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NUR 2260 Exam 3 2214c Study Guide {2020/2021}
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Adult 2 Exam 2 Respiratory, Burns, Renal 2012RESPIRATORY
The primary purpose of the respiratory system is gas exchange (the transfer of O2 and CO2 between the
atmosphere and the blood).
The lungs are lined with visceral pleura and the chest wall is lined with parietal pleura. The space between the two
is filled with thin fluid (about 20-25mL). If there is an increased amount of fluid this is called plural effusion. This
could be caused by a malignancy, CHF or pneumonia. Purulent pleural fluid is called empyema.
The diaphragm is the major muscle of respiration
Key terms”
o Ventilation- inspiration and expiration
o Elastic recoil- elasticity of tissue to expand and contract
o Diffusion- high to low concentration (for gas exchange)
o Compliance- ability of the lungs to contract w/ increased volume or breaths. Increased compliance means
lung can expand the proper amount. Decreased compliance means there is a decreased ability to expand.
In older people there is decreased space related to posture so there is also decreased compliance.
o Surfactant- liquid that decreases surface tension and helps prevent against alveoli collapse.
o Tidal Volume: volume of air inhaled and exhaled w/each breath (VT=500 mL)
o Residual Volume: Volume of air remaining in lungs after MAX exhalation (RV 1200 mL)
o Perfusion: flow of blood through pulmonary capillary bed which provides an extremely efficient structure
for gas exchange to take place. When the blood vessels sense a low oxygen content in the alveoli they
vasoconstrict=hypoxic vasoconstriction. Doesn’t matter how much o2 you give, if no perfusion, o2 won’t get
through.
Geriatric Considerations- in older people there is a decrease in elastic recoil of the lung and chest wall compliance
(can’t take deep breaths). Increase in anterior to posterior ratio (there is more dead space for the lungs to expand
in-OVER EXPANSION could lead to or be caused by emphysema). They have a decrease in functional alveoli, cell-
mediated immunity, and cough.
Respiratory Nursing Diagnoses-
Ineffective Airway Clearance r/t COPD, asthma
o Suction as needed
o Sputum culture
o Perform percussion, vibration, postural drainage
o Firmly secure ET / trach tube
o Assess fluid balance and maintain adequate hydration
Impaired Gas Exchange r/t pneumothorax, ARDS
Ineffective Breathing pattern r/t flail chest
Impaired Spontaneous Ventilation r/t COPD
o Assess VS (esp resp status)
o Monitor ABGs and O2 sat levels
o Admin O2 as ordered
o Fowler’s or High-Fowler’s
o Assist with ADLs, minimize activities
o Prepare for ET tube and mech vent -Explain procedure, it’s temporary, and you can’t talk
o Dysfunctional Ventilatory Weaning Response
Acute Pain r/t rib fractures
Ineffective Cerebral Perfusion r/t hypoxia
Imbalanced Nutrition less than required r/t emphysema
Compromised Family Coping r/t COPD
Decisional Conflict r/t smoking
Ineffective Health Maintenance r/t smoking
, Ineffective Denial r/t smoking abuse
Risk for Injury r/t PE & anticoagulant therapy
Anxiety r/t asthma & fear of suffocation
Ineffective Therapeutic Regimen Management r/t asthma meds
Impaired Home Maintenance r/t activity intolerance & ADL’s
Decreased Cardiac Output r/t PEEP ventilation
Ineffective Protection r/t anticoagulant therapy & bleeding
Hopelessness/Anticipatory Grieving r/t pulmonary hypertension
Resp Diagnostic Studies
Blood: hgb, hct, WBG, ABG
Oximetery (95%)
Sputum
Chest x-ray
CT scan, MRI
VQ Scan-looking for ventilation & blood flow to lung; NO dye used)
Pulmonary Angiogram- use of dye to assess perfusion
Bronchoscopy (biopsy, visualize structures)
Thoracentesis (withdraw fluid off thorax)
Pulmonary Function Tests- check amount of air going in/out of lung
Pneumothorax- this is caused by an accumulation of air in the pleural space. These
can occur spontaneously, without apparent cause, as a complication of preexisting
lung diseases, as a result of blunt or penetrating trauma to the chest, or from an
iatrogenic cause (following thoracentesis)
Spontaneous pneumothorax- develops when an air-filled bleb, or blister, on
the lung surface ruptures. Rupture allows air from the airway to enter the
pleural space. Air accumulates until pressures are equalized or until collapse
of the involved lung section seals the leak.
o Primary (simple)- affects previously healthy people normally, tall,
slender men between 16-24. The cause is unknown.
o Secondary- generally caused by over distention and rupture of an alveolus, is more serious and
potentially life threatening. It develops in clients with underlying lung disease, usually COPD. It may also
be associated with asthma, cystic fibrosis, pulmonary fibrosis, TB, ARDS and other lung disorders.
o Manifestations of spontaneous pneumothorax- Abrupt onset of pleuritic chest pain and SOB.
