Exam #2-Ch. 17, 26-19 (Respiratory System)

Ch. 17-Fluid, Electrolytes and Acid-Base Imbalances
1. Know the normal ABG value.
*pH: 7.35-7.45
-high: alkalosis
-low: acidic

*PaCO2 (respiratory): 35-45 mm Hg
-high: acidic
-low: alkalosis

*HCO3 (metabolic): 22-26 mEq/L
-high: alkalosis
-low: acidic

*What is the overall pH?
*Is it respiratory or metabolic?
*Is there compensation?
-zero compensation
-partial compensation
-total compensation

2. Review the processes of acid-base regulation.
*buffer system
-fastest acting, primary system
-change strong acids into weaker acids or neutralize acid

*respiratory system
-excrete by-products of cellular metabolism, CO2 and water

*renal system
-reabsorb and conserve bicarbonate
-eliminate excess H ions

3. Recognize clients at risk for acid-base imbalances.
-patients with diabetes mellitus, chronic obstructive pulmonary disease, kidney disease, vomiting, diarrhea, older patients, or patients with serious illnesses

4. Use the NP to provide nursing care to a client with an acid-base imbalance.
*assessment
-subjective: past medical history, medications, diet, lifestyle, health perception, tingling, numbness, n/v/d, light-headedness
-objective: irregular breathing, low BP, irregular heartrate, confusion, lethargy
-dx: serum electrolyte values, ABGs, serum glucose, BUN, creatinine

*diagnoses
-ineffective breathing pattern
-risk for injury
-acid/base imbalance

*planning
-replacement of electrolyte and oral/intravenous fluids

*implementation
-treat underlying cause

5. Given lab values, identify the acid-base imbalance and the resulting nursing care.
*respiratory acidosis, hypoventilation
-7.3, 50, 30
-deep breath

*respiratory alkalosis, hyperventilation
-7.5, 30, 20
-deep breath

*metabolic acidosis, severe diarrhea
-7.3, 30, 20
-Lactated Ringer’s

*metabolic alkalosis, severe vomiting or excess gastric suctioning
-7.5, 50, 30
-anti-enemics, monitor suctioning

Ch. 26-Nursing Assessment of the Respiratory System
1. Review the factors that control respiration.
*chemoreceptors: responds to change of chemical composition of the fluid surrounding it
-central, peripheral
-changes respiratory rate

*mechanical receptors: stimulated by physiologic factors like irritants, muscle stretching, and alveolar wall distortion
-located in lungs, upper airways, chest walls, and diaphragm

2. Explain the pulmonary changes associated with aging. (Table 26-4)
*alterations in:
-structure: decreased elasticity and compliance
-defense mechanisms: less forceful cough, less functional cilia, and dry mucous membranes
-respiratory control: decreased response to changes in blood gases

3. Explain the different diagnostic tests. (Table 26-11)
*blood studies: assesses Hb, Hct, and ABGs

*oximetry: assesses oxygen saturation

*sputum studies: tests infecting microorganism

*skin tests: tests for allergic responses

*radiologic studies: screens lungs for lesions, areas of inadequate airflow, and evaluates change

*endoscopic examinations: uses scopes to inspect the lungs and collect specimen

*lung biopsy: obtain tissue, cells, or secretions for evaluation

*thoracentesis: locally anesthesized, fluid collected from pleural space

*pulmonary function tests: measure lung volumes and air-flow to diangose pulmonary disease, monitor disease progression, and evaluate disability /response to bronchodilators

*exercise testing: determines exercise capacity for disability evaluation

4. Use the NP to provide care to the patient pre- and post- thoracentesis/ bronchoscopy. (Table 26-11)
*thoracentesis:
-explain and obtain signed permission for procedure
-position patient upright with elbows on overbed table with feet supported
-instruct patient not to cough or talk during procedure
-observe signs of hypoxia and pneumothorax
-monitor lung sounds in all fields after procedure
-encourage deep breathing for lung expansion
-send specimen to lab

