Basic Human Needs:Physiological Concepts Oxygenation, Page 35

INFANT (BIRTH-1 YEAR)TABLE 38-1

Respiratory rate-30-55 breaths/min Respiratory pattern-Abdominal breathing, irregular in rate and depth Chest wall-Thin, little muscle, ribs and sternum easily seen Breath sounds-Loud, harsh crackles at end of deep inspiration Shape of thorax-Round

Level of Health-affects oxygenation (Just added because professor spoke a lot about this)

Acute and chronic illnesses can affect a person's cardiopulmonary function dramatically. For example, people with renal or cardiac disorders often have compromised respiratory functioning because of fluid overload and impaired tissue perfusion. People with chronic illnesses often have muscle wasting and poor muscle tone. These problems affect all the muscles, including those of the respiratory system. Alterations in muscle function contribute to inadequate pulmonary ventilation and respiration, as well as inadequate functioning of the heart. Anemia can result in impaired respiratory function. As discussed previously, anemia may lead to an inadequate supply of oxygen to the tissues of the body. Because hemoglobin also carries carbon dioxide to the lungs, anemia results in diminished carbon dioxide exchange. Myocardial infarction causes a lack of blood supply to the heart muscle. Damage to the heart muscle interferes with effective contractions of the heart muscle, leading to decreased perfusion of tissues and decreased gas exchange. Physical changes such as scoliosis (curvature of the spine) influence breathing patterns and may cause air trapping. Research reveals a statistically significant correlation between obesity and chronic bronchitis. Moreover, people who are obese are often short of breath during activity, ultimately leading to less participation in exercise. As a result, the alveoli at the base of the lungs are rarely stimulated to expand fully.

Physiological data-level of consciousness(1409)

Alterations in oxygenation to body tissues can be a result of respiratory or cardiac distress and lead to altered mental status.

Stressors- Internal-Anemia

Anemia, a decrease in the amount of red blood cells or erythrocytes, results in insufficient hemoglobin available to transport oxygen. This may lead to an inadequate supply of oxygen to the tissues of the body.

Diagnosis Data-see below

Arterial Blood Gas and pH Analysis Cardiac Biomarkers CBC Cytologic Study

PROMOTING HEALTH 38-1 OXYGENATION

Assessment Checklist almost always sometimes almost never 1. I breathe easily, without discomfort and without feeling short of breath. 2. I exercise regularly. 3. I maintain normal weight for my height and body frame. 4. I live in an environment free of pollution. 5. I avoid substances (tobacco, chemicals) that cause respiratory problems. 6. I arrange to receive recommended immunizations. Self-Care Behaviors Follow a regular exercise program with at least 150 minutes of moderate-intensity aerobic activity, 75 minutes of vigorous-intensity aerobic activity, or an equivalent mix of the two each week (CDC, 2011). Maintain normal body weight. Obtain medical evaluation for chest pain, problems with breathing, and/or chronic cough with sputum or blood. Evaluate personal use of tobacco. Incorporate a plan to reduce smoking, then stop smoking on a specific target date. Avoid exposure to secondhand smoke when possible. Arrange to have a tuberculin test (PPD) done annually. Receive a yearly influenza vaccine and a pneumococcal vaccine. Avoid chemical substances that cause respiratory depression. Maintain a pollution-free environment (as much as possible). Support federal and community efforts to keep the air free of pollution.

Physiological data-lung sounds(1411)

Auscultation of the lungs assesses air flow through the respiratory passages and lungs. Listen for normal and abnormal lung sounds. Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Auscultate as the patient breathes slowly through an open mouth. Breathing through the nose can produce falsely abnormal breath sounds. In addition to air flow, listen for adventitious sounds (extra, abnormal sounds of breathing), such as wheezing or crackles. Abnormal lung sounds can occur as a result of alterations in the respiratory and cardiovascular systems and lead to impaired oxygenation. Crackles, frequently heard on inspiration, are soft, high-pitched discontinuous (intermittent) popping sounds. They are produced by fluid in the airways or alveoli and delayed reopening of collapsed alveoli. They occur due to inflammation or congestion and are associated with pneumonia, heart failure, bronchitis, and COPD. Wheezing are continuous musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors. They are often heard in patients with asthma, tumors, or a buildup of secretions.

