CEN 간호사 시험 준비 1) 호흡기계 Jeff solheim summary

Airway intervention(suctioning)

- limit suction to 10 sec
- suctioning can stimulate the vegal response(bardycardia and hypotesntion)  especially in the infant.
- place head in sniffing position(intubation position) for nasopharyngeal suctioning;  
     (*any position for oropharyngeal suctioning*)
-Nasopharyngeal suctioning should use catheter with a diameter of no more than 1/2 diameter of the naris.
-Bulb suctioning-> depress bulb before inserting, release when in area of secretion.
                                       for oral suction, aim toward inside of cheeks, not back of throat

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Breathing intervention

-Nasal cannula
1L> 24%(Fio2) 2> 28%(Fio2)............ 6L>44%(Fio2) (*Fio2 increases 3-4% per liter increase in flow rate.)
*Decreased effect for 'mouth breathers ' and may dry out nasal mucosa.

-Simple mask
5 to 6L > 40%(Fio2), 6 to 7L>50%(Fio2) 7 to 8L> 60%(Fio2) (*Flow rate should be at least 5-6L/min to minimize rebreathing of Co2)
*Effective for "mouth breather" or those with nasal obstruction. But may cause drying of the eyes.

-Non-rebreathing  mask
more than 10L/min> 80% up to 100%(Fio2) (lack of oxygen flow may lead to "rebreathing of Co2" so O2 level should be high enough that reservoir bag never collapses)
*may cause drying of the eyes.

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Respiratory patterns

Kussmaul's Resp ("Rapid and deep breathing without pauses.")

*appears to be "air hungry" gasping to breath.
Associated with states of acidosis

Biot's Resp (" Fast and deep breathing punctuated by periods of apnea")

Associated damage in medulla oblongata(연수) from stroke or trauma/ meningitis

Central neurogenic Resp (" Very deep and Rapid Resp with no apneic periods")

Assoiciated IICP

Cheyne-Stoke Resp (" Rhythmic crescendo and decrescendo of rate and depth of Resp, includes brief periods of apnea")

Associated with increases of Co2 in the cerebrum(대뇌)

Apneustic breath (" Prolonged inspiratory and expiratory pause of 2-3 sec.")

Signify presense of brainstem lesion usually at the level of the pons(뇌교).
 

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Blood gases

Procedure

-Flex wrist 30 degree
-Insert needle at 30-45 degree angle.
-Blood should automatically fill syringe (1-2mL)
-Expel all gas bubble(falsely elevate PO2)
-Apply direct pressure to puncture site foe 3-5 min(*10 min if anticoagulated)
 

Gas abnormalities

Normal -> pH 7.35-7.45/ Co2 35-45 mmHg/ Hco2 22-26mmHg/ Base Excess( 염기 과잉) -2 to +2

Abnormalities

Resp Acidosis

Cause) Hypoventilation (Durg overdose with CNS depression/ COPD/ brain stem injury)
Symptom) Co2 necrosis( headache, dizziness, confusion, decrease LOC)
 

Resp Alkalosis

Cause) Hyperventilation (anxiety, fever, pain, hypoxia, asthma, high altitude, brain tumor)
Symptom) Hypocalcemia (tingling finger, twitching(경련), tremor, carpopedal spasms(수족 경련), tetany, dizziness,                                                      lightheaded)

 

Metabolic Acidosis

Cause) Increased systemic acids( DKA, hypoxia, kidney failure)  / Diarrhea
Symptom) Kussmaul, confusion, Lethargy, COMA

 

Metabolic Alkalosis

Cause) Loss of hydrogen ions(수소이온), Elevated K+, Decreased Chloride, Loss of gastric content, Baking soda,
             IV sodium bicarbonate)
Symptom) Hypocalcemia (tingling finger, twitching, tremor, carpopedal spasms, tetany, dizziness, lightheaded)
 

*) Why potassium cause alkalosis?

"As the extracellular potassium concentration decreases, potassium ions move out of the cells. To maintain neutrality, hydrogen ions move into the intracellular space. Administration of sodium bicarbonate in amounts that exceed the capacity of the kidneys to excrete this excess bicarbonate may cause metabolic alkalosis."
 

how does chloride loss causes alkalosis?

large volume loss of gastric secretions will correlate as a loss of hydrogen chloride, an acidic substance, leading to a relative increase in bicarbonate in the blood, thus driving alkalosis.

