1. Nursing Management of Clients with Stressors of Respiratory Function Assessment & Diagnosis NUR133 Lecture #4 K. Burger, MSEd, MSN, RN, CNE

2. Anatomy of Respiratory Tract Review your NUR123 objectives on anatomy of upper and lower airways

3. Assessment of Respiratory System Review your NUR123 objectives on Subjective and objective assessment techniques

4. Anatomy Knowledge Factors Affecting Respiration Integrity of the airway system (ventilation) Functioning cardiovascular system (perfusion) Functioning alveoli (diffusion) Functioning neurocontrols

5. Assessment Knowledge Respiratory Assessment Respiratory Hx includes: Allergies Medications Medical Hx Smoking Lifestyle Stressors Hazard exposures

6. Assessing Respiratory Function Inspection Shape (AP diam), skeletal abnormalities, chest movement and expansion, rate,rhythm, effort Percussion Diaphragmatic excursion, tactile fremitus Auscultation Vesicular +, adventitious sounds

7. Assessing Respiratory Functioning Respiratory Rate: Eupnea Tachycardia Bradycardia Apnea Respiratory Depth: Deep Shallow

8. Assessing Respiratory Functioning Respiratory Rhythm: Regular Cheyne-Stokes Kussmauls Apneustic breathing Biots

9. Assessing Respiratory Functioning Respiratory Quality: No difficulty Dyspnea and DOE Orthopnea Retractions Cough: Nonproductive Productive Sputum Hemoptysis

10. Assessing Respiratory Functioning Auscultation: Vesicular Bronchial Bronchvesicular Adventitious: Rales/crackles Rhonchi Wheeze Stridor Stertor

11. 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)

12. 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 hold Average = 5700 ml

13. 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

14. Normal ABG Values PH 7.35 – 7.45 Acid --------------- Alkaline PCO235-45 mm Hg Partial Pressure of carbon dioxide HCO322-26 mEq/L Bicarbonate PO280-100 mm Hg Partial Pressure of oxygen MEMORIZE THESE VALUES !!!

15. 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”

16. 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

17. 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 )

18. CO2 and H Relationships Carbon Dioxide Results in Free Hydrogen CO2 + H2O = H2CO3 = H + HCO3 More Hydrogen = Lower PH ACIDOSIS

19. CO2 and H Relationships Carbon Dioxide Results in Free Hydrogen CO2 + H2O = H2CO3 = H + HCO3 Less Hydrogen = Higher PH ALKALOSIS

20. Acid Base Mnemonic R O M E R Respiratory O Opposite pH up PCO2 down = Alkalosis pH down PCO2 up = Acidosis M Metabolic E Equal pH up HCO3 up = Alkalosis pH down HCO3 down = Acidosis

21. Steps for ABG Analysis 1.Evaluate the PH 7.45 is Alkalosis PH = 7.29

22. Steps for ABG Analysis 2. Evaluate VENTILATION PCO2 > 45 indicates Respiratory Acidosis PCO2 < 35 indicates Respiratory Alkalosis PCO2 = 47

23. Steps for ABG Analysis 3. Evaluate METABOLIC PROCESSES HCO3 26 reflects Metabolic Alkalosis HCO3 = 24

24. Steps for ABG Analysis 4.Evaluate OXYGENATION PO2 80-100 = normal PO2 60-80 = mild hypoxia PO2 40-60 = moderate hypoxia PO2 < 40 = severe hypoxia PO2 = 58

25. Steps for ABG Analysis 5.Evaluate COMPENSATION Is compensation taking place? Yes if PH within normal limits and: Compensated Respiratory Acidosis = Increased HCO3 Compensated Respiratory Alkalosis = Decreased HCO3 Compensated Metabolic Acidosis = Decreased PCO2 Compensated Metabolic Alkalosis = Increased PCO2 PH 7.37 PCO2 46 HCO3 29 PO2 77

26. 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 = 78 The nurse analyzes these results as indicating: a.Metabolic acidosis, compensated b.Metabolic alkalosis, uncompensated c.Respiratory alkalosis, compensated d.Respiratory acidosis, uncompensated

27. 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

28. 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

29. 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

30. 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)

31. 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

32. Interventions for Respiratory Alkalosis Encourage appropriate breathing patterns Re-breathing techniques Anxiety control O2 therapy with caution

33. Nursing Diagnoses Impaired gas exchange Ineffective airway clearance Ineffective breathing pattern Risk for infection Activity intolerance Risk for injury Self-care deficit +++++++++++++++++++++++++++++++++

34. 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 +++++++++++++++++++++++++++++++++

35. Medications Bronchodilators Alupent Brethine Isuprel Proventil Atrovent Theophylline Anti-tuberculars Isoniazid Rifampin Antibiotics Mucolytics Mucomyst Anti- inflammatory –Corticosteroids: Dexamethasone –Anti-Leuketrines –Mast Cell Stabilizers