Environmental-Inhalents/Drugs(1405)

Many medications affect the function of the cardiopulmonary system. Patients receiving drugs that affect the central nervous system need to be monitored carefully for respiratory complications. For example, opioids are chemical agents that depress the medullary respiratory center. As a result, the rate and depth of respirations decrease. Be alert for the possibility of respiratory depression or arrest when administering any narcotic or sedative. Other medications decrease heart rate, with the potential to alter the flow of blood to body tissues.

Environmental-Tobacco(1418,1406)

Cigarette smoking is a major risk factor in cardiopulmonary diseases. The inhalation of cigarette smoke increases airway resistance, reduces ciliary action, increases mucus production, causes thickening of the alveolar-capillary membrane, and causes bronchial walls to thicken and lose their elasticity. Smoking is the most common cause of chronic obstructive pulmonary disease (COPD), and increases the risk for many types of cancer, including cancers of the oral cavity, esophagus, lung, urinary bladder, and kidneys. In addition, cigarette smoking causes reduced circulation by narrowing the blood vessels (arteries). Smoking causes coronary heart disease, the leading cause of death in the United States, and causes a much greater risk for stroke, peripheral vascular disease, and abdominal aortic aneurysm (abnormal dilation of blood vessels). These effects occur in both smokers and nonsmokers (children and adults) who live with smokers (CDC, 2010). Habitual smokers usually have great difficulty quitting or reducing their smoking and need much encouragement. The American Lung Association and the American Heart Association (AHA) offer many free educational materials to aid and support patients who are trying to stop smoking. Their addresses and phone numbers are listed in local telephone directories; both agencies offer extensive information online. As a nurse, it is important to play a key role in presenting accurate information about the effects of smoking. Encourage the decision to never start smoking or to stop smoking. Provide appropriate information, counseling, support, and resources to assist patients to be successful with smoking cessation. Cigarette smoking (active or passive) is a major contributor to lung disease and respiratory distress, heart disease, and lung cancer. Cigarette smoking is the most important risk factor for chronic COPD (Macnee, 2007). Smoking causes coronary heart disease, the leading cause of death in the United States (Centers for Disease Control and Prevention [CDC], 2010).

Sociocultural data(1406)

Cultural influences can also play a role in a person's lifestyle, encouraging or discouraging healthy choices. Culture is a strong force in the determinants of health and behavior change. An understanding of a patient's cultural background is necessary to promote health and disease prevention in any population (Ritter & Hoffman, 2010). For example, consider the implications of the use of traditional methods for health restoration, such as cupping by patients of Chinese descent to treat lung congestion (Spector, 2009). An important part of care would be to assess the impact of this practice and belief on a patient's readiness to participate in the proposed plan of care related to the treatment of pneumonia.

EARLY CHILDHOOD (1-5 YEARS)TABLE 38-1

Respiratory rate-20-40 breaths/min Respiratory pattern-Abdominal breathing, Chest wall- irregularSame as infant's but with more subcutaneous fat Breath sounds-Loud, harsh expiration longer than inspiration Shape of thorax-Elliptical

Stressors- Internal-Hemorrhage(1402)

Hemorrhage or loss of blood can decrease cardiac output. A decrease in cardiac output causes a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues.

Physiological data-color(1401,1409)

Hypoxia-when not enough oxygen is available to cells... pallor-(lack of color) of skin and mucous membranes can indicate less than optimal oxygenation. cyanosis-(bluish discoloration) of these areas indicates decreased blood flow or poor blood oxygenation.

Environmental-External temperature/Altitude(1400 and 1407)

If environmental oxygen is reduced, such as when a person is at higher altitudes or in the presence of toxic fumes, less oxygen is available for diffusion. When oxygen is administered, an increased amount of oxygen is available, resulting in greater diffusion across capillary membranes. Although it is impossible to pinpoint all the effects of air pollution, researchers have demonstrated a high correlation between air pollution and cancer and lung diseases. For example, a person with adequate respiratory functioning who is exposed to air pollution may experience stinging of eyes and nasal passages, coughing, choking, headache, and dizziness. Occupational exposure to asbestos, silica, or coal dust, as well as environmental pollution, can lead to chronic pulmonary disease. Chronic exposure to radon, radiation, asbestos, and arsenic can lead to lung cancer. Additionally, people who have experienced an alteration in respiratory functioning in the past often have difficulty continuing to perform self-care activities in a polluted environment.

