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Nurs 246- Exam 3 (Week 9) Pulmonary/ oxygenation
Questions With Complete Solutions
What is the angle of Louis? correct answer: •Joint formed by the articulation between the manubrium and the body of the sternum •Where the sternum and second ribs meet midaxillary line correct answer: An imaginary vertical line that starts at the middle of the axilla (armpit) and extends down the side of the chest. 2 What do we listen for in the lateral thorax? And what should it sound like? correct answer: Lateral thorax ◦Vesicular sounds ◦Softer lower pitch and found in the thorax what do we inspect for in the anterior thorax for? Posterior thorax for? and describe them correct answer: inspect the same things anteriorly and posteriorly Observe accessory muscles. ◦Should not see pt working to breathe •Observe for pts breathing patterns •Look at neck muscles for inappropriate movement during breathing
•And adults should not be using abdominal muscles to breath (this is different for peds and infants) Palpate muscles and skeleton. Compare right and left sides. ◦Should be equal bilaterally Auscultate for bronchial sounds. ◦Normally heard over the trachea •Look for mucus secretions at lower lobes bc it is where gravity pulls it How many lobes in the right lung? How many lobes in the left? why? correct answer: 3 lobes in the right 2 lobes in the left left is smaller bc hear occupies that side of rib cage are lung sounds better heard anteriorly or posteriorly? correct answer: better hear posteriorly where is the 1st rib found? correct answer: under and above the clavicle upper parts of lung found here to visual signs that someone is struggling to breath correct answer: restlessness nasal flaring supraclavicular retraction
what 2 major things are required to keep alveoli open? what can happen if pt in pain from fractured rib? what is it called when alveoli collapse? what is used to prevent lung collapsing? correct answer: surfactant and positive pressure when pt has fractured rib, they don't take deep breaths and alveoli are susepticable to collapsing atelectasis Use a incentive spirometers to help expanding lungs (helps decrease risk of pneumonia Compliance vs resistance correct answer: Compliance ◦Ability of lungs to expand and distend. It decreases with pulmonary edema plural fibrosis and congeneraler abnormalities such as kyphosis or broken ribs Resistance ◦Broncial constriction can increase resisotance -Things like COPD ◦When resistance increases oxygen delivery decreases ◦Chemical injury can increase resistance (swelling restricts air flow Factors Affecting Oxygenation: Physiological factors and examples (4)? Conditions affecting chest wall movement? Chronic diseases correct answer: Physiological factors ◦Decreased oxygen-carrying capacity ->Anemia, decreased hemoglobin, carbon monoxide poisoning (pulse ox will look fine)
◦Hypovolemia ->Decreased fluid ◦Decreased inspired oxygen concentration -> Airway obstruction, decreased ventilation ◦Increased metabolic rate -> Anyting that increased MR increased HR and breathing bc more nutrients needed -> Anxiety, caffeine, fever, exercise Conditions affecting chest wall movement ◦Pregnancy (pushes on the diaphragm) , obesity (compresses the lungs), neuromuscular disease, musculoskeletal abnormalities, trauma,, CNS alterations, high altitude Influences of chronic diseases COPD, asthma, Cystic fibrosis, Congestive heart failure, polio What is hypoventilation and what can cause it? What is hyperventilation and what can cause it and what are some S&S? What is hypoxia and what causes it and what are S&S? what is cyanosis and when do we see this? correct answer: Hypoventilation -Alveolar ventilation inadequate to meet the body's oxygen demand or to eliminate sufficient carbon dioxide -Opiods can cause respiratory depression Hyperventilation -Ventilation in excess of that required to eliminate carbon dioxide produced by cellular metabolism -caused by anxiety, infection sepsis, and some meds
◦Asbestos What 6 things are included in respiratory assessment correct answer: -In-depth history of a patient's normal and present cardiopulmonary function -Past impairments in circulatory or respiratory functioning -Methods that a patient uses to optimize oxygenation -Review of drug, food, and other allergies -Physical examination -Laboratory and diagnostic tests What do we assess for when taking pt history (11) correct answer: Pain •Pts with chest pain require immediate attention and evaluation •Thoracic chest pain is the inflammation of the plural space of lungs and pain typically radiates to the back •Musculoskeletal pain is often present after exercise, rib trauma or a coughing episode Fatigue •Indicates decline Dyspnea •Clinical hypoxia •Is the subjective feeling of shortness of breath Cough •What makes it worse or better? Amount? Color? •Do you cough something up when you cough? If yes, how long, how much, what color, what consistency, do you have any pain, is it worse at a certain time of day
