Chapter 29 Respiratory Assessment Preface: Trach care - high risk for completely losing airway.

It is a skill, but very complex with a lot of decision-making. ABG - compensated/uncompensated. On exam - will be tested on uncompensated. Lecture: A & P - there is a relationship of how much oxygen is breathed in, and what is actually transferred to the alveoli in the lungs. V/Q mismatch - Ventilation/Perfusion mismatch. If there is a perfusion issue - there will be a problem with the capillary. If there is a ventilation issue - there will be a problem with the alveoli. There is not an appropriate exchange of gases. EX: A person with a pulmonary embolus - breathing fine, moving plently of oxygen into the alveoli, but they have a clot, they will not be receiving adequate perfusion. This is a mismatch. Chart 29-1 - Changes in Respiratory System related to aging Surface area decrease - o2 sat will be a lower baseline Elastic recoil decreases - the alveoli cannot expand and contract - (sufactant) Ability to cough decreases - alveolie become chronically collapsed increased risk for pneumonia and atelectasis. Nursing interventions: Ambulate them, turn cough deep breathe, Pronate (change the area of lung that is being perfused-improve perfusion and ultimately out V/Q mis-match improves) When a patient is laying supine the lower portion of the lung is getting the most perfused. The upper airway serves as a humidifier and a heater for the rest of the respiratory system. Gas exchange best occurs at a specific temperature - body regulates. Arteriosclerosis of the pulmonary artery can lead to pulmonary hypertension. Respiratory Assessment - history, any kind of exposure to chemicals, prior TB exposure, ventilator, smoking. Hemoptysis Pink frothy sputum is NOT hemoptysis - it is a sign of pulmonary edema. Paroxysmal nocturnal dyspnea - intermittent dyspnea during sleep. Positional orthopnea - may need pillows DOE can be caused by both V and Q mis-match. What can cause DOE from a perfusion standpoint? Heart failure Tactile fremitus - assessment of the base of the lungs - you should feel vibration in the base of the lung. If the patient has pneumonia - it will cause increase tactile fremitus due to fluid buildup in the airways. If a patient has pleural effusion it will be decreased. Percussion

dullness in the higher lobes - could be tumor or cancer. D-Dimer (+) is indicative of a clot somewhere (DVT, PE), blood test. Measure the clotting cascade. Auscultating - concerned with crackles (indicative of fluid build up-pulmonary edema or pneumonia). Which is more concerning, wheezing or stridor! (swelling of the pharyngeal epiglottis airway) Stridor is an emergency caused by pharyngeal edema, epiglottal edema. If you cant resolve stridor right away with a dose of epinephrine, you must entubate right away. If you dont it will close all the way, and we will not be able to entubate. You can hear it without a stethoscope. If they are not moving much air and trying to assess, put steth on side of neck and you will be able to hear stridor. Wheezing - pay attention to this, someone with asthma/COPD/acute allergic process. Listening for the quality of the wheeze and how much air they are moving with each breathe. CT - reveals suspicious lesion or when a clot is suspected, because pulmonary soft tissue densities, tymors, and blood clots can be seen. IV contrast dye - to see visibility of structures such as tumors, blood vessels, and chambers of the heart. (iodine allergy) Pulse oximetry - You have to get the patients baseline to find what you need to be concerned about. Assess for how quick they can oxygenate (compensate) after they have gone without oxygen for a while. This will tell you the reserve (how quickly they can come back) - tells you the acuity of the lung disease that is going on. ABGs Go back and look at early charts to see if you can pull up previous ABG. PH - measure of acid or alkaline in the body (acidic 7.35-7.45-alkalotic - usually 7.4) CO2 - measure of acid for respiratory system (35-45 mmHg) More acidotic = >45 (respiratory acidosis) More alkalotic = <35 (respiratory alkalosis) HCO3 - measure of base in the metabolic system (22-26 mEq/L) More acidotic = <22 (metabolic acidosis) More alkalotic = >26 (metabolic alkalosis) CO2 retention - hypercapnia (respiratory acidosis)- the patient has ineffective exhalation on the ventilation. Pateints that retain CO2 are patients that are sedated, taking death breaths, acute respiratory failure, post-op, someone on a ventilator (rate is set too low)rate we set is called tidal volume-based on patients weight, usually grossly underestimated - patient will retain too much CO2. Compensating - the kidneys notice too much CO2.

Causes: states of dehydration, septic shock states, diabetic ketoacidosis, lactic acidosis (muscle breakdown from drug or trauma). When would a patient blow off too much CO2 cause a low CO2 and a subsequent respiratory alkalosis = hyperventilation!!! They become dizzy and light headed because CO2 gets low. Hyperventilating by too high of a rate on the ventilator - you can cause a person to have respiratory alkalosis-losing too much CO2). Nursing Interventions: cupped hands, brown paper bagincreasing the amount of CO2 in the body. If they are on a ventilator and you get the ABG back and the CO2 is too low, increase the rate of a ventilator. Causes: Vomiting, NG tube suction, ingested substances. Know ABGs Understand why certain ABG abnormalities occur, interventions for each abnormality. Severely acidotic - bicarb drip to bring the pH back down to where its supposed to be. Base deficit - BE number - patient needs fluids, ABG will correct itself. Respiratory is the fastest compensating side. Chapter 30 Oxygen Therapy and Tracheostomy Oxygen therapy - must have an order, nurses can apply o2 to a pt in an emergency situation. * Nasal cannula - good flow, some issues - can dry out nose and make nose bleed, irritated nares, skin breakdown, increased fall risk. DO NOT SMOKE!!!!! Oxygen concentrater room air and concentrates it and delivers through nasal cannula. *least concentration* Face mask - more areas of skin breakdowns, post-op. *little more concentration* Non-rebreather mask - provides the highest oxygen level of the low-flow systems. They are not rebreathing the air they have breathed before. Precursor for intubation, post-op. *highest percentage of oxygen* Highest percentage of oxygen that provides full artificial ventilation - bag valve mask (make sure bag fills up). You can use this to ventilate the patient. Tent - goes over trach - probably be humidified. May be used with endotracheal tube. Tracheostomy - from oral cancer, laryngeal cancer. Trach care - most people can care for it at home. Risks: The artery that run on each side of the trachea - inominent arteries - when they access the trach - it could rupture or hemorrhage. Laryngeal nerve can be damaged when the trach is place, vocal cord paralysis.

Usually placed in an OR by a surgeon, can be done at bedside for emergency, small incision made in less controlled environmentpointed and sharp. Inner cannula risk - oxygen they lose while you take it out, this decreases risk for infection. Changing strap risk - losing the airway, if the patient coughs and it comes out, do not put it back in, but put the obturator inside!! It should be hanging above the bed. Buvona Wean off trach - First, deflate the cuff, allows them to breathe around the cuff. We are hoping the patient will cough to get the secretions out and into the lungs. Risk for infection. Second, the tube is changed. Fenestrated trach - re-establishes normal airflow through the nasopharynx. Cuffless-allows air to flow around. When a small fenestrated tube is placed, the tube is capped so that all air passes through the upper airway and the fenestra, with non passing through the tube. You cannot suction a fenestrated trach. DO NOT!!! Risk for infection - make sure tube is clear of humidification so oxygen can flow. Make sure the trach is clean, when they cough - it should not dry there, you should change that regularly.

ABG Case study 26 - mechanical ventilation