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NUR 201

NUR 201. I believe… we are responsible for preparing and learning. we learn best by interacting & discussing collegially. we must respect everyone. we are continually learning – building on previously learned concepts. in an open environment in which questions & observations are welcome.

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NUR 201

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  1. NUR 201 I believe… • we are responsible for preparing and learning. • we learn best by interacting & discussing collegially. • we must respect everyone. • we are continually learning – building on previously learned concepts. • in an open environment in which questions & observations are welcome. • I do not have all of the answers • I will always find the answer, rationale, reason • everyone has potential to become more than they are today

  2. Interferences with VentilationObjectives • Discuss assessment—breath sounds • Describe diagnostic tests for pulmonary function • Discuss acid-base balance • Examine signs, symptoms, pathophysiology, treatments, and nursing care of respiratory distress syndromes • Discuss nursing interventions – mechanical ventilation, tracheostomy, postural drainage • Discuss pulmonary accidents—chest trauma, aspiration

  3. Content Approach • Anatomy & Physiology Review • Demographics/occurrence • Pathophysiology • Clinical Picture • Medical Management • Nursing Process (APIE) Assessment - Nursing Actions - Education

  4. Interferences with VentilationRespiratory Anatomy & Physiology • Anatomy • Structure of the Chest Wall: Ribs, pleura, muscles of respiration • Upper Respiratory: nose, pharynx, adenoids, tonsils, epiglottis, larynx, and trachea • Lower Respiratory: bronchi, bronchioles, alveolar ducts, and alveoli • Physiology • Ventilation: inspiration and expiration • Elastic Recoil: elastin fibers that recoil after expansion • Diffusion: Exchange of oxygen and carbon dioxide • Arterial Blood Gases / Oximetry

  5. Lungs A & P Review

  6. Respiratory AssessmentA&P Review

  7. Thorax Anatomical Landmarks

  8. Interferences with VentilationAlveolar Gas Exchange

  9. Interferences with VentilationAssessment • History • Cues to Respiratory Problems: • Shortness of breath – dyspnea • Orthopnea / Nocturnal dyspnea • Wheezing • Cough / sputum production • Hemoptysis • Voice change • Fatigue

  10. Interferences with VentilationAssessment Thorax & Lungs • Inspection: • Posture, chest movement, abnormalities of sternum • Respiratory rate, depth, rhythm • Palpation: • Equality of chest expansion • Tactile Fremitus • Percussion: • Hyperresonance • Dullness • Auscultation: • Discontinuous: fine crackles/rales / coarse crackles / rales • Continuous: Wheeze, Rhonchi • Pleural friction rub

  11. Respiratory AssessmentPercussion

  12. LarynxAnatomical Landmarks

  13. Respiratory Assessment

  14. Respiratory AssessmentAscultation Landmarks

  15. Respiratory AssessmentBreath Sounds

  16. Respiratory AssessmentNormal Breath Sounds

  17. Respiratory AssessmentAdventitious Breath Sounds

  18. Respiratory AssessmentAssessment Definition Clinical Picture

  19. Interferences with VentilationDiagnostic Studies • Blood Studies: Hgb, Hct, ABGs • Sputum Studies: C&S, Gram Stain, Acid-fast smear; Cytology • Radiology: • Chest x-ray-- posterior-anterior / lateral • Computed tomography (CT) – cross sections of the lung with and without contrast – used often • Magnetic resonance imaging (MRI) – images of pulmonary structures – limited use • Pulmonary angiogram – x-rays after injection of radiopaque dye– used to dx pulmonary embolism • Positron emission tomography (PET) – IV glucose administration – malignant tumors show increased uptake of glucose • Ventilation-Perfusion Scan – Perfusion: isotope administration which outlines pulmonary vasculature; Vent: inhalation of radioactive gas which outlines the alveoli – dx pulmonary emboli

  20. Interferences with VentilationDiagnostic Studies • Endoscopic Exams (done in x-ray or OR): • Bronchoscopy – fiberoptic visualization of bronchi – biopsy; also used to remove mucous plugs, foreign bodies, obstructions • Mediastinoscopy – scope through a small incision n the suprasternal notch – visualize mediastinum for tumors, lymph nodes, infections, sarcoidosis • Biopsy: Transbronchial or open lung biopsy – done in x-ray or OR • Thoracentesis – insertion of a needle into the pleural space – pleural fluid, install medication - done at bedside • Pulmonary Function Testing – tests to measure lung volumes and used to dx pulmonary disease, monitor progress, evaluate disability, evaluate response to bronchodilators – done in pulmonary lab • Skin Testing – intradermal planning of test dose to assess skin reaction by measuring mm induration – TB, various lung diseases

  21. Pulmonary Function Test Relationship of Lung Volumes & Capacities

  22. Respiratory Diagnostic Testing Fiberoptic Bronchoscopy

  23. Diagnostic Lung Tests Thoracentesis

  24. Pair Share – Critical Thinking • Upon performing a lung sound assessment of the anterior chest, the nurse hears moderately loud sounds on inspiration that are equal in length with expiration. Where in the airway would this lung sound be considered normal? a. Trachea b. Primary bronchi c. Lung fields d. Larynx

  25. Pair Share – Critical Thinking • The name that describes the particular lung sound in the previous questions is which of the following? • a. Bronchial • b. Bronchovesicular • c. Vesicular • d. Basilar