Stressors- Internal-Pain-Best guess(1400)

If you have an injury that prevents deep breathing then you can develop ATELECTASIS- incomplete lung expansion or collapse of alveoli. Then you could develop pneumonia too!

Environmental-Microorganisms-best guess

If you were to get the flu, a respiratory virus, tuberculosis, your pulmonary function would be disrupted. You could end up will swelling of the bronchi, mucus build up, it could make patients with asthma worse. You may need to seek treatment with corticosteroids, nebulizer treatments, or antibiotics if an infection develops.

Stressors- Internal-Anxiety(1407,1418)

It is important to create an environment that is likely to reduce anxiety. Help institute measures to alleviate discomfort immediately. Use effective listening skills and accurate observation to display a caring attitude. Attempt to understand the patient's life experiences and habits without judging them. Patients with harmful health habits often fear they will be judged, which impedes the use of nursing interventions. Patients who believe nurses are genuinely concerned about them and their families are more willing to work toward achieving mutually desirable outcomes. It is important to minimize anxiety in patients with alterations in oxygenation in order to promote optimal functioning.

Psychological data(1407)

Many psychological factors and conditions can affect the respiratory system. People responding to stress may sigh excessively or exhibit hyperventilation (increased rate and depth of ventilation, above the body's normal metabolic requirements). Hyperventilation can lead to a lowered level of arterial carbon dioxide. Generalized anxiety has been shown to cause enough bronchospasm to produce an episode of bronchial asthma. In addition, patients with respiratory problems often develop some anxiety as a result of the hypoxia caused by the respiratory problem.

FOCUS ON THE OLDER ADULT NURSING STRATEGIES TO ADDRESS AGE-RELATED CHANGES IN OXYGENATION Age-Related Changes Decreased Gas Exchange and Increased Work of Breathing Decreased elastic recoil of the lungs Expiration requiring use of accessory muscles Fewer functional capillaries and more fibrous tissue in alveoli Decreased skeletal muscle strength in thorax Reduction in vital capacity and increase in residual volume

Nursing Strategies Encourage rest periods, as necessary. Encourage cessation or moderation of smoking and second-hand smoke exposure. Teach breathing exercises. Remind about avoiding air pollutants. Caution about effect of extreme weather conditions. Instruct to avoid narcotics and sleeping pills. Discuss home management with patient and family. Teach avoidance of infection and preventive measures (i.e., pneumococcal and flu vaccination). Use pillows as necessary to sleep.

Age-Related Changes Decreased Cardiac Output and Ability to Respond to Stress Reduction in the elasticity of the heart's tissues Heart muscle becomes less efficient—working harder to pump the same amount of blood through the body. Progressive atherosclerosis (fatty buildup or plaques, thickening) in arterial walls and loss of elasticity Capillary walls thicken slightly, leading to a slower rate of exchange of gases, nutrients, and waste.

Nursing Strategies Encourage the inclusion of physical activity in the daily routine; pace activities. Encourage a healthy low-fat, low-salt diet, including plenty of fruits, vegetables and whole grains. Assist with smoking cessation and/or avoid the use of tobacco. Teach the importance of regular check-ups Assist with weight control. Teach the importance of medication compliance. Teach stress-reduction activities.

Age-Related Changes Decreased Ventilation and Ineffective Cough Less air exchange; more secretions remain in lungs Drier mucous membranes Altered pain sensation Different norms for body temperature; fever may be atypical Greater risk for aspiration due to slower gastric motility Impaired mobility and inactivity, effects of medication

Nursing Strategies Encourage increased fluid intake, especially water, as allowed. Use cool-mist humidifier (teach proper cleaning technique). Encourage attendance at pulmonary exercise rehabilitation program. Discourage use of over-the-counter medications. Teach how to splint thorax and cough effectively. Instruct in use of supplemental oxygen. Teach avoidance of milk products if they are troublesome

Physiological data-respirations(1409)

Observe the respiratory rate, rhythm, and depth. Normally, respirations are quiet and nonlabored, and occur at a rate of 12 to 20 times each minute in healthy adults. Note any flaring of the nostrils, muscular retractions, tachypnea(rapid breathing), or bradypnea(slow breathing), which are suggestive of a health deviation requiring further evaluation.

