nursing management of clients with stressors of respiratory function assessment & diagnosis...
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![Page 1: Nursing Management of Clients with Stressors of Respiratory Function Assessment & Diagnosis NUR133 Lecture #4 K. Burger, MSEd, MSN, RN, CNE](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d775503460f94a592e7/html5/thumbnails/1.jpg)
Nursing Management of Clients with Stressors of Respiratory
FunctionAssessment & Diagnosis
NUR133 Lecture #4
K. Burger, MSEd, MSN, RN, CNE
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Anatomy of Respiratory Tract
Review your NUR123 objectives on
anatomy of upper and lower airways
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Assessment of Respiratory System
Review your NUR123 objectives on
Subjective and objective assessment
techniques
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Anatomy KnowledgeFactors Affecting Respiration
• Integrity of the airway system (ventilation)• Functioning cardiovascular system
(perfusion)• Functioning alveoli (diffusion)• Functioning neurocontrols
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Assessment KnowledgeRespiratory Assessment
• Respiratory Hx includes:
• Allergies
• Medications
• Medical Hx
• Smoking
• Lifestyle
• Stressors
• Hazard exposures
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Assessing Respiratory Function
• InspectionShape (AP diam), skeletal abnormalities,chest movement and expansion, rate,rhythm, effort
• PercussionDiaphragmatic excursion, tactile fremitus
• AuscultationVesicular +, adventitious sounds
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Assessing Respiratory Functioning
• Respiratory Rate:• Eupnea• Tachycardia• Bradycardia• Apnea• Respiratory Depth:• Deep• Shallow
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Assessing Respiratory Functioning
• Respiratory Rhythm:
• Regular
• Cheyne-Stokes
• Kussmauls
• Apneustic breathing
• Biots
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Assessing Respiratory Functioning
• Respiratory Quality:• No difficulty• Dyspnea and DOE• Orthopnea• Retractions
• Cough:• Nonproductive• Productive• Sputum• Hemoptysis
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Assessing Respiratory Functioning
• Auscultation:• Vesicular• Bronchial• Bronchvesicular
• Adventitious:
• Rales/crackles
• Rhonchi
• Wheeze
• Stridor
• Stertor
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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)
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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
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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
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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 !!!
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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”
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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
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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)
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CO2 and H Relationships
Carbon Dioxide Results in Free Hydrogen
CO2 + H2O = H2CO3 = H + HCO3
More Hydrogen = Lower PH
ACIDOSIS
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CO2 and H Relationships
Carbon Dioxide Results in Free Hydrogen
CO2 + H2O = H2CO3 = H + HCO3
Less Hydrogen = Higher PH
ALKALOSIS
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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
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Steps for ABG Analysis
1. Evaluate the PH
< 7.35 is Acidosis> 7.45 is Alkalosis
PH = 7.29
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Steps for ABG Analysis
2. Evaluate VENTILATION
PCO2 > 45 indicates Respiratory AcidosisPCO2 < 35 indicates Respiratory Alkalosis
PCO2 = 47
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Steps for ABG Analysis
3. Evaluate METABOLIC PROCESSES
HCO3 < 22 reflects Metabolic AcidosisHCO3 > 26 reflects Metabolic Alkalosis
HCO3 = 24
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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
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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
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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
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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
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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
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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
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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)
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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
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Interventions for Respiratory Alkalosis
• Encourage appropriate breathing patterns
• Re-breathing techniques
• Anxiety control
• O2 therapy with caution
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Nursing Diagnoses
• Impaired gas exchange• Ineffective airway clearance• Ineffective breathing pattern• Risk for infection• Activity intolerance• Risk for injury• Self-care deficit+++++++++++++++++++++++++++++++++
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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
+++++++++++++++++++++++++++++++++
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Medications• Bronchodilators
AlupentBrethineIsuprelProventilAtroventTheophylline
• Anti-tuberculars IsoniazidRifampin
• Antibiotics
• MucolyticsMucomyst
• Anti-inflammatory– Corticosteroids:
Dexamethasone– Anti-Leuketrines– Mast Cell Stabilizers