1. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 24: Patient Assessment: Respiratory System

2. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Respiratory Assessment: Inspection Scan body from head to toe Observe general overall appearance and mentation Observe head and neck: position of trachea Observe chest for symmetry and overall respiratory function Observe spine for alignment Observe extremities

3. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Palpating the Thorax

4. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Palpating Chest Expansion

5. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Palpating the Trachea

6. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Percussing the Anterior Thorax

7. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Percussing the Posterior Thorax

8. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Auscultating the Chest

9. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Purpose of Pulse Oximetry Trending of arterial O2 saturation –Determine correlation with ABGs –Values of O2 saturation affected by hemoglobin level

10. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Limitations of Using a Pulse Oximeter Meds that cause vasoconstriction IV contrast dyes Shock Cardiac arrest Severe anemia Elevated carboxyhemoglobin levels Use of nitrates or lidocaine

11. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Purpose of End-Tidal CO2 Monitoring It provides a noninvasive means to predict the ventilation status by measuring the carbon dioxide level from exhaled air.

12. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins SaO2 - Oxygen Saturation Oxygen bound to hemoglobin Need to know hemoglobin to determine overall amount of O2 available in blood PaO2 - Oxygen Pressure Oxygen bound to plasma - 3% Does not tell amount of O2 available in the blood

13. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Role of pH pH is the measurement of the hydrogen ion concentration in the blood 7.35 to 7.45 Acidity means <7.35 –Volatile acids - eliminated by respiratory system –Nonvolatile acids - eliminated by metabolic system Alkalinity means >7.45 –Base

14. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Role of PCO2 Carbon dioxide gas dissolved in the arterial blood Byproduct of cellular metabolism Regulated by ventilation PaCO2 (35 - 45 mm Hg) –<35: hyperventilation leads to respiratory alkalosis –>45: hypoventilation leads to respiratory acidosis

15. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Role of HCO3 Bicarbonate is the base. Regulated by the kidneys Metabolic process 22 to 26 mEq/L –<22: metabolic acidosis –>26: metabolic alkalosis

16. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following statements describes how the kidneys respond to respiratory alkalosis? A. There is a decrease in hydrogen secretion and bicarb reabsorption. B. There is an increase in hydrogen secretion and bicarb reabsorption. C. There is an increase in the rate and depth of respirations. D. There is a decrease in the rate and depth of respirations.

17. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. There is a decrease in hydrogen secretion and bicarb reabsorption. Rationale: Kidneys respond to a respiratory-induced alkalosis by decreasing the secretion of hydrogen in the urine and reabsorbing the sodium bicarb in the tubules.

18. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins The Relationship of Acid-Base Disorders Acid-Base DisorderpHAcid/Base Respiratory acidosis<7.35PaCO2 > 45 mm Hg Respiratory alkalosis>7.45PaCO2 < 35 mm Hg Metabolic acidosis<7.35HCO3 < 22 mEq/L Metabolic alkalosis>7.45HCO3 > 26 mEq/L

19. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A client’s arterial blood gas results are as follows: pH 7.33, PaO2 75, PaCO2 52, HCO3 28 mEq/L. The nurse would interpret this to mean: A. Metabolic acidosis uncompensated B. Metabolic alkalosis partially compensated C. Respiratory acidosis uncompensated D. Respiratory acidosis partially compensated

20. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer D. Respiratory acidosis partially compensated Rationale: The respiratory system is responsible for the acidotic pH and the kidneys are trying to compensate. Whenever the pH is abnormal, find out if it is borderline to the following levels. If the pH is 7.41 to 7.45, then the cause is alkalosis. If the pH is 7.35 to 7.39, then the cause is acidosis. If the other system is trying to compensate, then it is partially compensated since the pH is abnormal.

21. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Mixed Venous Oxygen Saturation SVO2 is used to assess the balance between the oxygen supply and the oxygen demand at the tissue level.

22. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question The nurse notes that the SVO2 is low. Which of the following is a possible cause? A. Hypothermia B. Hyperthermia C. Hypothyroidism D. Early stage of septic shock

23. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. Hyperthermia Rationale: A low SVO2 occurs when there is either a decrease in the supply of O2 to the tissues or an increased demand for O2 by the tissues, so hyper states, low hemoglobin, or low cardiac output can cause a low SVO2. A high SVO2 occurs when there is either an increase in the supply of O2 to the tissues or an decreased demand for O2 by the tissues. The other answers are all possible causes of a high SVO2.