Stressors- Internal-Allergies(1418)-best answer

On days when pollution alerts are announced, people with altered respiratory function should reduce their activities, stay indoors, and use an air conditioner, electronic air cleaner, or air filter. If pollen alters the patient's respiratory function, the same principles apply.

PERFUSION(Just added because professor spoke a lot about this)

Oxygenated capillary blood passes through the tissues of the body in the process called perfusion. The amount of blood flowing through the lungs is a factor in the amount of oxygen and other gases that are exchanged. The amount of blood present in any given area of lung tissue depends partially on whether the person is sitting, standing, or lying down. Perfusion is greater in dependent areas. The perfusion of lung tissue also depends on the person's activity level. Greater activity results in an increased need for cellular oxygen by the body's tissues and a subsequent increase in cardiac output and consequently in increased blood return to the lungs. In addition, perfusion to the body's tissues depends on an adequate blood supply and proper cardiovascular functioning to carry oxygen and carbon dioxide to and from the lungs (discussed later).

Complete Blood Count (CBC)

PREPARATION Review the procedure with the patient. Inform the patient that this test can assist in evaluating the body's response to illness. Inform the patient that specimen collection takes approximately 5 to 10 minutes. Address concerns about pain and explain that there may be some discomfort during the venipuncture (puncture of the vein). There are no food, fluid, or medication restrictions unless ordered by the primary health care provider. AFTERCARE Reinforce information given by the patient's primary health care provider regarding further testing, treatment, or referral to another health care provider. Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of illness. Evaluate test results in relation to the patient's symptoms, health care problems, and other tests performed.

Stressors- Internal-Posture(1418)

Proper positioning is important to ease respirations. A proper position for breathing is a position that allows free movement of the diaphragm and expansion of the chest wall. Alternately, sitting in a slumped position permits the abdominal contents to push upward on the diaphragm, decreasing lung expansion during inspiration. People with dyspnea and orthopnea are most comfortable in a high Fowler's position because accessory muscles can easily be used to promote respiration. Research has demonstrated that, in patients with pulmonary disease who are acutely ill, turning to the prone position on a regular basis promotes oxygenation (Dirkes et al., 2012; Rickelmann, 2012). In this position, the posterior dependent sections of the lungs are better ventilated and perfused.

AGED ADULT (65+ YEARS)TABLE 38-1

Respiratory rate-16-24 breaths/min Respiratory pattern-Thoracic, regular Chest wall-Thin, structures prominent Breath sounds-Clear Shape of thorax-Barrel shaped or elliptical

LATE CHILDHOOD (6-12 YEARS)TABLE 38-1

Respiratory rate-18-26 breaths/min Respiratory pattern-Thoracic breathing, regular Chest wall-Further subcutaneous fat deposited, structures less prominent Breath sounds-Clear inspiration is longer than expiration Shape of thorax- Elliptical

Cardiac Biomarkers

STUDY CK and isoenzymes are enzymes that are released as a result of injury to tissues, including the heart muscle. Troponin is a protein found in skeletal and cardiac muscle fibers and is also released after injury to the heart. These biomarkers are used to monitor cardiac injury and myocardial infarction. Measuring the levels of these enzymes can help determine the extent and timing of the damage. PREPARATION Review the procedure with the patient. Inform the patient that this test can assist in assessing for heart damage. Inform the patient that a series of samples will be required; based on facility protocol, samples could be taken three to four times, in 3- to 4-hour intervals. Inform the patient that specimen collection takes approximately 5 to 10 minutes. Address concerns about pain and explain that there may be some discomfort during the venipuncture (puncture of the vein). There are no food, fluid, or medication restrictions unless ordered by the primary health care provider. AFTERCARE Recognize anxiety related to test results. Provide teaching and information regarding the implications of the test results. Reinforce information given by the patient's primary health care provider regarding further testing, treatment, or referral to another health care provider. Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of illness. Evaluate test results in relation to the patient's symptoms, health care problems, and other tests performed.

