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July 8 Notes

July 8 Notes

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Published by Lindsey Lowrie
Notes from Med surg 1
Notes from Med surg 1

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Published by: Lindsey Lowrie on Jul 08, 2013
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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 actuallytransferred 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 thealveoli, but they have a clot, they will not be receiving adequate perfusion. This is a mis-match.Chart 29-1 - Changes in Respiratory System related to agingSurface area decrease - o2 sat will be a lower baselineElastic recoil decreases - the alveoli cannot expand and contract - (sufactant)Ability to cough decreases - alveolie become chronically collapsed increased risk forpneumonia and atelectasis. Nursing interventions: Ambulate them, turn cough deepbreathe, Pronate (change the area of lung that is being perfused-improve perfusion andultimately 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 pillowsDOE can be caused by both V and Q mis-match.What can cause DOE from a perfusion standpoint? Heart failureTactile fremitus - assessment of the base of the lungs - you should feel vibration in the baseof the lung.If the patient has pneumonia - it will cause increase tactile fremitus due to fluid buildup inthe 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 clottingcascade.Auscultating - concerned with crackles (indicative of fluid build up-pulmonary edema orpneumonia).Which is more concerning, wheezing or
stridor!
(swelling of the pharyngeal epiglottisairway)
 
Stridor is an emergency caused by pharyngeal edema, epiglottal edema. If you can’t resolve
stridor right away
with a dose of epinephrine, you must entubate right away. If you don’t it 
will close all the way, and we will not be able to entubate. You can hear it without astethoscope. 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 eachbreathe.CT - reveals suspicious lesion or when a clot is suspected, because pulmonary soft tissuedensities, tymors, and blood clots can be seen.IV contrast dye - to see visibility of structures such as tumors, blood vessels, and chambersof the heart. (iodine allergy)Pulse oximetry - You have to
get the patient’s 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”)
- tellsyou the acuity of the lung disease that is going on.ABGsGo 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 exhalationon the ventilation. Pateints that retain CO2 are patients that are sedated, taking deathbreaths, 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 becauseCO2 gets low. Hyperventilating by too high of a rate on the ventilator - you can cause aperson to have respiratory alkalosis-losing too much CO2). Nursing Interventions: cuppedhands, brown paper bag
increasing the amount of CO2 in the body. If they are on aventilator 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 ABGsUnderstand why certain ABG abnormalities occur, interventions for each abnormality.Severely acidotic -
bicarb drip to bring the pH back down to where it’s 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 emergencysituation. *Nasal cannula - good flow, some issues - can dry out nose and make nose bleed, irritatednares, 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 arenot 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 (makesure 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 theyaccess the trach - it could rupture or hemorrhage. Laryngeal nerve can be damaged whenthe trach is place, vocal cord paralysis.

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