Wheezing •Caused by air passing through a narrow airway
- caused by asthma (bilateral wheeze) , broncitis, pneumonia (can be unilateral or bilateral for last 2) •High pitched •Associated with copd(starts with exhalation usually) and asthma (starts with exhalations) and pts with burns (starts with either inhalations or exhalations Smoking •CO poisoning •Flu like symptoms and decreased LOC Respiratory infection •At pt about TB test Allergies •Do they have any or any environmental allergens •Goes into anaphylactic shock the first things that happens is difficulty breathing Health risks •Underlying conditions and history Medications l-egal, illegal, over the counter, etc. Orthopnea •Difficulty breathing laying down •Noctural (happens at night)
What is subcutaneous emphysema? correct answer: a characteristic crackling sensation felt on palpation of the skin, caused by the presence of air in the soft tissue how do you document normal breath sounds in both lungs? what do you never say? correct answer: Documented as clear and equal NEVER say you didn't hear anything What are vesicular breath sounds? correct answer: low-pitched, soft sound during expiration heard over most of the lungs normal breath sounds what are bronchovesicular sounds? are they normal correct answer: medium-pitched blowing sounds heard over the major bronchi normal breath sounds crackles (rales): what is it caused by? what does it sound like course vs fine and when can they be heard? does it clear with coughing correct answer: ◦Caused by sudden re-inflation of alveoli or by disrupted passage of air through the airway ◦Fine- High pitched short interrupted crackly sounds heard at the end of expiration and do not clear with coughing ◦Course- loud, bubbly sounds heard during inspiration, not cleared with coughing
Ascultation: what do we want to avoid listening over? how do we want our pts breathing? what do we see in obese pts? what does absence of lung sounds indicate? correct answer: •Avoid listening over bone •Have pt take slow deep breaths •May be harder to hear lung sounds in obese pts •May sound fainter and softer •With young children my be better to use bell to hear better •Listen for absence of lung sounds in collapsed and removed (never hear that you heard nothing, you heard clear) Ronchi: what causes it? what does it sound like and when can it be heard? can it clear with coughing? correct answer: ◦Loud, low pitch rumbling hear during inspiration or expiration (sounds like underwater to me) ◦And can clear with coughing Caused by muscle spasms, fluid or mucus in the larger airways, or a growth Wheezes: what do they sound like? when can it be heard? what causes it? correct answer: ◦High pitch musical sounds (sounds like whale eco location to me) ◦During inspiration or expreation, loudest during expiration (but will always start with expiratory) Caused by narrow or restricted aorpassage ways
Environmental pollutants ◦Secondhand smoke, work chemicals, and pollutants -make sure wearing proper ppe Pulmonary acute care: list and describe the 7 correct answer: Dyspnea management •Oxygen therapy helps with dyspnea associated with exercise and hypoxemia Airway maintenance Mobilization of pulmonary secretions •Get them up and moving (ambulation) -chest percussions (hit with cupped hand)/vibrations -postural drainage Hydration •Oral hydration but if cannot then IV hydration Humidification
- hydrates O2 received, needed for necessary for pts receiving o2 therapy greater than 4 liters long term Nebulization •Albuterol •Causes bronchodilation Coughing and deep-breathing techniques
•Belly breathing to encourage deeping breathing for increased air What aspect of hygiene is extra important in Pulmonary pts? correct answer: oral hygiene when is chest percussions and vibrations contraindicated? correct answer: •Contraindicated in pts with bleeding disorders, osteoporosis, or a fractured rib what suctioning techniques are used when the pt can cough effectively, but is not able to clear secretions? correct answer: Oropharyngeal and nasopharyngeal suctioning what suctioning techniques are used when the pt is unable to manage secretions by coughing and does not have an artificial airway? which is the preferred airway? correct answer: orotracheal and nasotracheal suctioning ◦Nose is preferred way bc it does not mess with the gag reflex how is tracheal suction used? correct answer: used with an artificial airway done via surgical opening of the trachea Do's and Don'ts of Suctioning correct answer: •Do not apply suction when inserting catheter •Only apply suction after catheter has been placed and being withdrawn