Skin Tests

STUDY These determine antigen-antibody reactions and are used to identify exposure to diseases such as tuberculosis. In intradermal tests, antigens (to which the patient may have previously been exposed) are injected into the superficial layer of the skin with a needle and syringe to evaluate immune response. PREPARATION Check the patient's history for hypersensitivity to any of the test antigens. If positive, notify the physician before performing the test. Cleanse the test area with alcohol and allow it to dry. AFTERCARE Instruct the patient to have the test results read at the appropriate time. After reading the results, document the reaction, noting the amount of erythema and induration. Note the presence of a positive result (elevated, red area), recording the diameter and elevation in millimeters. Record the test, time, date, method, and site of administration on the patient record.

TABLE 38-2 Common Laboratory Studies Used to Assess Cardiopulmonary Function Arterial Blood Gas and pH Analysis

STUDY These examine arterial blood to determine the pressure exerted by oxygen and carbon dioxide in the blood and blood pH. This test measures the adequacy of oxygenation, ventilation, and perfusion. Normal results are: pH, 7.35 to 7.45; PCO2, 35 to 45 mm Hg; PO2, 80 to100 mm Hg; HCO3, 22 to 26 mEq/L; and base excess or deficit, -2 to +2 mmol/L. PREPARATION Explain to the patient that this test requires an arterial puncture and collection of a blood specimen. The radial, brachial, or femoral arteries are usually the sites of choice. Perform Allen's test to ensure adequate ulnar blood flow when using the radial artery. AFTERCARE Record supplemental oxygen or respirator settings on specimen information. The arterial specimen is immediately placed on ice and taken to the laboratory. Apply pressure for 5 to 10 minutes and watch for evidence of bleeding. If the patient is taking anticoagulants, pressure must be applied for a longer interval.

Cytologic Study

STUDY This involves a microscopic examination of sputum and the cells it contains. It is done primarily to detect cells that may be malignant, determine organisms causing infection, and identify blood or pus in the sputum. PREPARATION Collect the specimen, if possible, in the morning before breakfast. The test usually involves 3 successive days of sputum collection. About 1 teaspoon of sputum is needed for a specimen. The patient should take a deep breath, then expel the air with a deep cough. Expectorate the specimen into a sterile specimen container with the appropriate preservative, if indicated. Close the container with a tight-fitting lid. AFTERCARE Advise the patient to inform the nurse when the specimen has been obtained. Label and package the specimen and send it to the laboratory as soon as possible.

Radiography

STUDY Radiography is an x-ray examination of the lungs and the thoracic cavity. Radiographic examinations of the lungs are done to help diagnose pulmonary diseases and to determine the progress or development of disease. PREPARATION Instruct the patient to remove clothing to the waist and put on a gown. All metal jewelry should be removed. The patient will be required to take a deep breath and hold it during the radiograph. AFTERCARE • No special care is required after a chest radiograph.

TABLE 38-3 Common Diagnostic Studies Used to Assess Cardiopulmonary Function-Cardiac Coronary Catheterization (Angiography)

STUDY A cardiac catheterization is an invasive study performed to evaluate coronary artery disease, visualize the coronary blood vessels, assess cardiac output, diagnose chest pain and complications of myocardial infarction, evaluate the need for coronary artery surgery, and assess the function of heart valves. Catheters are introduced into blood vessels of the right and left sides of the heart. Contrast dye is injected through the catheters and allows for x-ray visualization of the heart. PREPARATION Verify that an informed consent was obtained. Check for allergies and elevated blood urea nitrogen (BUN) or creatinine levels. The patient is NPO after midnight before the procedure; if the study is late in the afternoon, the patient may have a clear liquid breakfast. Inform the patient that when dye is given, a feeling of warmth or flushing, or a metallic taste, may occur. AFTERCARE Assess the catheter insertion site for bleeding. Apply pressure to the site as needed, based on facility policy. Assess pulses distal to the insertion site. Monitor vital signs and electrocardiogram according to facility policy. Bedrest should be maintained according to facility policy, usually for 4 to 6 hours after the study. Instruct the patient not to drive or climb stairs for 24 hours; avoid heavy lifting, sports, and strenuous housework for 3 days; and to take no baths until the wound is healed. Patients may shower and change the site dressing after 24 hours.

