox; parenteral therapy, monitor fluid and electrolytes; maintain nutritional support Cystic Fibrosis - Autosomal recessive chromosome disorder with exocrine gland dysfunction which manifests in multiple body systems - Multi-system involvement: respiratory, pancreatic, liver, and GI * Goal is to increase longevity Cystic Fibrosis Pathophysiology - Mutation of a single gene that codes for a particular type of chloride channel, referred to as the cystic fibrosis transmembrane regulator (CFTR) - Epithelial membrane relatively impermeable to chloride - Altered secretions Respiratory: - Decreased ciliary function and increased thickness of mucous secretions occur - Decreased function of alveoli and alveolar plugs leads to repeat infections and COPD - COPD leads to cor pulmonate and chronic hypoxemia Cystic Fibrosis GI Pathophysiology - Thick secretions block ducts leading from pancreases to duodenum - Malabsorption occurs because digestive enzymes don't reach food; predominantly affects fats and fat-soluble vitamins A, D, E, and K; leads to malnutrition if untreated Pancreases: Damage causes an increase risk of Type 1 DM Liver: biliary obstruction leads to cirrhosis and gallbladder disease Cystic Fibrosis Diagnostic Tests and Nursing Management - Classic NaCl sweat test (2-5x greater than normal) - Chest Xray and PFTs Medications: bronchodilators, antibiotics as needed, dornase alfa (Pulmozyme), corticosteroids, immunizations, pancrealipase (Pancrease)