Fundamentals of Nursing: Chapter 39: Oxygenation, chapter 39 oxygenation, ch 39 oxygenation, Taylor Fundamentals of Nursing Chapter 38: Oxygenation + Perfusion, Fundamentals Chapter 39: Oxygenation and Perfusion, chapter 39 Oxygenation and perfusion...
Barrel Chest
May be a result of *AGING or COPD*
Alveoli
air sacs in the lungs
A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is a) "His infection is causing him to breathe harder." b) "He is using his chest muscles to help him breathe." c) "His lung muscles are swollen so he is using abdominal muscles." d) "He will require additional testing to determine the cause."
"He is using his chest muscles to help him breathe." Explanation: The client will use accessory muscles to ease dyspnea and improve breathing. 1352
The nurse determines that the student who has been instructed about lung function and smoking requires additional teaching when the student says a) "An older person may breathe more shallowly than a younger person." b) "Smoking only once in a while will not make a person addicted to smoking." c) "An upright position will help someone breathe with less effort." d) "A physically fit athlete breathes more slowly than a sedentary person."
"Smoking only once in a while will not make a person addicted to smoking." Explanation: During adolescence, more than 3000 young men and women begin smoking every day, and most will become addicted before age 20. One reason for this finding is that adolescents don't believe they will become addicted to tobacco when they start to smoke. 1357
Oxygenation of body tissues depends on several factors:
-integrity of airway system to transport air to and from lungs -properly functioning alveolar system -properly functioning cardiovascular system and blood supply to carry nutrients and wastes to and from body cells.
PHYSICAL HEALTH and cardiopulmonary functioning!
1) *Acute and chronic illnesses* can affect cardiopulmonary function. 2) *Renal and cardiac disorders* have compromised respiratory function because of fluid overload and impaired tissue perfusion. 3) Alterations in muscle function contribute to inadequate pulmonary ventilation and respiration, as well as inadequate functioning of the heart. 4) *Anemia* can result in inadequate oxygen supply due to lack of hemoglobin. 5) *Scoliosis* influences breathing patters and may cause AIR TRAPPING. 6) Statisitically significant correlation between *obesity and chronic bronchitis* as well as lack of stimulation of the alveoli at the base of the lungs.
Age Related Changes in Oxygenation
1) Decreased gas exchange makes effective breathing more difficult. 1a) Decreased elastic recoil of lungs 1b) Expiration requiring use of accessory muscles 1c) Decreased ventilation (volume of air in/out) 2) Decreased cardiac output and ability to respond to stress. 2a) Reduction in the elasticity of the heart's tissues. 2b) Heart muscle becomes *less efficient* due to progressive atherosclerosis 3) Capillary walls thicken slightly, leading to a slower rate of exchange of gasses, nutrients and waste.
Cyanosis
1) Indicates decreased blood flow or poor blood oxygenation
Pallor
1) Indicates less than optimal oxygenation 2) Symptom of *hypoxia* 2a) Other symptoms of hypoxia include: Dyspnea, increased BP, RR and HR, cyanosis, and behavioral changes like anxiety, restlessness, confusion and drowziness.
MEDICATIONS and cardiopulmonary functioning!
1) Patients receiving drugs that affect the CNS need to be monitored carefully for respratory complications. 2) Opioids DEPRESS the medullary respiratory center and as a result both the *RATE + DEPTH* of respirations *DECREASE*
PSYCHOLOGICAL HEALTH and cardiopulmonary functioning!
1) People responding to stress may sigh excessively or exhibit *HYPERVENTILATION* 2) Hyperventilation can lead to a *LOWERED* level of arterial carbon dioxide (Respiratory Acidosis) 3) Generalized anxiety has been shown to cause enough bronchospasm to produce an episode of *BRONCHIAL ASTHMA* 4) Chronic hypoxia caused by respiratory problems can cause patient to feel *anxiety as a symptom.*
what is the process of ventilation?