Tachypnea and tachycardia due to affected gas exchange. Chest wall movement may be asymmetrical,
breath sounds on affected side may be diminished or absent. Hypoxemia is more pronounced in
secondary pneumothorax.
Traumatic pneumothorax-Blunt or penetrating trauma of the chest wall and pleura can cause pneumothorax.
o Closed pneumothorax- MVA, falls, CPR- fractured ribs penetrate the pleura and cause collapse of the
lung. Rib fracture is the most common cause of a closed pneumothorax. Occurs with blunt trauma that
allows air from the lung to enter the pleural space.
o Open pneumothorax- (sucking chest wound) results from penetrating chest trauma such as a stab
wound, gunshot wound, or impalement injury. With this, air moves freely between the plural space and
the atmosphere through the wound. Pressure on the affected side equalizes with the atmosphere and
the lung collapses rapidly. Occurs with penetrating chest trauma that allows air from the environment
to enter the pleural space.
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, o Iatrogenic pneumothorax- may result from puncture or laceration of the visceral pleura during central-
line placement, thoracentesis or lung biopsy.
o Manifestations of traumatic pneumothorax- Pain, dyspnea, tachycardia and tachypnea may masked,
missed or attributed to other trauma. Focused pneumothorax assessment is essential. Chest wall
movement on the effected side is diminished and breath sounds are absent. If a penetrating wound air
may be felt or heard moving through respiratory effort. Hemothorax frequently accompanies traumatic
pneumothorax.
Tension pneumothorax- injury to the chest wall or lungs allow air to enter the pleural space but prevents it from
escaping. The lung on the affected side collapses and pressure on the mediastinum shifts thoracic organs to the
unaffected side of the chest, placing pressure on the opposite lung as well. As intraplural pressure increases,
heart, great vessels, trachea, and esophagus shift. Ventilation is severely compromised, and venous return to
the heart is impaired (decreased cardiac output). MEDICAL EMERGENCY requires IMMEDIATE INTERVENTION!
o Manifestations- severe resp distress/dyspnea, hypotension and JVD are evident as venous return and
cardiac output are affected. Tachycardia, tachypnea; Asymmetrical chest expansion, tracheal deviation
toward the uninjured side and severe dyspnea.
o Interventions/Treatments- High fowlers, oxygen, immediate needle thracostomy and chest tube
insertion. 3 sided dressing vs petroleum.
Diagnosis of pneumothorax-Oxygen saturation & ABG’s(for gas exchange) and chest x-ray.
Treatment- Chest tubes are the treatment of choice to removed air or fluid from the pleural cavity. Closed
drainage system.
Flail Chest – 2 or more consecutive ribs fractured in multiple places causing free floating chest wall segment and
paradoxical movement
S/S: Paradoxical chest movements, Dyspnea, Pain increasing on inspiration, Unequal chest expansion, Palpable
crepitus, Diminished breathe sounds, Crackles
TX: Intubate & mechanically ventilate w/+ pressure to stabilize flail, Intercostal nerve block to decrease pain,
Internal surgical fixation of flail, Preventive use of seatbelts and airbags
Pulmonary Contusion – bruise injury to lung tissue, can lead to pulmonary edema, and often leads to ARDS
S/S: May take 12-24 hrs to develop, Increasing SOB, Restlessness/apprehension, Chest pain, Tachypnea,
tachycardia, Blood tinged sputum, Cyanosis
TX: Similar to ARDS & acute resp. failure
Note: s/sx develop later (12-24 hrs) after bruise sets in, inflammatory response, then difficulty breathing.
Pleural Effusion: excess fluid in pleural space (normal is 10-20ml) (collapsed lung from fluid)
Etiology: Systemic – HF, Liver Dis., Renal Fail., Connective tissue dis./SLE; Local –
Pneumonia, Atelectasis, TB, Lung CA, Trauma CAN HAPPEN TO YOUNG MEN
SPONTANEOUSLY ; Most common in COPD pt
Types: Empyema – pus; Hemothorax – blood; Hemorrhagic – blood & pleural fluid;
Chylothorax – lymph
S/S: Dyspnea, Reduced pain w/fluid, Dull percussion, Absent or diminished breathe
sounds, Reduced chest wall movement
TX: Thracentesis 1,200-1,500 ml limit, Antibiotics for empyema, Thoracotomy & surgical
excision, Pleurodesis, Chest tube auto-transfusion 4 hrs
Chest Tube Care
Assess Respiratory status at least q4 hrs. Maintain a closed system. Tape all connections and secure the chest tube to
chest wall. Keep the collection apparatus below the level of the chest (gravity helps with drainage), check tubes for kinks
or leaks, monitor for air bubbles that could indicate an air leak. Check the water seal or negative pressure indicator
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