*bronchoscopy
-NPO 6-12 hours prior
-obtain signed permission
-administer ordered sedative before procedure
-continue NPO status until gag reflex returns after procedure
-monitor laryngeal gag reflex
-monitor recovery from sedative
-monitor for hemorrhage and pneumothorax
-blood tinged mucus is not abnormal

Ch. 27- Nursing Management: Upper Respiratory Problems
1. Use the NP in care of a client with influenza and OSA
**Influenza
*assessment
-subjective: abrupt onset of symptoms (cough, fever, myalgia), headache, sore throat, weakness, patient health history
-objective: dyspnea, crackles, purulent sputum
-dx: influenza in the community

*diagnoses
-risk for infection
-ineffective airway clearance
-ineffective breathing

*planning
-symptom relief
-prevention of secondary infection

*implemenation
-drug therapy: antivirals to relieve symptoms and prevent spread

*evaluation
-does the patient have difficulty in breathing?
-is the patient free of secondary infection?

**OSA
*assessment
-subjective: frequent awakenings at night, insomnia, daytime sleepiness, witnessed apneic episodes, snoring, morning headaches, personality changes, irritability, inability to concentrate, impaired memory…
-objective: hypertension, dysrhythmias
-dx: polysomnography (more than 10 episodes of oxygen desaturation of below 90%)

*diagnoses
-ineffective breathing
-disturbed sleep pattern

*planning
-patient will understand methods to treat mild-severe OSA

*implementation
-avoid sedatives and alcohol 3-4 hours before sleep
-referral to weight loss programs for OSA r/t excessive weight
-oral appliance to prevent airflow obstruction
-CPAP, BiPAP, or uvulopalatoplasty
-monitor SpO2, HR, BP...

*evaluation
-does the patient demonstrate understanding of the treatment methods?

Ch. 28-Nursing Management: Lower Respiratory Problems
1. Explain the pathophysiology of pneumonia, HAP, CAP, tuberculosis, pulmonary edema, pulmonary hypertension, cor pulmonale, lung cancer, pulmonary embolus, and atelectasis.
-pneumonia: congestion (fluid fills alveoli), red hepatization (dilation of capillaries, making the lung appear red and granular), gray hepatization (decreased blood flow and consolidation of affected part of lung), resolution (exudate lysed by macrophages and gas-exchange returns to normal)
-HAP: same as above, acquired in hospital
-CAP: same as above, acquired in community
-tuberculosis: active bacteria that multiply and cause clinically active disease
-pulmonary edema: increased hydrostatic pressure or decreased colloidal oncotic pressure pulls fluids into interstitial space
-pulmonary hypertension: deficient release of vasodilators to pulmonary epithelium causing increased pulmonary pressure
-cor pulmonale: enlargement of right ventricle secondary to diseases of the lung, thorax, or pulmonary circulation
-lung cancer: hypersecretion of mucus, desquamation of cells, cancerous cells of upper lobes
-pulmonary embolus: thrombus, fat or air embolus, or tumor tissue blocking pulmonary arteries obstructing perfusion
-atelectasis: collapsed, airless alveoli commonly caused by airway obstruction from retained exudate and secretions observed in post-operative patients

2. Identify clinical situations and patient populations at risk for developing the listed pulmonary conditions.
-pneumonia: decreased defense mechanisms-age, air pollution, ALOC, immune suppression, prolonged immobility, chronic diseases, debilitating illiness, inhalation of noxious substances, tube feeding, malnutrition, smoking, upper respiratory tract infection, intubation…
-HAP: VAP and HCAP
-CAP: smokers
-tuberculosis: immunocompromised, exposure to infected individuals
-pulmonary edema: most commom cause is left-sided HF
-pulmonary hypertension: use of Fen-Phen, more women than men
-cor pulmonale: patients with disease of lung, thorax, or pulmonary circulation
-lung cancer: smokers or exposure to second-hand smoke
-pulmonary embolus: post-surgery or childbirth-immobilization, stroke, history of DVT, and malignancy
-atelectasis: post-operative patients