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COPD

Asthma

Excaberation due to triggers-> cough / increased work of breathing
Physical find) Hyperresonance, wheezing(inhale frist then exhale), breath sounds decrease (lower lobe first then                                upper lobe)

Chronic bronchitis

Productive cough
Physical find) polycythemia, cor pulmonale(폐고혈압- 혈관수축), Risk for DVT, PE, MI

Emphysema

Dyspnea on exertion(progress to dyspnea at rest)
Physical find) Hyperresonance( on percussion), Increased diameter of chest, Pulsed lip breath,
                      Accessory muscle use,  Speak short sentense
 
 

Pulsus paradoxus

* Drop of more than 10mmHg when comparing inspiratory to expiratory systolic blood pressure
A-line 잡아서 모니터링 하다보면 다음과 같은 그래프 모양이 보일 때가 있다.
systolic arterial pressure는 흡기 시에, 원래 정상적으로 3~4 mmHg 정도는 떨어진다.
그보다 크게, 흡기시에, 10 mmHg 이상으로 떨어지는 것을 pulsus paradoxus라고 한다.
 

 

PEFR(Peak Expiratory Flow Rate - objective measurement of airflow, 최대호기량 측정 )  

Process
- Sit upright with leg dangling
- Inhale fully, seal circumference of mouthpiece and exhale fully
- Note position of flow meter
- Repeat 3 times and base treatment decision on the best of the three reading

Findings
<At home>
- 50-80% expected value: moderate exacerbation
- < If 50 % seek medical attention
 
<Vary depend on sex, age, height>
40-70% expected value: moderate exacerbation
- < 40 % : severe exacerbation

Treatment

-Position) sit upright and leaning forward
-Cardiac monitoring
-Oxygen therapy) Controlled( Venturi, low flow oxygen)
-Positive Pressure Ventilation) CPAP/ BiPAP, Ventilator
-Pharmacology) Mucolytic(점액용해) Agent, Sympathomimetic, Anticholinergics, Steroid
 

Sympathomimetic
"Epinephrine(Adrenalin), Racemic epinephrine(Micronefrin, Asthmanefrin), Terbutaline(Brethaire)
 Albuterol(Proventil, Ventolin), Isoetharine(Bronkosol), Salmeterol(Serevent), Xopenex(Levabuterol)"
-> Relax smooth muscle of the bronchiles, produce bronchodilation, elevate HR

Parasympatholytic
"Ipratropium(Atrovent)
->Inhibit contraction of Bronchial smooth muscle and limit secretions of muscle
*S/E = dry mouth, pupil dilation, increased HR, blurred vision

Corticosteroid
"Inhaled [Dexamethasone(Decadron, Respinhaler), Beclomethasone(Beclovent, vanceril), Triamcinolone, Flunisolide], Oral outpatient treatment- predisone, IV treatment - Methylpredinisolone(Solu-Medrol)
->Anti-inflammatory properties and immunosupressant effect (reduce airway inflammation, inhibit mucous production, decrease airway swelling and hyperactivity)

 
- metered dose inhaler

1. Shake inhaler and hold it one to two inches from the face
2. Exhale completely and press down inhale as you begin and continue to inhale as deeply
3. Hold your breath as you count to ten slowly (B-2 agonist, wait one minute between puffs)
*if it's 'SPACER' =should press down on the inhaler then wait five sec before beginning to inhale*

 
Discharge

Asthma	Chronic bronchitis / Emphysema
- Avoid known allergen - Escape pillow and mattress in Vinyl - Wash bedding every week in temp 130F(54.5C) - Consider carpet removal - Keep cat/ dog outside - Remain inside with air conditioner during   early morning and midday - Never stop steroid abruptly(need to tapered)	-Stress the importance of pneumococcal   and viral immunization -Avoid crowd and exposure to Resp infection -Eat small, frequent meal (allow maximal excursion of the chest) - Stress hydration to keep secretion moist - Stress exercise - STOP SMOKE

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Pulmonary Embolism

Blood	*Blood clot migrates from another part of the body.  (Risk factor is immobility, preg, increased age)
Fat	*Occur 24-48hr after a long bone fx(femur, humerus, pelvis)
Amniotic Fluid	*sx show up after delivery of an infant

 
Sx) Sudden onset of shortness of breath
Tachypnea/ Tachycardia
Diaphoresis, Syncope, Fever,
Crackles on ausculation
Accentuated S2 Heart sound
Large PE cause JVD and Hypotension
Elevated D-Dimer and ESR
 
Tx) Oxygen
      Anticoagulant/ Fibrinolytics
      IV fluid / vasopressor(승압제) to treat hypotension
 

 