1. the diaphragm contracts and descends, lengthening the thoracic cavity 2. the external intercostal muscles contract, lifting the ribs upward and outward 3. the sternum is pushed forward, enlarging the chest from front to back 4. increased lung volume and decreased intrapulmonic pressure allow air to move from an area of greater pressure (outside lungs) to lesser pressure (inside the lungs) 5. the relaxation of these structures result in expiration
6 Factors Affecting Cardiopulmonary Functioning
1.) PHYSICAL HEALTH 2.) DEVELOPMENT 3.) MEDICATION 4.) LIFESTYLE 5.) ENVIRONMENT 6.) PSYCHOLOGICAL HEALTH
Adult Respiratory Rate
12-20 breaths/min 1) Aduts chest contour is *SLIGHTLY CONVEX* with NO sternal depression. 2) The anteroposterior diameter (front to back) should be LESS than the transverse diameter (side to side). 3) Thoracic breathing
Aged Adult (65 +)
16-24 breaths/min 1) May have a barrel shaped thorax 2) *KYPHOSIS* can limit respiriatory ventilation
The nurse is assessing the vital signs of a newborn. The nurse documents which respiratory rate as normal? a) 12 to 15 breaths per minute b) 12 to 20 breaths per minute c) 30 to 60 breaths per minute d) 20 to 30 breaths per minute
30 to 60 breaths per minute Explanation: The nurse should expect the baby to have a respiratory rate of 30 to 60 breaths per minute. Toddlers and preschoolers have a respiratory rate of 20 to 30 per minute. School-age children and adolescents have a respiratory rate of 12 to 20 breaths per minute. 1355
Infants Respiratory Rate
30-55 breaths/min 1) Has large harsh *CRACKLES* at end of inspiration (Normal). 2) ROUNDED thorax 3) Abdominal breathing
surfactant
A detergent like phospholipid reduces the surface tension between the mouse membranes of the alveoli preventing their collapse.
dysrhythmia
Abnormal heart rhythm
The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which of the following assessment findings is consistent with hypoxia?
Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.
Upon auscultation of the client's lungs, the nurse hears loud, high-pitched sounds over the larynx. What term will the nurse use in documentation to describe this breath sound?
Bronchial breath sounds are loud, high-pitched sounds heard primarily over the trachea and larynx. Vesicular breath sounds are low-pitched, soft sounds heard over the peripheral lung fields. Bronchovesicular breath sounds are medium-pitched blowing sounds heard over the major bronchi. Vesicular, bronchial, and bronchovesicular breath sounds are normal breath sounds. Adventitious breath sounds are abnormal lung sounds.
Angina
Chest discomfort or shortness of breath caused when heart muscles receive insufficient oxygen-rich blood.
The nurse is assessing the vital signs of a newborn. The nurse documents which respiratory rate as normal? a) 12 to 20 breaths per minute b) 20 to 30 breaths per minute c) 12 to 15 breaths per minute d) 30 to 60 breaths per minute
Correct response: 30 to 60 breaths per minute Explanation: The nurse should expect the baby to have a respiratory rate of 30 to 60 breaths per minute. Toddlers and preschoolers have a respiratory rate of 20 to 30 per minute. School-age children and adolescents have a respiratory rate of 12 to 20 breaths per minute
In which of the following clients would the nurse assess for a depressed respiratory system? a) A client taking insulin for diabetes b) A client taking opioids for cancer pain c) A client taking amlodipine for hypertension d) A client taking antibiotics for a urinary tract infection
Correct response: A client taking opioids for cancer pain Explanation: Many medications affect the function of, and depress, the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations
The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of a) Bronchospasm b) Epiglottitis c) Atelectasis d) Croup
Correct response: Atelectasis Explanation: Stiffer lungs tend to collapse and their alveoli also collapse. This condition is called atelectasis
A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from a) Pulmonary embolism b) Congestive heart failure c) Myocardial infarction d) Lung cancer
Correct response: Congestive heart failure Explanation: A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure.
Which of the following dietary guidelines would be appropriate for the elderly homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat? a) Snack on high-carbohydrate foods frequently b) Contact the physician for Ensure c) Eat one large meal at noon d) Eat smaller meals that are high in protein
Correct response: Eat smaller meals that are high in protein Explanation: The client should consume a diet in which the body can produce plasma proteins. The client should have sufficient caloric and protein intake for respiratory muscle strength.