3. Use the NP to care for clients with pneumonia, HAP, CAP, pulmonary edema, pulmonary hypertension, cor pulmonale, lung cancer, pulmonary embolus, and atelectasis.
**pneumonia, HAP, CAP
*assessment
-subjective: chest pain, confusion, fatigue, headache, sore throat, nausea,
-objective: sudden onset of fever, shaking chills, SOB, productive cough, rust-colored sputum, crackles, bronchial breath sounds, vomiting, diarrhea
-dx: chest x-ray, CBC, blood stain, sputum test

*diagnoses
-impaired gas-exchange
-ineffective breathing pattern
-ineffective airway clearance

*planning
-clear breath sounds
-normal breathing patterns
-no signs of hypoxia
-normal chest x-ray
-no complications related to pneumonia

*implementation
-teaching: hygiene, rest, exercise, and good health habits
-position to minimize risk of aspiration, repositioning every 2 hours
-“good lung down”
-elevate HOB for tube feedings and VAP patients
-infection control
-CDB/IS
-medication routine

**tuberculosis
*assessment
-subjective: weight loss, fatigue, malaise, night sweats, anorexia
-objective: productive cough with white, frothy sputum, chest pain
-dx: chest x-ray, TB skin test, bacteriologic studies

*diagnoses
-ineffective breathing pattern
-imbalanced nutrition: less than body requirements
-noncompliance
-activity intolerance
-ineffective health maintenance

*planning
-comply with therapeutic regimen
-no recurrence of disease
-normal pulmonary function
-prevention of disease spread

*implementation
-isolation
-appropriate drug therapy
-stage disease
-teach patient to prevent spreading disease
-follow-up care

**lung cancer
*assessment
-subjective: exposure to airborne carcinogens, smoking history, frequent respiratory infections, persistent cough, chest pain, headache
-objective: fever, jaundice, edema of neck and face, clubbing, lung sounds (stridor, wheezing), unsteady gait
-dx: chest x-ray, sputum testing, bronchoscopy, MRI, PET, lung scan…

*diagnoses
-ineffective airway clearance
-ineffective health maintenance
-ineffective breathing pattern

*planning
-effective breathing pattern
-adequate airway clearance
-adequate oxygenation of tissues
-minimize pain

*implementation
-referral to quit smoking
-teach methods to reduce pain
-therapeutic communication, therapy

**pulmonary embolus
*assessment
-subjective: anxiety
-objective: rapid and weak pulse, low BP, hypoxemia, severe dyspea, pallor, dysrhythmia, ALOC, crackles, blood streaked sputum
-dx: ventilation-perfusion lung scan, D-dimer test

*diagnoses
-inadequate tissue perfusion
-inadequate cardiac output
-decreased level of comfort

*planning
-maximize breathing
-monitor VS
-limit progression and recurrence

*implementation
-position in semi-fowlers
-therapeutic communication
-teaching regarding long term anti-coagulation

**pulmonary hypertension
-treat underlying cause

**pulmonary edema
-monitor cardiac and respiratory function
-fluid therapy

**atelectasis: CDB, IS

**cor pulmonale:
-chronic management, resulting from COPD: continuous low-flow O2 during sleep, exercise, and small, frequent meals to feel better and be more active

4. Nursing care of a post lung/chest surgery patient. (Table 28-2)
-monitory respiration
-reposition
-oxygen therapy
-monitor bubbling and tidaling in water-seal chamber
-prevent air leaks and keep drainage container below chest
-pain management
-IS

Ch. 29-Nursing Management: Obstructive Pulmonary Disease
1. Recognize the clinical profile of a patient with COPD.
-exposure to noxious particles and gases: smoker, occupational chemical and dusts, urban air pollution
-prone to infection
-AAT deficiency: hereditary risk factor
-aging: change to lung structure, thoracic cage, and respiratory muscles

2. Explain the measure needed to teach patients to prevent COPD.
-quit or do not begin smoking
-avoid exposure to occupational and environmental pollutants
-IS: shows how much function has been lost, but can be regained