Lung Scan

STUDY A lung scan is the recording on a photographic plate of the emissions of radioactive waves from a substance injected into a vein as it circulates through the lung. A perfusion scan (Q scan) is done to measure integrity of pulmonary blood vessels and evaluate blood flow abnormalities (e.g., pulmonary emboli). A ventilation scan (V scan) is done to detect ventilation abnormalities (especially in patients with emphysema). Both scans used together provide greater and more accurate diagnostic information than either test used alone. PREPARATION Verify that an informed consent was obtained, if required by facility. Explain that no fasting is required. The patient should be told to remove jewelry from the chest area. AFTERCARE No special care is required after the lung scan. Reassure the patient that no radiation precautions are necessary.

Echocardiogram

STUDY Echocardiography is a noninvasive ultrasound test used to evaluate abnormal heart sounds; size of the heart; size and function of the heart's structures; direction and speed of blood flow through the heart; and presence of abnormalities, such as tumors. PREPARATION Inform the patient that the test is painless. The patient should be told to remove jewelry from the chest area. AFTERCARE Reinforce information given by the patient's primary health care provider regarding further testing, treatment, or referral to another health care provider. No special care is required after the echocardiogram.

Endoscopic Studies

STUDY These involve direct visualization of a body cavity. A bronchoscope is used to examine the larynx, bronchi, and trachea. Bronchoscopy is used to view lesions, obtain a biopsy, improve drainage, remove foreign substances, evaluate trauma, and drain abscesses. PREPARATION Verify that an informed consent was obtained. The patient should be NPO for 6 to 8 hours before the test. An analgesic, sedative, and/or anticholinergic may be administered before the test. Local anesthetic is sprayed into the throat. AFTERCARE Withhold food and fluids until the gag reflex returns. Check vital signs according to facility protocol. Observe carefully for signs of respiratory impairment. Emergency resuscitation equipment should be available. Warm saline gargles may relieve throat irritation once the gag reflex has returned.

Holter Monitor

STUDY This noninvasive study records the electric activity of the heart over a period of time, usually 24 to 48 hours, with an electronic recording device. It allows the patient to perform normal daily activities so that the response of the heart to these activities can be evaluated. It is also used to detect and evaluate dysrhythmias, evaluate chest pain and other symptoms, effectiveness of heart medications, and pacemaker function. PREPARATION Inform the patient of the purpose of the study and the importance of the patient's role in obtaining the needed information. Instruct the patient to keep a diary of activities. Instruct the patient to trigger the event marker on the device whenever pain or other symptoms occur. Demonstrate and have the patient give a return demonstration regarding how to trigger the event marker. Inform the patient that the recorder should remain dry; avoid bathing and showering. Contact with electrical devices—such as shavers, toothbrushes, and electric blankets—should be avoided. AFTERCARE Instruct the patient to immediately report symptoms such as fast heart rate or difficulty breathing. Reinforce information given by the patient's primary health care provider regarding further testing, treatment, or referral to another health care provider.

Cardiac Exercise Stress Testing

STUDY This procedure is a noninvasive way to evaluate the response of the cardiovascular system to physical stress, helping to identify the presence of coronary artery disease, the cause of chest pain, the functional capacity of the heart, the effectiveness of some cardiac medications, and evaluate dysrhythmias that occur during exercise. The patient exercises on a treadmill or pedals a stationary bicycle while the patient's electrocardiogram and blood pressure are monitored. The study is performed in a series of stages, gradually increasing the speed or resistance, until the patient reaches 85% of the maximum heart rate, becomes symptomatic, or displays changes on the electrocardiogram consistent with ischemia. PREPARATION The patient should be NPO for 4 hours before the test and should avoid stimulants such as tobacco and caffeine. Medications may be taken with a sip of water; however, patients should follow the directions given by their health care provider regarding taking certain cardiac medications before the test. Instruct the patient to wear comfortable clothing and shoes. Inform the patient that this study can assist in assessing the heart's ability to respond to an increasing workload. Question the patient about chest pain within the past 48 hours or a history of angina. Inform the patient that the study takes approximately 30 to 60 minutes, and to report any symptoms, such as dizziness, breathlessness, or pain, that occur during the test. AFTERCARE Recognize anxiety related to test results. Provide teaching and information regarding the implications of the test results. Instruct the patient to report any angina or other discomfort experienced after the test. Reinforce information given by the patient's primary health care provider regarding further testing, treatment, or referral to another health care provider.