A client with no prior history of respiratory illness has been admitted to a postsurgical unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery? a) Educating the client on pursed-lip breathing techniques b) Oropharyngeal suctioning twice daily c) Administration of inhaled corticosteroids d) Educating the client on the use of incentive spirometry
Correct response: Educating the client on the use of incentive spirometry. Explanation: Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery.
The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is "Ineffective Airway Clearance related to copious and tenacious secretions." Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan? a) Encouraging the client to consume two to three quarts of clear fluids daily b) Creating an environment that is likely to reduce anxiety c) Positioning the client supine d) Encouraging the client to decrease the number of cigarettes smoked daily
Correct response: Encouraging the client to consume two to three quarts of clear fluids daily Explanation: Clients can help keep their secretions thin by drinking two to three quarts (1.9 L to 2.9 L) of clear fluids daily. Although it is important to create an environment that is likely to reduce a client's anxiety, doing so will not assist in promoting airway clearance. The nurse should not encourage the client to decrease the number of cigarettes smoked daily, but should encourage the client to stop smoking. Proper positioning to ease respirations includes placing the client in a high-Fowler's position.
A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client? a) Nasal cannula b) Flowmeter c) Nasal strip d) Oxygen analyzer
Correct response: Flowmeter Explanation: The nurse should use a flowmeter to regulate the amount of oxygen delivered to the client. A flowmeter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client.
A client with chronic obstructive pulmonary disease requires low flow oxygen. How will the oxygen be administered? a) Venturi mask b) Simple oxygen mask c) Nasal cannula d) Partial rebreather mask
Correct response: Nasal cannula Explanation: Nasal cannula and tubing administers oxygen concentrations at 22% to 44%.
A patient's primary care provider has informed the nurse that the patient will require thoracentesis. The nurse should suspect that the patient has developed which of the following disorders of lung function? a) Pleural effusion b) Tachypnea c) Wheezes d) Pneumonia
Correct response: Pleural effusion Explanation: Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion). Tachypnea and wheezes are not symptoms that directly indicate a need for thoracentesis and pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.
During oxygen administration to the client, which of the following pieces of equipment would enable the nurse to regulate the amount of oxygen delivered? a) Nasal cannula b) Flow meter c) Oxygen analyzer d) Humidifier
Correct: Flow meter Explanation: In order to regulate the amount of oxygen delivered to the client, the nurse should use a flow meter. A flow meter is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. A humidifier is a device that produces small water droplets and may be used during oxygen administration, since oxygen dries the mucous membranes. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It provides a means for administering a low concentration of oxygen
Which of the following medications are administered in the home or the hospital to relieve inflammation in the lung tissue? a) Bronchodilators b) Corticosteroids c) Expectorants d) Antibiotics
Corticosteroids Explanation: In many cases, bronchodilators and corticosteroids are required to open airways and ease breathing. Corticosteroids relieve inflammation. 1372
capnography
procedure to record carbon dioxide levels
Oxygen and carbon dioxide move between the alveoli and the blood by a) Osmosis b) Hyperosmolar pressure c) Diffusion d) Negative pressure
Diffusion Explanation: Oxygen and carbon dioxide move between the alveoli and the blood by diffusion, the process in which molecules move from an area of greater concentration or pressure to an area of lower concentration or pressure. 1361
A client with no prior history of respiratory illness has been admitted to a postsurgical unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery? a) Administration of inhaled corticosteroids b) Educating the client on the use of incentive spirometry c) Educating the client on pursed-lip breathing techniques d) Oropharyngeal suctioning twice daily
Educating the client on the use of incentive spirometry Explanation: Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery. 1368
The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which of the following assessment findings should the nurse interpret as abnormal? a) Respiratory rate of 18 breaths per minute b) Vesicular breath sounds audible over peripheral lung fields c) Resonance on percussion of lung fields d) Fine crackles to the bases of the lungs bilaterally
Fine crackles to the bases of the lungs bilaterally Explanation: Except in the case of infants, fine crackles always constitute an abnormal assessment finding. A respiratory rate of 18 is within acceptable range. Vesicular sounds over peripheral lung fields and resonance on percussion are expected assessment findings. 1361
2-3 days
How long does it take to have a balanced intake/output?