  26. Interferences with VentilationRegulation of Acid-Base BalanceReview • Acid – contributes hydrogen ion • Two types: • Volatile respiratory acid • Dehydrates and excreted in the form of a gas • Nonvolatile metabolic acid • Metabolized and excreted in the form of body fluids

  27. Interferences with VentilationRegulation of Acid-Base Balance Review • Base – accepts or removes hydrogen ion • Buffer- controls the hydrogen ion concentration: • Absorbing hydrogen ions when an acid is added OR • Releasing hydrogen ions when base is added. • Three Buffer Systems: • Bicarbonate – operates in lungs & kidneys • Phosphate – renal tubules • Protein – Hgb, plasma proteins, & intracellular protein

  28. Interferences with VentilationRegulation of Acid-Base Balance • Factors to remember: • Lungs – Eliminate or retain carbon dioxide C02 • Kidneys – excrete or form bicarbonate HC03 Food – converted by the body – H20 + CO2 + energy Lung Kidney C02 + H20 = H2CO3 = HCO3- + H+

  29. Interferences with VentilationNormal Acid-Base Balance

  30. Interferences with VentilationRegulation of Acid-Base Balance • Lungs/Respiratory System • Increase or decrease hydrogen ion concentration • Through respiratory rate and depth • Result: C02 is either retained or eliminated • Changes can occur within minutes • Controlled in the medulla oblongata—respiratory center > = increased; < = decreased • <pH causes > respirations = <C02 + correcting pH • >pH causes < respirations = >C02 + correcting pH

  31. Interferences with VentilationRegulation of Acid-Base Balance • Renal System • Reabsorb and conserve bicarbonate • Can generate additional bicarbonate and eliminate excess hydrogen ions as compensation for acidosis • Three mechanisms: • Secretion of small amounts of free hydrogen into the renal tubule • Combination of hydrogen ions with ammonium to form ammonium • Excretion of weak acids • Urine pH 4 – 8

  32. Interferences with VentilationRegulation of Acid-Base Balance> = increased; < = decreased

  33. Respiratory RespiratoryAlkalosisAcidosis

  34. Acid-Base ImbalanceRespiratory Acidosis • Hypoventilation from primary lung problem • Atelectasis • Pneumonia • Respiratory failure • Airway obstruction • Chest wall injury • Cystic fibrosis • Hypoventilation from other factors • Drug overdose • Head injury • Paralysis of respiratory muscles • Obesity

  35. Acid-Base ImbalanceRespiratory Alkalosis • Hyperventilation from primary lung problem • Asthma • Pneumonia • Inappropriate ventilator settings • Hyperventilation from other factors • Anxiety • Disorders of the central nervous system • Salicylate overdose

  36. Interferences with VentilationRegulation of Acid-Base BalanceRespiratory Function

  37. Pair Share – Critical Thinking • What acid-base imbalance would you suspect for the patient having respiratory problems with respiratory rate: 28/min and expiratory wheezing?

  38. Pair Share – Critical Thinking • What acid-base imbalance would you suspect for the post-operative patient with respiratory rate 10/min, difficulty to arouse, but arouses with verbal stimuli

  39. Interferences with VentilationRegulation of Acid-Base Balance> = increased; < = decreased

  40. Metabolic MetabolicAlkalosisAcidosis

  41. Acid-Base ImbalanceMetabolic Acidosis • Starvation • Diabetic ketoacidosis • Renal failure • Lactic acidosis from heavy exercise • Use of drugs (ASA, methanol, ethanol) • Acute renal tubular necrosis • Diarrhea

  42. Acid-Base ImbalanceMetabolic Alkalosis • Excessive vomiting • Prolonged nasogastric suctioning • Hypokalemia or hypocalcemia • Excess aldosterone • Use of drugs (steroids, sodium bicarbonate, diuretics)

  43. Interferences with VentilationRegulation of Acid-Base BalanceMetabolic Function

  44. Interferences with VentilationRegulation of Acid-Base Balance • Normal Values:

  45. Interferences with VentilationRegulation of Acid-Base BalanceArterial Blood Gas Intrepretation> = increased; < = decreased • Step 1: Evaluate the pH • pH <7.35 = acidosis • pH >7.45 = alkalosis • Step 2: Evaluate Respiratory Function • Paco2 >45 mm HG = ventilatory failure & respiratory acidosis • Paco2 <35 mm HG = hyperventilation & respiratory alkalosis

  46. Interferences with VentilationRegulation of Acid-Base Balance Arterial Blood Gas Intrepretation> = increased; < = decreased • Step 3: Evaluate Metabolic Processes • Serum bicarbonate HCO3 <22 mEq/L = metabolic acidosis • Serum bicarbonate HCO3 >26 mEq/L = metabolic alkalosis • Step 4: Determine the Primary Disorder • When Paco2 & HCO3 are both abnormal: • Determine which follows the deviation from the pH and • Deviates the most from normal

  47. Interferences with VentilationRegulation of Acid-Base Balance Arterial Blood Gas Interpretation • Respiratory Acidosis:

  48. Interferences with VentilationRegulation of Acid-Base Balance Arterial Blood Gas Interpretation • Respiratory Alkalosis:

  49. Respiratory AssessmentRelationship between PaO2 & SpO2

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