Unit 3 study guide Unit 3 Respiratory Study guide Differentiate arterial blood gases, respiratory vs metabolic alkalosis/acidosis

Maintenance of acid-base balance 1. Chemical and protein buffers: first line of defense, either bind or release hydrogen ions as needed, respond quickly 2. Respiratory buffers: second line of defense, control levels of hydrogen levels through control of CO2 levels (hyperventilation decreases hydrogen ions, hypoventilation increases hydrogen ions) 3. Renal buffers: much slower to respond, but most effective with longest duration, kidneys control movement of bicarbonate in the urine (high hydrogen ions: bicarbonate reabsorption and production, low hydrogen ions: bicarbonate excretion) a. remember: bicarbonate is a buffer for hydrogen ions, as more hydrogen ions increase in blood, more bicarbonate is needed to balance. b. Hydrogen: H+ c. Bicarbonate: HCO3

pH 7.35 - 7.45 Less than 7.35 Less than 7.35 Greater than 7.45 Greater than 7.45

PaCO2 35 - 45 Greater than 45 35 - 45 Less than 35 35 - 45

HCO3 22 - 26 22 - 26 Less than 22 22 - 36 Greater than 26

Diagnosis Homeostasis Respiratory Acidosis Metabolic Acidosis Respiratory Alkalosis Metabolic Alkalosis

Respiratory acidosis: increased CO2, Increased H+ concentration 1. Results from respiratory depression, inadequate chest expansion, airway obstruction, alveolar capillary blockade, inadequate mechanical ventilation 2. Vital signs: tachycardia, dyshythmias, anxiety irritability, pale/cyanotic, ineffective shallow breathing 3. Nursing care: oxygen therapy, maintain patent airway, enhance gas exchange through positioning and breathing techniques/ ventilatory support Respiratory alkalosis: decreased CO2, decreased H+ concentration 1. Results from hyperventilation, hypoxemia from asphyxiation, high altitudes, shock, asthma 2. Vital signs: tachypnea, anxiety, tetany, convulsions, light headedness 3. Nursing care: oxygen therapy, anxiety reduction, rebreathing techniques Metabolic acidosis: decreased HCO3, increased H+ 1. Results from: excess production of hydrogen ions (DKA, lactic acidosis, starvation, heavy exercise, fever), inadequate elimination of H+, inadequate production of HCO3 (renal failure, liver failure, dehydration), excess elimination of bicarbonate(diarrhea) 2. Vital signs: confusion, drowsiness, bradycardia, weak peripheral pulses, hypotension, tachypnea, rapid deep respirations 3. Nursing care: varies with cause of acidosis (renal vs GI ect), administration of bicarb IV. Metabolic alkalosis: increased HCO3, decreased H+ 1. Results from: oral ingestion of bases (antacids), venous administration of bases, acid deficit (loss of

gastric excretions from vomiting), potassium depletion 2. Vitals signs: tachycardia, normotensive or hypotensive, numbness, tingling, tetany, muscle weakness, hyperreflexia, confusion 3. Nursing care: varies with cause (GI vs potassium depletion), restore fluid volume with NaCl.

Four Methods of physical assessment of respiratory system

1. Inspection: Mental state, color, lips, neck, chest, fingers, legs 2. Palpation: Systematic expansion, tenderness, tactile fremitus (vibrations felt) 3. Auscultation: a. crackles: soft, high pitched, discontinuous popping sounds that occur during inspiration. Secondary to fluid in airways or alveoli b. wheezes: continuous, musical, high pitched, whistle-like sounds. Associated with bronchospasm, asthma c. friction rubs: harsh, crackling sounds, secondary to inflammation and loss of lubricating pleural fluid d. stridor: high pitched sound resulting from an obstruction in the upper airway 4. Percussion: detects fluid or air in spaces. a. resonance: loud intensity, low pitch, long duration (normal lung) b. hyperresonance: very loud intensity, low pitch, longer duration (emphysema lung) c. tympany: loud intensity, high pitch, musical timbre (puffed out cheek) d. dullness: medium intensity, high pitch, short duration (liver) e. flatness: soft intensity, high pitch, short duration (thigh) bascially resonance, hyperresonance have loud intensity with a low pitch, while dullness and flatness have softer intensity with higher pitch.

