Nursing Management of Clients with Stressors of Respiratory Function Assessment & Diagnosis NUR133...
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Transcript of Nursing Management of Clients with Stressors of Respiratory Function Assessment & Diagnosis NUR133...
Nursing Management of Clients with Stressors of Respiratory
FunctionAssessment & Diagnosis
NUR133 Lecture #4
K. Burger, MSEd, MSN, RN, CNE
Anatomy of Respiratory Tract
Review your NUR123 objectives on
anatomy of upper and lower airways
Assessment of Respiratory System
Review your NUR123 objectives on
Subjective and objective assessment
techniques
Anatomy KnowledgeFactors Affecting Respiration
• Integrity of the airway system (ventilation)• Functioning cardiovascular system
(perfusion)• Functioning alveoli (diffusion)• Functioning neurocontrols
Assessment KnowledgeRespiratory Assessment
• Respiratory Hx includes:
• Allergies
• Medications
• Medical Hx
• Smoking
• Lifestyle
• Stressors
• Hazard exposures
Assessing Respiratory Function
• InspectionShape (AP diam), skeletal abnormalities,chest movement and expansion, rate,rhythm, effort
• PercussionDiaphragmatic excursion, tactile fremitus
• AuscultationVesicular +, adventitious sounds
Assessing Respiratory Functioning
• Respiratory Rate:• Eupnea• Tachycardia• Bradycardia• Apnea• Respiratory Depth:• Deep• Shallow
Assessing Respiratory Functioning
• Respiratory Rhythm:
• Regular
• Cheyne-Stokes
• Kussmauls
• Apneustic breathing
• Biots
Assessing Respiratory Functioning
• Respiratory Quality:• No difficulty• Dyspnea and DOE• Orthopnea• Retractions
• Cough:• Nonproductive• Productive• Sputum• Hemoptysis
Assessing Respiratory Functioning
• Auscultation:• Vesicular• Bronchial• Bronchvesicular
• Adventitious:
• Rales/crackles
• Rhonchi
• Wheeze
• Stridor
• Stertor
Diagnostic Studies• Hemoglobin and RBC count• Sputum specimens: C&S, gram stain,
acid-fast, cytology• Radiographics: CXR, CT with contrast,
Ventilation/Perfusion scan, Bronchoscopy, Pulmonary angiography
• Thoracentesis• Pulmonary Function Tests: VC,RV,TLC• Peak Flow Meter• Mantoux PPD (purified protein derivative)• Arterial Blood Gases (ABGs)
Lung Volumes and Capacities• Tidal Volume (TV)– volume of air entering or
leaving the lungs during a single breath.Average at rest = 500 ml
• Vital Capacity (VC)- maximum volume or air that can be moved out during a single breath Average = 4500 ml
• Residual Volume (RV) – minimum volume of air remaining in the lungs even after a maximal expiration. Average = 1200 ml
• Total Lung Capacity (TLC) – maximum volume of air the lungs can holdAverage = 5700 ml
What are ABG’s ?
• Arterial Blood Gases
• Measurement of body’s acid/base balance
• Indicator of body’s oxygenation status
• Most often drawn from radial artery; usually by RT
Normal ABG Values
• PH 7.35 – 7.45
Acid --------------- Alkaline
• PCO2 35-45 mm Hg
Partial Pressure of carbon dioxide
• HCO3 22-26 mEq/L
Bicarbonate
• PO2 80-100 mm Hg
Partial Pressure of oxygen
MEMORIZE THESE VALUES !!!
Memory Tools
Normal CO2 is 35 – 45
Normal PH is 7.35–7.45
Tip:
Notice that both the
CO2 and PH have
a 35 and 45 in them
• Normal HCO3
(Bicarbonate) is 22-26
Tip:
Many a new driver buys
their own first car
between 22-26 y.o
Think of Bicarbonate as
“buycarbonate”
What is the difference between PO2 and SaO2?