DEVELOPMENT and cardiopulmonary functioning!
INFANTS: (30-55 respirations per minute) 1) The infant's chest is small, airways short = *aspiration risk.* 2) *HIGHER* respiratory rate than any other age 3) As the *alveoli increase in number and size*, adequate oxygenation is accomplished at lower respiratory rates. 4) *Surfacant* is formed in utero at *34-36 weeks* 5) Infant born *before 34 weeks* may not have pruduced sufficient surfacant, leading to collapse of the alveoli and poor alveolar exchange. 6) Synthetic surfacant can be given to the infant to help reopen the alveoli. 7) Respriatory activity is primarily abdominal (diaphramiatic). 8) Pulse rate is more rapid in infancy than adulthood, limiting the infant's ability to increase cardiac output by increasing the heart rate. OLDER ADULTS: 1) Tissues and airways of the respiratory tract (including alveoli) become *less elastic.* 2) Power of the respiratory and abdominal muscles *is reduced*, therefore the diaphragm moves less efficently. 3) The chest is *unable to stretch as much*, resulting in a decline in maximum inspiration and expiration. 4) *Airways collapse more easily.* 5) Natural physical alterations increase the risk for disease, especially pneumonia and other chest infections.
A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula? a) It can cause anxiety in clients who are claustrophobic. b) It can cause the nasal mucosa to dry in case of high flow. c) It can result in an inconsistent amount of oxygen. d) It can create a risk of suffocation.
It can cause the nasal mucosa to dry in case of high flow. Explanation: When using a nasal cannula to deliver oxygen to a client, the nurse should remember that the nasal cannula can cause the nasal mucosa to dry in case of high oxygen flow. A simple mask can cause anxiety in clients who are claustrophobic. Clients using a partial rebreather mask are at risk of suffocation. A face tent may deliver an inconsistent amount of oxygen, depending on environmental loss. 1375
A client with chronic obstructive pulmonary disease requires low flow oxygen. How will the oxygen be administered? a) Simple oxygen mask b) Partial rebreather mask c) Venturi mask d) Nasal cannula
Nasal cannula Explanation: Nasal cannula and tubing administers oxygen concentrations at 22% to 44%. 1375
A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which of the following delivery devices should the nurse use in order to administer oxygen to the client? a) Nasal cannula b) Face tent c) Simple mask d) Non-rebreather mask
Nasal cannula Explanation: The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Non-rebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill. 1375
What structural changes to the respiratory system should a nurse observe when caring for older adults? a) Increased mouth breathing and snoring b) Diminished coughing and gag reflexes c) Increased use of accessory muscles for breathing d) Respiratory muscles becomes weaker
One of the structural changes affecting the respiratory system that a nurse should observe in an older adult is respiratory muscles becoming weaker. The nurse should also observe other structural changes: the chest wall becomes stiffer as a result of calcification of the intercostals cartilage, kyphoscoliosis, and arthritic changes to costovertebral joints; the ribs and vertebrae lose calcium; the lungs become smaller and less elastic; alveoli enlarge; and alveolar walls become thinner. Diminished coughing and gag reflexes, increased use of accessory muscles for breathing, and increased mouth breathing and snoring are functional changes to the respiratory system in older adults.
A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of which of the following?
Pneumonia, which causes the lungs to swell and stiffen, can lead to atelectasis. Stiffer lungs tend to collapse, and their alveoli also collapse. Consequently, the amount of space available for gas exchange in the lungs decreases. Croup, asthma, and alcohol abuse do not lead to atelectasis. Croup is a common condition in young children that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol abuse depresses the central respiratory center.