Diagnostic Tests:
1. Bronchoscopy: visualization of larynx, trachea, and bronchi through a fiberoptic, a. used for visualization of tumors, inflammation, and other abnormalities, biopsies, or aspiration b. nursing action: remove dentures, maintain NPO, lidocain or throat sprays used before procedure, sedatives during procedure, monitor respirations, BP, pulse oximetry, heart rate, swallow reflex. c. older patients at risk for respiratory infection due to reduction in cough and deep breathing 2. Chest X-ray: visualization of lungs for fluid accumulation or inflammation, common test order when pneumonia is suspected. 3. pulmonary function test: used to assess respiratory function and ventilatory volume, patient breaths into a spirometer, typically a combination of normal inspiration and expiration and forced inspiration and expiration 4. Thoracentesis: surgical perforation of the chest wall and pleural space with a large bore needle a. performed under local anesthesia, with the use of ultrasound for guidance b. potential diagnosis include: heart failure, cirrhosis, nephritic syndrome, exudates, emphysema, pneumonia c. amount of fluid is limited to 1 L, encourage deep breathing after procedure, obtain post procedure chest x ray for effusions and penumothroax. 5. Incentive Spirometry: device used to encourage patient to deep breath by inspiration 6. PPD/Mantoux test: intra-dermal tuberculosis test.

Classify Drugs according to their actions and purposes

Benadryl: antitussive (non-opioid), antihistamine 1. Suppresses cough through suppression of histamines 2. used for cough suppression, antihistamine response Albuterol/ Proventil/Ventolin/ Alupent/Bronkosol :Beta-Adrenergic Agonists 1. activates beta receptors in bronchial smooth muscle, resulting in bronchodilation 2. Bronchospasm is relieved, histamine release is inhibited, ciliary motility is increased 3. Used for prevention of asthma attack, treatment for ongoing asthma attack, or long term asthma control Theophylline/Aminophylline: Methylxanthines 1.causes relaxation of bronchial smooth muscle, resulting in bronchodilation 2. long term control of chronic asthma Robitussin/Dexamethoraphan: antitussive (non opioids) 1. suppresses cough through action on CNS 2. used for cough suppression INH (Isoniazid): anti-tuberculosis inhibits mycolic acid/bacterial cell wall production Diflucan/Amphotericin B: antifungal used for fungal infections in mouth, throat, esophagus, stomach, lungs and blood. Atropine: anticholinergic action on parasympathetic nervous system inhibits salivary and mucous glands Codeine: Opioids 1. suppresses cough reflex through action of central nervous system 2. used for chronic nonproductive cough Mucinex: Expectorant 1. promotes increased cough production through increasing mucous secretion 2. most often used in combination with antitussives, and decongestants Advair: combination of fluticasone (corticosteroid) and salmeterol (long acting beta adrenergic agonist) Used for treatment of asthma, COPD Steroids: 1. prevent inflammation, suppress airway mucus production, promote responsiveness of beta receptors in bronchial tree. 2. used for status asthmaticus, long term prophylaxis of asthma, long term control of asthma

Common types of COPD, how they are alike, how they differ, treatment for each

Classified as two disorders: emphysema, and chronic bronchitis 1. Emphysema: loss of lung elasticity and hyperinflation of lung tissue, which causes destruction of alveoli, leads to decreased surface area for gas exchange, CO2 retention, and respiratory acidosis 2.Chronic bronchitis: inflammation of the bronchi due to chronic exposure to irritants Physical assessment: 1. dyspnea upon exertion 2. productive cough (sever in morning) 3. respiratory acidosis, compensatory metabolic alkalosis 4. crackles, wheezes, rapid shallow respirations, use of accessory muscles 5. barrel chest (with emphysema) 6. hyperresonance on percussion (from trapped air) 7. thin extremtities, enlarged neck muscles, dependent edema secondary to right side HF 8. pallor, cyanosis, decreased O2 saturation Tests: 1. increased hematocrit due to low chronic O2 levels 2. WBC counts to assess respiratory infections 3. pulmonary function test: comparisons of forced expiratory volume to forced vital capacity, as COPD advances forced expiratory volume to forced vital capacity ratio decreases 4. chest x ray: reveals hyperinflation of alveoli, flattened diaphragm in late stages of emphysema 5. blood gases: a. hypoxemia (PaO2 below 80 mm Hg) b. hypercarbia (paCO2 above 45 mm Hg) c. respiratory acidosis with compensatory metabolic alkalosis Nursing care: 1. high fowlers to maximize ventilation 2. encourage effective coughing, deep breathing, administer breathing treatments, administer O2 3. Promote adequate nutrition (increases breathing workload increases calorie demand) 4. Incentive spirometry 5. patients who have chronically increased PaCO2 usually require 1 to 2L of O2 (important caution: primary drive to breath in these patients is low arterial oxygen levels, healthy patients drive to breath is high CO2, so giving too much O2 to a COPD patient can shut down their drive to breath ) 6. Medications such as bronchodilators, anti inflammatory agents