• PO2 ( from the ABG) reflects the amount of dissolved O2 in the blood
• SaO2 ( from pulse oximetry ) reflects the percentage of hemoglobin that is saturated with O2
• Normal SaO2 = 95-98%
• The O2 bound to hemoglobin does not contribute to the PO2 of the blood
Carbon Dioxide transportation
• Only 10% of CO2 is physically dissolved in blood
• 30% CO2 is bound to hemoglobin• Majority of CO2 ( 60%) is transported as
Bicarbonate HCO3
CO2 + H2O = H2CO3 = H + HCO3 (carbonic acid)
CO2 and H Relationships
Carbon Dioxide Results in Free Hydrogen
CO2 + H2O = H2CO3 = H + HCO3
More Hydrogen = Lower PH
ACIDOSIS
CO2 and H Relationships
Carbon Dioxide Results in Free Hydrogen
CO2 + H2O = H2CO3 = H + HCO3
Less Hydrogen = Higher PH
ALKALOSIS
Acid Base MnemonicR O M E
• R Respiratory • O Opposite
pH up PCO2 down = AlkalosispH down PCO2 up = Acidosis
• M Metabolic• E Equal
pH up HCO3 up = AlkalosispH down HCO3 down = Acidosis
Steps for ABG Analysis
1. Evaluate the PH
< 7.35 is Acidosis> 7.45 is Alkalosis
PH = 7.29
Steps for ABG Analysis
2. Evaluate VENTILATION
PCO2 > 45 indicates Respiratory AcidosisPCO2 < 35 indicates Respiratory Alkalosis
PCO2 = 47
Steps for ABG Analysis
3. Evaluate METABOLIC PROCESSES
HCO3 < 22 reflects Metabolic AcidosisHCO3 > 26 reflects Metabolic Alkalosis
HCO3 = 24
Steps for ABG Analysis
4. Evaluate OXYGENATION
PO2 80-100 = normalPO2 60-80 = mild hypoxia
PO2 40-60 = moderate hypoxia
PO2 < 40 = severe hypoxia
PO2 = 58
Steps for ABG Analysis
5. Evaluate COMPENSATIONIs compensation taking place?
Yes if PH within normal limits and:
Compensated Respiratory Acidosis = Increased HCO3Compensated Respiratory Alkalosis = Decreased HCO3Compensated Metabolic Acidosis = Decreased PCO2Compensated Metabolic Alkalosis = Increased PCO2
PH 7.37 PCO2 46 HCO3 29 PO2 77
Sample NCLEX Question
A nurse reviews the arterial blood gas result of a client and notes the following:PH 7.45, PCO2 30 mmHg, HCO3 21 mEq/L.PO2 = 78The nurse analyzes these results as indicating:
a. Metabolic acidosis, compensatedb. Metabolic alkalosis, uncompensatedc. Respiratory alkalosis, compensatedd. Respiratory acidosis, uncompensated
Causes of Respiratory Acidosis
• Any condition that causes an obstruction of airway or depresses respiratory status
• Hypoventilation
• Sedatives, narcotics, anesthetics
• COPD
• Atelectasis and/or pneumonia
• Pulmonary edema
Assessment of Respiratory Acidosis
• RR increases in rate and depth (attempt to compensate – blow off CO2)
• Hypoxia S/S: ha, restlessness, mental status changes, cyanosis
• Hyperkalemia (excess H moving into cells / K moves out into blood)
• Dysrhythmia leading to V-Fib• Muscle weakness
Interventions for Respiratory Acidosis
• O2 administration and med/neb treatments• HOB elevated• Increase flds to thin secretions/ IV flds to dilute K• Low carb, Hi fat diet to reduce CO2 production • Deep breathing / pursed lips• Possible ventilator support• Drug therapies:
- bronchodilators and corticosteroids- mucolytics
Causes of Respiratory Alkalosis
• Any overstimulation to respiratory system• Hyperventilation• Severe anxiety• Overventilation on mechanical vents• Increased metabolism – fever• Pain• Hypoxia in some cases ( ie: high altitudes
and initial stages of pulmonary emboli)
Assessment of Respiratory Alkalosis
• Initial hyperventilation and tachypnea(in effort to compensate)
• Hypoxia S/S: ha, lightheadness, mental status changes
• Muscle cramping can lead to tetany and convulsions
• Numbness/ Tingling of extremities
• Hypokalemia and hypocalcemia
Interventions for Respiratory Alkalosis
• Encourage appropriate breathing patterns
• Re-breathing techniques
• Anxiety control
• O2 therapy with caution
Nursing Diagnoses
• Impaired gas exchange• Ineffective airway clearance• Ineffective breathing pattern• Risk for infection• Activity intolerance• Risk for injury• Self-care deficit+++++++++++++++++++++++++++++++++
NOC Outcomes
Client will:• Demonstrate improved ventilation and
adequate oxygenation AEB ABG WNL, clear lung fields, and SaO2 WNL
• Demonstrate effective coughing and clear breath sounds; free of cyanosis & dyspnea
• Maintain a patent airway at all times
+++++++++++++++++++++++++++++++++
Medications• Bronchodilators
AlupentBrethineIsuprelProventilAtroventTheophylline
• Anti-tuberculars IsoniazidRifampin
• Antibiotics
• MucolyticsMucomyst
• Anti-inflammatory– Corticosteroids:
Dexamethasone– Anti-Leuketrines– Mast Cell Stabilizers