3. Explain the pathophysiology of asthma, emphysema and bronchitis.
-asthma: chronic inflammation causing acute airflow limitation, hyperresponsiveness occurs with exposure to allergens or irritants
-emphysema: abnormal permanently enlarged air spaces with destructed walls and no obvious fibrosis
-bronchitis: chronic productive cough for 3 months in each of the last 2 consecutive years with not other cause

4. Explain information needed to teach patients on the correct use of MDI’s and PDI’s.
-when it is appropriate to use
-does it need to be shaken?
-duration of inspiration
-cleaning and storage of inhaler

5. Use the NP to provide care to a client with asthma, emphysema and bronchitis
**asthma
*assessment
-subjective: past medical history, medications, family history, lifestyle, sleep pattern, stress
-objective: body positioning, sweating, eczema, cyanosis, wheezing, crackles, nasal drainage, use of accessory muscles, tachycardia, low SpO2
-dx: ABGs, allergy skins tests, peak expiratory flow rate

*diagnoses
-ineffective airway clearance
-inadequate gas exchange
-inadequate tissue perfusion

*planning
-maintain >80% of personal best PEFR or FEV1
-have minimal symptoms during day and night
-maintain acceptable activity levels
-have no or decrease incidence of asthma attacks
-have knowledge to carry out management

*implementation
-educate to identify personal triggers and how to avoid or reduce risk of attack
-educate on medications which can inhibit bronchodilation or immunity
-monitor lung sounds and cardiac functions for red flags
-deep breath

**emphysema and bronchitis
*assessment
-subjective: exposure to smoke or irritants, weight loss/gain, past medical history, family history, lifestyle, PND, headache, soreness, anxiety, constipation, gas, bloating
-objective: cyanosis, poor skin turgor, shallow breathing, tachycardia, ascites, barrel chest, accessory muscle use, wheezing, crackles
-dx: ABGs, chest x-ray, pulmonary function tests

*diagnoses
-ineffective airway clearance
-inadequate tissue perfusion
-ineffective breathing pattern
-disturbed sleep pattern

*planning
-prevent disease progression
-improve activity tolerance
-symptom relief
-no COPD related complications
-improve quatity of life
-ability to implement long-term treatment

*implementation
-breathing techniques
-monitor respiratory and cardiac function
-position techniques to maximize breathing
-oxygen therapy

6. Methods of oxygen administration and related nursing care. (Table 29-22)
-nasal cannula: pad ears to avoid pressure points
-simple face mask: clean, check for pressure points on ears, and keep at 5 L/min
-partial rebreathing mask: check for occlusion
-non-rebreathing mask: snug fit with the bag adequately inflated at inspiration and expiration
-oxygen-conserving cannula: check for pressure points on ears, for long-term use
-transtracheal catheter: not appropriate for patients with excessive mucus
-face tent: maintain aerosol at body temperature
-tracheostomy collar: clean to prevent aspiration and infection
-tracheostomy T-bar: should be removed when suctioning, and emptied as necessary
-venturi mask: check for occlusion

7. Explain the mode of action of the different drug categories used in the management of these conditions and resulting nursing care. (Table 29-7)
*anti-inflammatory agents: decreases inflammatory response
-administer in AM with milk
-discontinue gradually over time
-observe for epigastric distress
-long-term corticosteroid therapy should be paired with vitamin D and calcium

*mast cell stabilizers: inhibit release of mast cells to suppress other inflammatory cells
-educate patient on correct use

*anti-cholinergics: blocks bronchoconstriction
-may cause blurred vision if contact with eyes
-cautious use for narrow-angle glaucoma or prostatic enlargement patients

*leukotriene modifiers: reverse bronchospasms of acute asthma attacks
-monitor liver enzymes
-effects metabolism of erythromycin, warfarin, and theophylline
-take 1 hour before or 2 hours after meals

*B2-adrenergic agonists: prevent bronchoconstriction and increase mucociliary function
-cautious use patients with diabetes, hypertension, angina, or cardiac disorders
-overuse may cause rebound bronchospasm

*methylxanthines: bronchodilator
-monitor cardiac function