Describe differences between high and low flow oxygen systems

signs of O2 toxicity: substernal discomfort, dyspnea, restlessness, fatigue, malaise, lung infiltrates High flow oxygen system: the total flow delivered to the patient is the only gas the patient breaths, so they must be very precise. a. examples include Venturi-mask (most reliable, used for COPD), Aerosol masks, trach collars, face tents, trans-tracheal catheters. Low flow oxygen system - delivers oxygen concentration from 21 - 100 percent with less reliability compared to high flow, the amount of O2 breathed in changes depending on breathing pattern examples: a. nasal cannula: one to six liters mixed with room air, not a good option for mouth-breathers b. simple mask; 24 to 66% O2 delivered, mask stores oxygen between patient breaths c. partial rebreather mask: has a reservoir bag that is inflated during inspiration and expiration

d. non-rebreather mask: has a reservoir bag but with 2 one way valves, can deliver up to 100%

Nursing considerations for clients with respiratory disorders, common nursing diagnoses and priority interventions
1. Elevate head of bed, or in chair, may lean over the bed table 2. Fresh air in room, but no drafts 3. Humidity beneficial, use vaporizer or humidifier 4. Rest is important, pulmonary pathology increases workload of heart 5. use sedative expectorants that liquefy secretions, increase oral intake of fluids to 2L per twenty four hours 6. Oral hygiene 7. Postural drainage should be before meals 8. no smoking 9. Suction prn if clients cough is not effective 10. If possible, avoid the use of narcotics (decreases respirations)

Describe each of the following respiratory disorders and the management for each:
1. Asthma: chronic inflammatory process involving constricted small air passages, disorder of bronchial airways characterized by episodes of bronchospasm. Status asthmaticus: sever and life threatening, sever bronchospasm that intensifies with workload of breathing increases 5 to 10 times, hypoxemia can lead to acidosis and cardiac arrest a. signs and symptoms: dyspnea, nasal flaring, pursed lip breathing, expiratory wheeze b. diagnosed through pulmonary function test, clinical manifestations c. treatment: anti-inflammatory drugs, bronchodilators, low dose O2, hydration, conserve energy 2. Bronchitis: inflammation of bronchial tree Acute: a. signs and symptom: sternal soreness, fever, general malaise b. treatment: mostly treat symptoms, cool steam inhalation, increased fluid intake, bedrest, antibiotics (after sputum culture is obtained) Chronic: (discussed above) a. signs and symptoms: productive cough lasting minimum of three months, history of frequent respiratory infections, common with history of smoking or pollution exposure b. diagnosed through ABGs, Chest xray, pulmonary function studies c. treatment: bronchodilators, postrual drainage and percussion, increase fluids, corticoid steroids 3. Emphysema: (discussed above) Alveolar walls are destroyed, leads to permanent distention of airspace a. signs and symptoms: progressive dyspnea on exertion, tachypnea with prolonged expiration, barrel chest, use of accessory muscles b. treatment: bonchodilators, steriods, O2 (1 to 3 L per nasal canula to raise P02 to 60 - 80, use O2 with caution, pursed lip breathing, keep mucous membranes moist 4. Tuberculosis: caused by mycobacterium tuberculosis, a. risk factors; airborne infection acquired by droplet inhalation, HIV, Age, malnutrition b. Patho: Primary infection: produces cavities, dead WBCs, necrotic lung tissue, which liqufies into bronchial tree where it is coughed up, forms scars, lesions may contain bacteria that can be reactivated years later (secondary infection) c. Diagnosis: positive TB test, hx of exposure, cough, fatigue, anorexia, low grade fever, chest pain, crackles, sputum is only definitive diagnostic tool, chest x ray d. treatment: Isonizid, Rifampin, Streptomycin, Pyrazinamide, rest.