Developmental data(1405)

Table 38-1-look at also The normal infant's chest is small, the airways are short, and aspiration is a potential problem. The respiratory rate is more rapid in infants than at any other age (see Table 38-1). As the alveoli increase in number and size, adequate oxygenation is accomplished at lower respiratory rates. Surfactant is formed in utero between 34 and 36 weeks. An infant born before 34 weeks may not have produced sufficient surfactant, leading to collapse of the alveoli and poor alveolar exchange. Synthetic surfactant can be given to the infant to help reopen the alveoli. Infants are at risk for upper respiratory tract infections and asthma as a result of exposure to secondhand smoke. Respiratory activity is primarily abdominal in infants. The pulse rate is more rapid in infancy than in adulthood, limiting the infant's ability to increase cardiac output by increasing the heart rate (Kyle & Carman, 2013). The preschool child's eustachian tubes, bronchi, and bronchioles are elongated and less angular. Thus, the average number of routine colds and infections decreases until the child enters daycare or school and is exposed more frequently to pathogens. Young children who are not placed in daycare usually have not had the opportunity to develop antibodies for the variety of viruses and bacteria they may encounter in a school setting. Encourage good hand hygiene and tissue etiquette. Most children at this age have colds or upper respiratory infections, but some have more serious problems of otitis media, bronchitis, and pneumonia. Children in this age group are also at risk for asthma as a result of exposure to secondhand smoke. By the end of late childhood and during adulthood, the immune system is prepared to protect the person from most infections. A child's blood vessels widen and increase in length over time. The blood pressure increases over time, reaching the adult level in adolescence. Specific physical changes occur in older adults that are unrelated to any pathology. Refer to the Focus on the Older Adult Box . The tissues and airways of the respiratory tract (including the alveoli) become less elastic. The power of the respiratory and abdominal muscles is reduced, therefore the diaphragm moves less efficiently. The chest is unable to stretch as much, resulting in a decline in maximum inspiration and expiration. Airways collapse more easily. These alterations increase the risk for disease, especially pneumonia and other chest infections.The normal aging heart can maintain adequate cardiac output under ordinary circumstances, but may have a limited ability to respond to situations that cause physical or emotional stress (Hinkle & Cheever, 2014). Decreased physical activity, physical deconditioning, decreased elasticity of the blood vessels, and stiffening of the heart valves can lead to a decrease in the overall function of the heart.

Physiological data-shape and symmetry of chest(1409,1404-1405)

The adult chest contour is slightly convex, with no sternal depression. The anteroposterior diameter should be less than the transverse diameter. Kyphosis (curvature of the spine) contributes to the older person's appearance of leaning forward and can limit respiratory ventilation. Barrel chest deformity may be a result of aging or COPD (chronic obstructive pulmonary disease). Note the contour of the intercostal spaces, which should be flat or depressed, and the movement of the chest, which should be symmetrical.

Physiological data-capillary refill(1409)

The presence of decreased skin temperature, pallor, cyanosis, decreased pulses, and prolonged capillary refill can indicate less than optimal cardiac function and oxygenation.

BOX 38-1 Commonly Measured Values from Pulmonary Function Tests

Tidal volume (TV): Total amount of air inhaled and exhaled with one breath Vital capacity (VC): Maximum amount of air exhaled after maximum inspiration Forced vital capacity (FVC): Maximum amount of air that can be forcefully exhaled after a full inspiration Forced expiratory volume (FEV): The amount of air exhaled in the first second after a full inspiration; can also be measured at 2 or 3 seconds Total lung capacity (TLC): The amount of air contained within the lungs at maximum inspiration Residual volume (RV): The amount of air left in the lungs at maximal expiration Peak expiratory flow rate (PEFR): The maximum flow attained during the FVC

