Nursing Management of Clients with Stressors of Respiratory Function

Anatomy of Respiratory Tract

Review your NUR123 objectives onanatomy of upper and lower airways

Assessment of Respiratory System

Review your NUR123 objectives onSubjective 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 AssessmentRespiratory Hx includes:AllergiesMedicationsMedical Hx

SmokingLifestyle StressorsHazard exposures

Assessing Respiratory FunctionInspection Shape (AP diam), skeletal abnormalities, chest movement and expansion, rate,rhythm, effortPercussion Diaphragmatic excursion, tactile fremitusAuscultation Vesicular +, adventitious sounds

Assessing Respiratory FunctioningRespiratory Rate:EupneaTachycardiaBradycardiaApneaRespiratory Depth:DeepShallow

Assessing Respiratory FunctioningRespiratory Rhythm:RegularCheyne-Stokes Kussmauls Apneustic breathingBiots

Assessing Respiratory Functioning

Respiratory Quality:No difficultyDyspnea and DOEOrthopneaRetractionsCough:NonproductiveProductiveSputumHemoptysis

Assessing Respiratory FunctioningAuscultation:VesicularBronchialBronchvesicularAdventitious: Rales/cracklesRhonchiWheezeStridorStertor

Diagnostic StudiesHemoglobin and RBC countSputum specimens: C&S, gram stain, acid-fast, cytologyRadiographics: CXR, CT with contrast, Ventilation/Perfusion scan, Bronchoscopy, Pulmonary angiographyThoracentesisPulmonary Function Tests: VC,RV,TLCPeak Flow MeterMantoux PPD (purified protein derivative)Arterial Blood Gases (ABGs)

Lung Volumes and CapacitiesTidal Volume (TV) volume of air entering or leaving the lungs during a single breath. Average at rest = 500 mlVital Capacity (VC)- maximum volume or air that can be moved out during a single breath Average = 4500 mlResidual Volume (RV) minimum volume of air remaining in the lungs even after a maximal expiration. Average = 1200 mlTotal Lung Capacity (TLC) maximum volume of air the lungs can hold Average = 5700 ml

What are ABGs ?Arterial Blood Gases

Measurement of bodys acid/base balance

Indicator of bodys oxygenation status

Most often drawn from radial artery; usually by RT

Normal ABG ValuesPH 7.35 7.45 Acid --------------- AlkalinePCO235-45 mm HgPartial Pressure of carbon dioxideHCO322-26 mEq/LBicarbonatePO280-100 mm HgPartial Pressure of oxygenMEMORIZE THESE VALUES !!!

Memory Tools Normal CO2 is 35 45Normal PH is 7.357.45Tip: Notice that both theCO2 and PH have a 35 and 45 in themNormal HCO3 (Bicarbonate) is 22-26Tip:Many a new driver buystheir own first car between 22-26 y.oThink of Bicarbonate asbuycarbonate

What is the difference between PO2 and SaO2?PO2 ( from the ABG) reflects the amount of dissolved O2 in the bloodSaO2 ( from pulse oximetry ) reflects the percentage of hemoglobin that is saturated with O2Normal SaO2 = 95-98%The O2 bound to hemoglobin does not contribute to the PO2 of the blood

Carbon Dioxide transportationOnly 10% of CO2 is physically dissolved in blood30% CO2 is bound to hemoglobinMajority of CO2 ( 60%) is transported asBicarbonate 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 ER Respiratory O Opposite pH up PCO2 down = Alkalosis pH down PCO2 up = AcidosisM MetabolicE Equal pH up HCO3 up = Alkalosis pH down HCO3 down = Acidosis

Steps for ABG Analysis

Evaluate the PH < 7.35 is Acidosis > 7.45 is Alkalosis

PH = 7.29

Steps for ABG Analysis2. Evaluate VENTILATION

PCO2 > 45 indicates Respiratory Acidosis PCO2 < 35 indicates Respiratory AlkalosisPCO2 = 47

Steps for ABG Analysis3. Evaluate METABOLIC PROCESSES

HCO3 < 22 reflects Metabolic Acidosis HCO3 > 26 reflects Metabolic AlkalosisHCO3 = 24

Steps for ABG AnalysisEvaluate OXYGENATION PO2 80-100 = normal PO2 60-80 = mild hypoxiaPO2 40-60 = moderate hypoxiaPO2 < 40 = severe hypoxiaPO2 = 58

Steps for ABG AnalysisEvaluate 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 PCO2PH 7.37 PCO2 46 HCO3 29 PO2 77

Sample NCLEX QuestionA 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:Metabolic acidosis, compensatedMetabolic alkalosis, uncompensatedRespiratory alkalosis, compensatedRespiratory acidosis, uncompensated

Causes of Respiratory AcidosisAny condition that causes an obstruction of airway or depresses respiratory statusHypoventilationSedatives, narcotics, anestheticsCOPDAtelectasis and/or pneumoniaPulmonary edema

Assessment of Respiratory AcidosisRR increases in rate and depth (attempt to compensate blow off CO2)Hypoxia S/S: ha, restlessness, mental status changes, cyanosisHyperkalemia (excess H moving into cells / K moves out into blood)Dysrhythmia leading to V-FibMuscle weakness

Interventions for Respiratory AcidosisO2 administration and med/neb treatmentsHOB elevatedIncrease flds to thin secretions/ IV flds to dilute KLow carb, Hi fat diet to reduce CO2 production Deep breathing / pursed lipsPossible ventilator supportDrug therapies: - bronchodilators and corticosteroids - mucolytics

Causes of Respiratory AlkalosisAny overstimulation to respiratory systemHyperventilationSevere anxietyOverventilation on mechanical ventsIncreased metabolism feverPainHypoxia in some cases ( ie: high altitudes and initial stages of pulmonary emboli)

Assessment of Respiratory AlkalosisInitial hyperventilation and tachypnea (in effort to compensate)Hypoxia S/S: ha, lightheadness, mental status changesMuscle cramping can lead to tetany and convulsionsNumbness/ Tingling of extremities Hypokalemia and hypocalcemia

Interventions for Respiratory Alkalosis

Encourage appropriate breathing patternsRe-breathing techniquesAnxiety controlO2 therapy with caution

Nursing DiagnosesImpaired gas exchangeIneffective airway clearanceIneffective breathing patternRisk for infectionActivity intoleranceRisk for injurySelf-care deficit+++++++++++++++++++++++++++++++++

NOC OutcomesClient will:Demonstrate improved ventilation and adequate oxygenation AEB ABG WNL, clear lung fields, and SaO2 WNLDemonstrate effective coughing and clear breath sounds; free of cyanosis & dyspneaMaintain a patent airway at all times

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MedicationsBronchodilators Alupent Brethine Isuprel Proventil Atrovent TheophyllineAnti-tuberculars Isoniazid RifampinAntibiotics

Mucolytics Mucomyst

Anti-inflammatoryCorticosteroids:DexamethasoneAnti-LeuketrinesMast Cell Stabilizers

***If necessary go to NR23 power point on thorax and lungs**

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