The nurse caring for a client with emphysema has determined that a priority nursing diagnosis for this client is "Imbalanced Nutrition: Less Than Body Requirements related to difficulty breathing while eating." Based upon this diagnosis, which of the following is an appropriate nursing intervention to include in the client's care plan? a) Encourage the client to alternate eating and using a nebulizer during meal time. b) Encourage the client to eat immediately before breathing treatments. c) Provide six small meals daily. d) Provide three large meals daily.
Provide six small meals daily. Explanation: The nurse should consider providing six small meals distributed over the course of the day instead of three large meals. Meals should be eaten one to two hours after breathing treatments and exercises. 1365
A patient returns to the telemetry unit after an operative procedure. Which of the following diagnostic tests will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the patient? a) Spirometry b) Thoracentesis c) Pulse oximetry d) Peak expiratory flow rate
Pulse oximetry Explanation: Pulse oximetry is useful for monitoring patients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative patients. Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled and evaluate lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes.
A patient returns to the telemetry unit after an operative procedure. Which of the following diagnostic tests will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the patient? a) Thoracentesis b) Pulse oximetry c) Peak expiratory flow rate d) Spirometry
Pulse oximetry Explanation: Pulse oximetry is useful for monitoring patients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative patients. Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled and evaluate lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes. 1361
Tachypnea
Rapid breathing
Cilia
The hairlike projections on the outside of cells that move in a wavelike manner
Upon evaluation of a client's medical history, the nurse recognizes that which of the following conditions may lead to an inadequate supply of oxygen to the tissues of the body? Pancreatitis Chronic anemia Parkinson's disease Graves' disease
The majority of oxygen is carried by the red blood cells. 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. Graves' disease, Parkinson's disease, and pancreatitis do not directly lead to a decrease in the number of red blood cells.
While examining a client, the nurse palpates the client's chest and back. Which of the following would the nurse expect to identify with this technique?
The nurse can assess patterns of thoracic expansion through palpation. Fluid-filled and consolidated portions of lungs can be assessed through percussion, not through palpation. Presence of pleural rub can be assessed through auscultation.
A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which of the following delivery devices should the nurse use in order to administer oxygen to the client?
The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Non-rebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.
Evaporation through the skin, Expiration from the Lungs
What are some insensible fluid losses?
Urination, Defecation, Wounds
What are some sensible fluid losses?
Sensible and Insensible losses
What 2 ways is fluid lost from the body?
Age, Body Fat, and Gender
What are factors that cause variations in fluid content?
Sodium(Na), Potassium(K), Calcium(Ca), Hydrogen(H), and Magnesium(Mg)
What are the major cations in the body?
Intracellular Fluid and Extracellular Fluid
What are the two main fluid compartments of the body?
An Ion that carries a + electric charge
What is a cation?
An ion that carries a - electric charge
What is an anion?
2,600 ml/day
What is the average amount of fluid intake/day?
2,500-2,900 mL
What is the average amount of fluid output/day
Transcellular Fluid
What is the third minor fluid compartment?
Infants and Elderly
Which 2 age groups are more prone to fluid imbalance?
A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula?
a) It can cause the nasal mucosa to dry in case of high flow. When using a nasal cannula to deliver oxygen to a client, the nurse should remember that the nasal cannula can cause the nasal mucosa to dry in case of high oxygen flow. A simple mask can cause anxiety in clients who are claustrophobic. Clients using a partial rebreather mask are at risk of suffocation. A face tent may deliver an inconsistent amount of oxygen, depending on environmental loss.
adventitious
accidental
bradypnea
an abnormally slow rate of respiration usually of less than 10 breaths per minute
A client with no prior history of respiratory illness has been admitted to a postsurgical unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery?
b) Educating the client on the use of incentive spirometry Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery.
During oxygen administration to the client, which of the following pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?
b) Flow meter In order to regulate the amount of oxygen delivered to the client, the nurse should use a flow meter. A flow meter is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. A humidifier is a device that produces small water droplets and may be used during oxygen administration, since oxygen dries the mucous membranes. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It provides a means for administering a low concentration of oxygen.