◦Tonge should rest under it ◦Use clean technique Have to measure for proper size and use specific technique ◦Measure from corner of mouth to tip of earlobe ◦Falange intended to rest on lips Artificial Airways- Endotracheal/Tracheal: what is it used for (4)? for how long? how is it kept in place? what kind of pt is it used on? who can insert this? correct answer: 1. Short-term use to ventilate, 2. relieve upper airway obstruction, 3. protect against aspiration, 4. clear secretions ◦Typically removed within 14 days ◦Comes in different sizes ◦Uses balloon to keep in place under vocal cords ◦Goes and stops carina (where bronchi start) ◦Use when someone is unresponsive ◦Can only be done by doctors or paramedics ( ET tube) Only CRNA's can do it List the types of artificial airways correct answer: oral, endotracheal, and tracheal
what happens if you hear air in the epigastric area following insertion of endotracheal tube? what do you want to hear correct answer: •If you hear air in the epigastric area, it means that it is not in the right area (it went down the esophagous) •Want sounds to be clear and equal bilaterally --> If you hear It in the right lung only, you went to deep, have to deflate it, pull out a bit, reposition, then reinsert and refill balloon Artificial Airways - Tracheostomy: what is it used for? how does it stay in place? correct answer: ◦Long-term assistance, surgical incision made into trachea ◦Has a bulb so that it does not sleep out ◦Can take out clean and put back in or replace with new one Maintenance and Promotion of Lung Expansion: what 3 things help with this and describe them? what do all of these prevent? correct answer: Ambulation -having pt move around Positioning •Try to get them vertical •45 semi fowlers best for lung expansion ◦Reduces pulmonary stasis, maintains ventilation and oxygenation Incentive spirometry ◦Encourages voluntary deep breathing ◦Decrease risk for pneumonia and atelectasis ◦DON'T blow into, you SUCK air out of it (Inhale)
Maintenance and Promotion of Lung Expansion - Noninvasive Mechanical Ventilation: what is the purpose and the 2 kinds? what do we need to watch for? correct answer: ◦Purpose is to maintain a positive airway pressure and improve alveolar ventilation Continuous positive airway pressure (CPAP)
- only offers a single pressure ◦Saves many from having to be intubations ◦Keeps pt airway open ◦Mask needs to fit right (good seals) (but enough slack to allow 1 or 2 fingers underneath Bilevel positive airway pressure (BiPAP) -offers inhale pressure and exhale pressure ** Both can cause facial or nasal skin breakdown, dried mucus, aspirated vomit (if pt nauseated keep eye on them) ** Maintenance and Promotion of Lung Expansion - Chest Tubes: what are the 2 kinds and what are they from? what should we watch for? when is the only time you can clamp a tube? correct answer: Pneumothorax ◦Collection of air in the pleural space ◦The loss of intrapleural pressure causes lung to collapse ◦Can be spontaneous or trauma related Hemothorax ◦Blood in the pleural cavity ◦From trauma
Special considerations ◦Chest tubes are closed systems and must be kept below chest, must be secured to chest wall ◦sterile ◦Make sure water seal channel at appropriate level ◦Watch for slow steady bubbling in the chamber ◦Note cloudy or bloody drainage ◦DO NOT look or kink tubing ◦Insertion and removal can be painful and be sure to educate pt ◦Assess tube area for subq emphysema (air has leaked into sub q ) (sounds like popping and crackling) ** •Clamping is only allowed for ambulation and nurse CAN NOT do this without a direct order from doctor ** Maintenance and Promotion of Oxygenation: why is oxygen therapy used? what safety precautions should be used? correct answer: Oxygen therapy ◦To prevent or relieve hypoxia Safety precautions ◦Flammable, keep 10 ft from any open flames •To much O2 can male someone O2 toxic (is a med so need med rights Methods of oxygen delivery: list the kinds? what are their flow rates? what are simple face masks contraindicated for correct answer: Nasal cannula ◦Offers 1-6 l of O -used for lower concentrations of O