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Resp Infection

	Acute bronchitis 급성기관지염	Bronchiolitis 세기관지염	Penumonia
Cx	Viral inflammation in Upper airway	Viral infection Upper lead to profuse secretion and necrotic response producing cellurar debris that can occlude the lower airway	Viral)slower onset/          common in winter Bacteria)rapid onset
Sx	-URI -dry, hacky nonproductive cough progress to productive cough (*most trouble at Night triggered by deep breathing, talking, laughing) -Chest pain	-Recent URI with progressive dyspnea and cough -Poor feeding, irritability, lethargy -Tachypnea, possible apnea for infant -Grunting, Nasal flaring 코 벌렁거림 - Intercostal retraction, cyanosis -Wheezing, air trapping in xray	-Elevated Temp -Pleuritic Chest pain -Productive cough(purulent) -Tachypnea/ Tachycardia -Breath sound decreased -pleural friction rub -Hyporesonance, increased fremitus over affected area
Dignosis	Clinically Evident	Nasopharyngeal culture chest x-ray	WBC, chest x-ray
Tx	-Corticosteroid -Bronchodilation -Humidification -Cough preparation	-Oxygen -Antiviral, anticholinergics,    adrenergic stimulant -admmision	-Antibiotic administer -CPAP, BiPAP or intubation

 

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Pulmonary Edema

Cx)

Cardiogenic	ARDS	Neurogenic	High altitude
-HF, MI, HTN -Hypertyroidsim -Severe Anemia -Myocarditis	Inflammatory non-cardiogenic pulmonary edema	Relaively Rare occur within hours of a  Severe Neurological insult	Occur 2-4/days after ascending above 8000 feet, descend for 2-4/week, than return home

 
Tx)
 

Improve oxygenation	Decrease Cardiac Workload	Treat underlying condition	High altitude
- give high O2 -BiCAP/CPAP -VENT	-Position upright, legs dangling -Vasodilator(Morphine, NTG,  nitroprusside) -Lasix -Digoxin -Dopamine	-Antibiotic for infection -ACE inhibitors for HF	-Descend below 8000 ft. -Bed rest -High flow o2 - Hyperbaric Oxygen therapy (HBOT, 고압산소치료) -Acetazolamide(이뇨제)

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Thoracic trauma

Rib Fx

*Flail chest- Two or more adjacent ribs are Fx in two or more location or detachment of the sternum
*Paradoxical chest wall movement -flail chest result in a free floating segment of the chest wall drawn inward during inspiration and outward during expiration

 

**Child) always be consider for "abuse"
 

Pulmonary contusion

Sx) Dyspnea, Hypoxia, Hemoptysis
Tx) Rib Fx-> -oxygen administer
-pain manage
-Oral or IV analgesia
-Intercostal nerve block(늑간신경차단술)
-Deep breathing/coughing
-Incentive spirometry
 
Flail chest-> -nursing on injured side
-Mechanical Vent
 
Pulmonary contusion-> -Nurse Semi-Fowler's position
-considor Mechanical Vent
- absence of hypovolemia: fluid restriction/ diuretic

 

Ruptured diaphragm

*abdominal content herniate into the chest and compress the lungs, heart and mediastinum
 
Sx)- lower chest, abd, epi pain that radiate to left shoulder
-dyspnea
-decreased Heart sound on affected side (heart sound shift to the right side)
-Sign of obstructive shock
-dysphagia
-bowel sound in middle to lower chest
 
Tx) Trauma care, surgery
 
 
 
 

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Problem in Pleural space

 

Blood	Hemothorax
Chyle	Chylothorax
Pus	Pyothorax	Pneumonia, Blood-borne infection, pancreatitis
Serous fluid	Hydrophorax	Left Ventricular Failure, Liver Failure, Pulmonary Embolism

 

Simple Pneumothorax	-Air enters the pleural space, causing a negative intrapleural pressure and collapse of the lung -Cx) Trauma, barotrauma(diving incident, explosion), spontanesous(common in smoker of tall stature between the ages of 20-40), Emphysema
Open Pneumothorax	-Opening at least 2/3 the diameter of the trachea from the outside of the body that penetrates the chest wall and allows accumulation of air in the pleural space
Tension Pneumothorax	-An accumulation of air in the pleural space that is so great it compress the contents of the chest cavity to one side or the other *Sings->Resp distress, Hyperresonance on the affected side, Tracheal deviation away from                the affected side

Open Pneumothorax  Tx) Apply non-occlusive dressing to wound at the height of inspiration, taping to three side

Tension Pneumothorax Tx) Needle thoracentesis

Needle thoracentesis
-14 or 16 gauge needle inserted into the second intercostal space, midclavicular line or fifth intercostal space, midaxillary line on the injured side
-Inserted directly over the lower rib of the intercostal space, bevel up(사면이 위로가게)
-Should result in an immediate rush of air

 

	Fluid Accumulation	Air Accumulation
Breath sound	Decreased	Decreased
Fremitus	Absent	Decreased
Percussion	Hyporesonance	Hyperresonance
Pain	Dull ache	Sharp pain (radiate to shouder on side of penumothorax)
Egophony	Near top of fluid line	Not present