A client with chronic obstructive pulmonary disease requires low-flow oxygen. How will the oxygen be administered? Select all that apply.
b) Nasal cannula c) Simple oxygen mask e) Partial rebreather mask Nasal cannula with tubing administers oxygen at low-flow rates and concentrations at 22-44%. Simple masks and partial rebreathers both deliver a low-flow rate at concentrations of 40-60%. Venturi masks mix oxygen with room air and create a high flow of oxygen.
An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's ...
b) hemoglobin level Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry.
A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction two days earlier. Since her surgery, the client has been unwilling to mobilize despite the nurse's education on the benefits of early mobilization following surgery. The nurse would recognize that the client's prolonged immobility creates a risk for what?
c) Atelectasis Prolonged bed rest can result in the incomplete lung expansion and collapse of alveoli that characterize atelectasis. Immobility is not commonly implicated in cases of pneumothorax or hemothorax. Tachypnea, if present, would likely be a sign of atelectasis rather than an independent finding.
what are some factors that influence diffusion of gases in the lungs?
change in surface area available (removal of lung or section of the lung), thickening of alveolar-capillary membrane (pneumonia), partial pressure (less oxygen)
hypoxia
condition in which an inadequate amount of oxygen is available to cells.
what is the function of the lower airways and components?
conduction of air, mucocilliary clearance, and production of pulmonary surfactant. components: trachea, right and left main stem bronchi, segmental bronchi, and terminal bronchioles
Dyspnea
difficulty breathing
dyspnea
difficulty breathing
what are common causes of hypoxia?
dyspnea, hyperventilation, hypoventilation
crackles
fine, crackling sounds made as air moves through wet secretions in the lungs
what is hypoxia? and some early/chronic symptoms?
inadequate amount of oxygen available to the cells early symptoms: shortness of breath, elevated blood pressure, increased respiratory rate, tachycardia chronic symptoms: bradycardia, extreme restlessness, dyspnea
atelectasis
incomplete lung expansion or the collapses of alveoli, prevents pressure changes ad the exchange of gas by diffusion in the lungs.
what is pulmonary ventilation?
inspiration (the active phase of ventilation; brings air into the lung) expiration: the passive phase of ventilation (movement of air out of the lung)
What are some factors essential to a normal functioning of the Respiratory System:
integrity of airway system (transport air to and from the lungs), properly functioning alveolar system (removes carbon dioxide from blood), properly functioning cardiovascular and hematologic system (carry nutrients and waste to and from the body cells)
respiration
involves gas exchange between the atmospheric air in the alveoli and blood in the capillaries.
what does the lung do and its components?
main organ of respiration for the body, located in the thoracic cavity. Right lung has 3 lobes and left lung has 2. composed of: alveoli (small air sacs; site for gas exchange), surfactant (detergent-like phospholipids; reduces surface tension to prevent alveoli collapse), pleura (serous membrane that covers and protects the lungs and thoracic activity)
cilia
microscopic hair- like projections, propel trapped material and accompanying mucus toward the upper airway so they can be removed by coughing.
what is diffusion?
movement of gas or particles from areas of higher pressure/ concentration to areas of lower pressure/ concentration
Cardiovascular
pertaining to the heart and blood vessels
cardiopulmonary
pertaining to the heart and lungs
what is the gas exchange?
refers to the intake of oxygen and release of carbon dioxide
alveoli
small air sacs. The alveoli are the site of gas exchange.
inspiration
the active phase involves movement of muscles and the thorax to bring air into the lungs
Hyperventilation
the condition of taking abnormally fast, deep breaths
pulmonary ventilation
the movement of air into and out of the lungs.
diffusion
the movement of gas or particles from areas of higher pressure or concentration to areas of lower pressure or concentrations.
expiration
the passive phase is the movement of air out of the lungs.
perfusion
the process by which oxygenated capillary blood passes through body tissues.
what does the mucus coated lining do?
traps particles and infectious debris, protects underlying tissue from irritation and infection
what does the upper airway do and components?
warms, filter, and humidify inspired air. components: nose, pharynx, larynx, epiglottis
