Diagnostic Test

chest x-ray – test for fluid, air, or atelectasis (under inflated tissue)

arterial blood gases – ABG hold pressure for 5 min on artery

sputum culture – collect in a.m. form deep within chest

pulse oximetry – use opposite side of body from BP arm

bronchoscopy – scope into lungs – sterile (must have consent)

TB skin test (PPD) check for redness, erythema, induration

Nursing Diagnoses – Ineffective Breathing pattern

R/T pain? Decreased energy?

Musculoskeletal impairment?

AEB – SOB, nasal flaring, abnormal ABG values, use of accessory muscles, cough, cyanosis

Nursing Diagnoses – Impaired Gas Exchange

R/T Imbalance of ventilation & perfusion

AEB – confusion, somnolence, restlessness, irritability, hypoxia

Outcome Identification – the client will...

mobilize pulmonary secretions

tissues will have adequate oxygenation

verbalize method to prevent recurrence of infection

Implementation – health promotion

hand hygiene

cover mouth when oughing

avoid large crowds in flu season

nutrition

rest

flu shots

Implementation

health promotion

smoking cessation guidelines ("Chantix" prescription med to aid smoking cessation)

reducing allergens

providing adequate hydration

positioning & ambulation

deep breathing

Incentive Spirometry – semi-Fowler's position, inhale & measure breath, hold 3 sec., slowly exhale

check for 8-10 breaths

Coughing & deep breathing

teach prior to surgery while pain is not an interfering factor

take 3 slow deliberate breaths

on 3^rd breath, hold it

splint the incision (hold hand gently, but firmly over incision)

cough deeply two or three times

Oxygen by nasal cannula

Altered Respiratory Function

Altered Respiratory Function

cough – voluntary / involuntary (⁎ codeine is addictive & ↓ respirations)

sputum – thick, tenacious, infective (wear gloves) can have odor

shortness of breath (SOB) dyspnea – humidified O₂ helps

chest pain – Does it fluctuate with breathing? = lung pain

Accessory muscle use – neck veins stand out – fatiguing

Barrel chest – work hard to breathe, chronic COPD – less capable of expanding / contracting

Cyanosis – bluish circumoral cyanosis

Clubbing – fingers rounded, fingernails with ↓perfusion

Hemoptysis – cough up blood

Altered Respiratory Function – impact on ADL

become dyspneic with simple tasks

eating is difficult if you have to take time to breathe, you don't have enough energy

"Pulmocare" -liquid supplement for people when it is difficult to chew / breathe

dressing

bathing

mobility

helpful to breathe in nose, out mouth (relaxing)

Assessment – subjective data – What is normal?

cough

sputum

How far can they walk before needing to rest? - a mile? block? one flight of stairs?

Assessment – subjective – What risk factors do they possess?

snoring

occupational hazards

Do they have a new pet?

How many "pack-years" have they smoked?

Assessment – objective data – inspection

color (circumoral cyanosis)

in people of color check mucous membranes – Are they pink?

observe rate & pattern of breathing

Are they using accessory muscles to breathe? Are they barrel-chested?

Assessment – objective data

palpation

percussion

auscultation – listening to breath sounds with stethescope

Lifespan Considerations – adult & older adult

Lifespan Considerations – adult & older adult

structural & functional changes

lungs become less resilient

cough is less effective

these changes contribute to activity intolerance in ADL's

Factors Affecting Respiratory Function

Body position – an upright posture with frequent position changes allows for greater lung expansion

Environment

1. less O₂ at ↑altitudes

2. temp. & humidity play role in asthmatics breathing

Factors Affecting Respiratory Function

Air pollution – may contribute to bronchitis & asthma

Pollens & allergens can cause allergic responses

Medications

Albuterol – bronchodilator (side effects: insomnia, anxiety)

Theophylline – bronchodilator (side effects: taccycardia, nervousness)

Corticosteroids – reduces inflammation (side effects: fluid retention, hypertension, hyperglycemia)

Need to assess blood sugar, BP, weight

Factors Affecting Respiratory Function – lifestyle & habits

smoking

alcohol consumption

nutrition

fluid (to thin secretions)

obesity makes breathing difficult while lying down

Introduction to Respiratory Assessment

Introduction to Respiratory Assessment

Respiratory Assessment Outline:

normal respiratory function

factors affecting respiratory function

altered respiratory function

assessment

nursing diagnoses

implementation & evaluation

Normal Respiratory Function

diaghragm contracts & lowers - neg air pressure -air goes in

early sign of hypoxia – restlessness

hypoxemia – low oxygen in blood

Defense Mechanisms – upper respiratory tract (nose, mouth, sinus, pharynx)

warm & humidify air

filter foreign particles

sneezing helps to expel trapper material

epiglottis acts as a trap door to prevent aspiration

Defense Mechanisms – lower respiratory tract – million of ciliated cells sweep particles up and out of

lungs. there are mucous-producing glands

trachea

bronchi – R & L

bronchioles – alveoli – most oxygen & carbon dioxide exchange here

Most Important lung defense is a strong & effective cough

smoking coats cilia with tar, reduces effectiveness of cough

Normal Breathing Pattern

smooth, even, & regular

12-20 breaths / min in adult

control of breathing is both voluntary & involuntary

Factors Affecting Respiratory Functioning

level of health – renal disease, pH balance, heart problems

developmental considerations

medications

lifestyle

environment

psychological health

Developmental Considerations - newborn & infant

surfactant is produced late in gestation (lubricant) - lung tissue expand & contract, ↓surface tension

newborns breathe rapidly – 30-60 breaths /min

breathing pattern is irregular

Developmental Considerations – toddler & preschooler

breathing pattern evens out

breathe 20-30 times / minute

prone to put things in mouth

must protect against aspiration

Developmental Considerations – child & adolescent

rate slows to 12-20 breaths / min

many adolescents start smoking tobacco

as nurses we must educate them about the hazards of smoking