FOCUSED ASSESSMENT GUIDE 38-1 OXYGENATION

Usual patterns of respiration How would you describe your breathing? Do you have allergies? What type(s) of allergies do you have? What relief measures do you use? Medications Are you taking any medications for your breathing, your heart, or for your blood pressure? What other medications are you taking? Health history Do you have any heart, lung, or breathing conditions? Does anyone in your family/home have any breathing conditions or respiratory infections? Recent changes Have you noticed any changes in your breathing (out of breath, cough, wheezing)? Have you noticed any changes in your ability to perform activities of daily living? Do you have any swelling or redness in your arms or legs? Do you have a respiratory infection? If so, what type? What relief measures are you using? Lifestyle and environment Do you smoke? If so, how many years have you smoked? How much do you smoke (i.e., how many packs per day or year)? Do you live with a smoker or are there smokers in your workplace? Are you exposed to respiratory irritants in your workplace? Are there other pollutants in your workplace? Cough How much and how often do you cough? What is it like (dry, bubbly, hoarse)? Do you cough up mucus? If so, how much and what does it look like? Do you have a history of allergies? Do you ever wheeze? Are you exposed to dust? Fumes? Sputum Do you ever cough up and spit out mucus? How much do you spit out and do you associate it with anything (time of day, environment)? What color is it? Is it ever blood tinged? What is its odor? Pain Do you have any chest pain? Do you have pain with breathing? Do you have pain in the arms or legs? When did it start? On a scale of 0 to 10 (10 being very painful), how severe is the pain? Where is the pain? Is the pain worse with inspiration? Expiration? Cough? Activity? Does the pain radiate? What measures are you using to relieve the pain? Dyspnea Is it constant or remittent or related to any activity? How do different positions affect it? How does it affect your daily activities? Can you sleep lying flat? How many pillows do you use? Fever Have you had pneumonia recently? Do you have any contact with people who have tuberculosis? Do you have night sweats? Are others in your household well or ill? Have you traveled anywhere recently? Fatigue Have you noticed you feel more tired lately? Are you getting your normal amount of sleep at night? Has your sleep at night been affected by any difficulty breathing? Do you become easily fatigued when you climb stairs?

Physiological data-pulse(best guess)(1402,1404)

When checking vital signs you notice a person has a low pulse, they may be having difficulty with blood circulation. Any abnormality in the blood's components affects internal respiration. For example, hemorrhage or loss of blood can cause a decrease in cardiac output. A decrease in cardiac output causes a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. with hypoxia-an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis. Stimulation of the SA and AV nodes by the sympathetic nerves increases the heart rate and force of contraction in response to increased activity, and as part of the response to real or perceived threats. Parasympathetic stimulation of the SA and AV nodes by the vagus nerve decreases the heart rate.

Physiological data-blood pressure(1402)-best guess

You need to check this because: Any abnormality in the blood's components affects internal respiration. For example, hemorrhage or loss of blood can cause a decrease in cardiac output. A decrease in cardiac output causes a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. with hypoxia-an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.

Physiological data-O2 saturation(1414)

is a noninvasive technique that measures the arterial oxyhemoglobin saturation (SaO2 or SpO2) of arterial blood. The reported result is a ratio, expressed as a percentage, between the actual oxygen content of the hemoglobin and the potential maximum oxygen-carrying capacity of the hemoglobin (Van Leeuwen, Poelhuis-Leth, & Bladh, 2011). Pulse oximetry is useful for monitoring patients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and monitoring postoperative patients. Pulse oximetry does not replace arterial blood gas analysis. Desaturation (decreased level of SpO2) indicates gas exchange abnormalities. Oxygen desaturation is considered a late sign of respiratory compromise in patients with reduced rate and depth of breathing (Johnson, Schweitzer, & Ahrens, 2011). Be aware of the patient's hemoglobin level before evaluating oxygen saturation because the test measures only the percentage of oxygen carried by the available hemoglobin. Thus, even a patient with a low hemoglobin level could appear to have a normal SpO2 because most of that hemoglobin is saturated. However, the patient may not have enough oxygen to meet body needs. A range of 95% to 100% is considered normal SpO2; values ≤90% are abnormal, indicate that oxygenation to the tissues is inadequate, and should be investigated for potential hypoxia or technical error.