This document contains basic notes from class as explained by professor. Each topic is simplified and is a basic summary from the words professor stated. It is helpful if you are studying for one of the first exams for Med Surg II.
Interventions:
● Thorough Hx and physical assessment to identify at risk pt
and initiate early interventions
● Deep breathing/ coughing, incentive spirometry, and early
ambulation
● Frequent assessment of high risk pt.
● Prevents: atelectasis (if surfactant damaged atelectasis
happens), pneumonia, complications of immobility, and
optimize hydration and nutrition
Dx: Inadequate Ventilation/ Ineffective Assessment Findings:
Breathing Pattern ● rate of breathing
● abnormal chest wall movement
● irregular breathing pattern
● abnormal work of breathing
Dx: Ineffective Airway Clearance Dx. Occurs when an artificial airway is used because normal
mucociliary transport mechanisms are bypassed and
impaired
Inadequate Airway Clearance Findings:
● Adventitious breath sounds.
● Abnormal respiratory rate, rhythm, and depth.
● Declining oxygen saturation.
● Ineffective or absent cough reflex.
● Copious mucus production.
● Hypoxemia.
● Restlessness.
● Change in level of consciousness
Interventions:
● Position to decrease secretions
, ● Suction as needed
● Mobilize secretions
● Give respiratory medications
● Involve respiratory therapy
Respiratory Rapid Assessment Assessment:
● position
● work of breathing
● breathing patterns
● ability to speak
● pursed lip breathing
● retraction
● paradoxical breathing
Assessment Priorities:
● do frequently
● assessment of ability to breathe and provide assistive
measures
● breath sounds
● LOC changes?
Oxygenation
● Oxygen into each cell
● Two components:
○ Respiratory
■ Airway: open passage for air
■ Ventilation: breathing muscle must expand to ventilate
■ Diffusion: gas exchange in alveoli
○ Circulation
■ Perfusion: adequate blood pressure to deliver blood to each cell
● pH less than 7.35 → acidic ;
● pH more than 7.45 → alkaline
, ● Compensation = pH within normal range but CO2/HCO3 values out of range
● Partial compensation = body changes values to correct pH but has not accomplished normal pH
1) Acidic or basic ??
2) Respiratory (CO2) or Kidney/metabolic (HCO3) ??
3) Compensated ?? → look at pH
Respiratory acidosis Tx: Metabolic Acidosis Tx:
● Look for sx hypoxia ● Can be caused by DKA
● Tx: O2 → 2L NC, paO2 <60 ● Tx: Dialysis, DKA intervention (insulin drip)
● IS, Raise HOB
● Bronchodilators
● Reverse airway obstruction
● Noninvasive and pressure ventilation
Respiratory Alkalosis Tx: Metabolic Alkalosis Tx:
● Slow Breathing: breathe into brown paper bag, ● Tx underlying cause: diuretics, steroids, NG
pursed lip breathing suction
● IS ● Hypokalemia
● IV fluids
Hypoxia Symptoms: Sx:
1) mental status changes: restless, agitation, confused
2) increased HR, RR, HTN
3) (LATE) cyanosis, coma, lethargy, somnolence, hypotension,
decreased CO
- Tx w/ hydration and IV bolus
Acute Respiratory Failure (ARF)
★ Occurs when oxygenation, ventilation, or both are inadequate
○ Not a disease but a symptom that reflects lung function
○ If bad, can progress to ARDS
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