Nursing Management of Clients with Stressors of Respiratory

FunctionAssessment & Diagnosis

NUR133 Lecture #4

K. Burger, MSEd, MSN, RN, CNE

Anatomy of Respiratory Tract

Review your NUR123 objectives on

anatomy of upper and lower airways

Assessment of Respiratory System

Review your NUR123 objectives on

Subjective 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 Assessment

• Respiratory Hx includes:

• Allergies

• Medications

• Medical Hx

• Smoking

• Lifestyle

• Stressors

• Hazard exposures

Assessing Respiratory Function

• InspectionShape (AP diam), skeletal abnormalities,chest movement and expansion, rate,rhythm, effort

• PercussionDiaphragmatic excursion, tactile fremitus

• AuscultationVesicular +, adventitious sounds

Assessing Respiratory Functioning

• Respiratory Rate:• Eupnea• Tachycardia• Bradycardia• Apnea• Respiratory Depth:• Deep• Shallow

Assessing Respiratory Functioning

• Respiratory Rhythm:

• Regular

• Cheyne-Stokes

• Kussmauls

• Apneustic breathing

• Biots

Assessing Respiratory Functioning

• Respiratory Quality:• No difficulty• Dyspnea and DOE• Orthopnea• Retractions

• Cough:• Nonproductive• Productive• Sputum• Hemoptysis

Assessing Respiratory Functioning

• Auscultation:• Vesicular• Bronchial• Bronchvesicular

• Adventitious:

• Rales/crackles

• Rhonchi

• Wheeze

• Stridor

• Stertor

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)

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

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

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 !!!

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”

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

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)

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 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

Steps for ABG Analysis

1. Evaluate the PH

< 7.35 is Acidosis> 7.45 is Alkalosis

PH = 7.29

Steps for ABG Analysis

2. Evaluate VENTILATION

PCO2 > 45 indicates Respiratory AcidosisPCO2 < 35 indicates Respiratory Alkalosis

PCO2 = 47

Steps for ABG Analysis

3. Evaluate METABOLIC PROCESSES

HCO3 < 22 reflects Metabolic AcidosisHCO3 > 26 reflects Metabolic Alkalosis

HCO3 = 24

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

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

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

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

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

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

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)

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

Interventions for Respiratory Alkalosis

• Encourage appropriate breathing patterns

• Re-breathing techniques

• Anxiety control

• O2 therapy with caution

Nursing Diagnoses

• Impaired gas exchange• Ineffective airway clearance• Ineffective breathing pattern• Risk for infection• Activity intolerance• Risk for injury• Self-care deficit+++++++++++++++++++++++++++++++++

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

+++++++++++++++++++++++++++++++++

Medications• Bronchodilators

AlupentBrethineIsuprelProventilAtroventTheophylline

• Anti-tuberculars IsoniazidRifampin

• Antibiotics

• MucolyticsMucomyst

• Anti-inflammatory– Corticosteroids:

Dexamethasone– Anti-Leuketrines– Mast Cell Stabilizers