5. Lung Abscesses: collection of pus within lung tissue, often resembles pneumonia in early stages, necrosis can develop if left untreated a. cause: aspiration of nasopharyngeal or oropharyngeal substance, infections b. signs and symptoms: impaired cough reflexes, fever, chills, pleurtic pain, cough, copious suptum, decreased breath sounds, dullness to percussion, friction rub over affected area c. diagnosis: chest xray, CT scan, sputum identifies organism d. treatment: antibiotics, bronchoscopy, postural drainage, frequent mouth care, high calorie diet 6. Pleurisy: pain that is sharp and sudden felt with deep inspiration and coughing, usually felt on lower lobes or on one side of stomach. Pleural effusion: accumulation of fluid in pleural spaces a. causes: Liver/ renal failure, infections, TB, lupus, trauma, lymphatic obstruction, CHF b. signs and symptoms: depends on amount of fluid present, degree of lung compression, dry nonproductive cough, percussion dull, pleurisy

Disorder Pneumonia Bronchitis Emphysema Asthma Pulmonary edema pleural effusion Pneumothorax Atelectasis

Tactile Fremitus increased normal decreased normal/decreased normal absent decreased absent

Percussion dull resonant hyperresonant resonant/ hyperresonant resonant dull to flat hyperresonant flat

Auscultation crackles decreased breath sounds, wheezes decreased breath sounds, prolonged expiration wheezes crackles at lung bases decreased breath sounds absent breath sounds decreased/absent breath sounds

(Probably focus on the disorder and auscultation in the above chart.)

Know types of pneumonia and the risk factors for developing this disease
Types: Community acquired, Hospital acquired, Immunocompromised, Aspiration Community-acquired pneumonia 1. occurs in community or first 48 hours of hospitalization, 2. under 60 pneumococcus is most common 3. over 60 H. influenzae is most common Hospital Acquired Pneumonia (AKA nosocomial penumonia) 1. occurs more than 48 hours after admission, common bacteria: E. coli, Klebsiella, MRSA 2. One of three conditions: a. host defenses are impaired, b. organisms reaches lower respiratory tract and overwhelms hosts defenses, c. the organism is highly virulent 3. Risk factors for HAP: illnesses, hospital environment, interventions Immunocompromised pneumonia a. corticosteriods, chemo, AIDS, use of broad spectrum antibiotics, long term life support Aspiration Pneumonia: pulmonary consequences resulting from entry of substances

a. most common, from bacteria in upper airway b. can be due to other substances aspirated into lungs: gastric contents, chemicals, gases General Patho: a. patient often has underlying disease b. affects both ventilation and diffusion, exudate is produced, bonchospasms occur c. impaired O2 and CO2, secretions and edema can cause occlusion, hypoventilation occurs Risk factors: COPD, smoking, immunosuppresed people, depressed cough, age, improperly cleaned equipment, NPO status, alcohol intoxication, antibiotic therapy Clinical Manifestations: fever, pain, cough, tachypnea, orthopnea, cyanosis Diagnosis: history, chest xray, blood cultures, sputum cultures Treatment: antibiotics, oxygen, antipyretics, antitussives, antihistamines, hydration, respiratory treatment, rest

Lung sounds and where they are found and treatment

1. Wheezing/Rhonchi: continuous, musical, high pitched, whistle-like sounds. Associated with bronchospasm, asthma a. found: rhonchi over trachea, wheeze over? b. treatment: bronchodilators, corticosteroids 2. Crackles/Rales: soft, high pitched, discontinuous popping sounds that occur during inspiration. Secondary to fluid in airways or alveoli a. found: b. treatment: treatment of underlying disease (such as pneumonia) with antibiotics, expectorants to clear secretions, hydration, oxygen 3. Friction Rub: harsh, crackling sounds, secondary to inflammation and loss of lubricating pleural fluid a. found: over chest wall b. treatment: treatment of underlying disease causing inflammation (such as pneumonia, tuberculosis ect) 4. Stridor: high pitched sound resulting from an obstruction in the upper airway a. found: b. removal of obstruction