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42 Cards in this Set
- Front
- Back
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What are the methods of assessing gas exchange?
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1. Inspection
2. Palpation 3. Ausultation 4. Percussion |
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Inspection
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Process of observation. Inspect from head to toe, of the pt for skin and mucus color, general appearance, level of consciousness, adequacy, of system circulation, breathing patterns and chest wall movement.
What is the method of assessment? |
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Inspection
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Include nails for clubbing ( clubbing shows prolonged o2 deficiency, endocarditis and congenital heart defects.)
Look for chest wall retraction, sinking if soft tissue of the chest between intercostals spaces. Look for paradoxical breathing, asynchronous breathing. Paradoxical- chest wall contracts during inspiration and expands during exhalation. Chest to have round shape COPD, advancing age, emphysema. What is the method of assessment? |
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Palpation
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provides assessment in several areas. It documents type and amount of thoracic excursion, elicits any areas of tenderness, and can identify tactile fremitus, chills, heaves, and the cardiac point of maximal impulse.
What is the method of assessment? |
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Palpation
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Shows abnormal masses, peripheral circulation (temp. and pulse)
feet and legs show presence or absence of edema Congestive heart failure and hypertension usually are associated with edemas. What is the method of assessment? |
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Ausultation
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let’s you hear normal or abnormal heart sounds.
What is the method of assessment? |
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Ausultation
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cardiovascular system include assessment for normal s1 and s2 sounds, and the presence of abnormal s3 and s4 sounds and murmurs or rubs.
What is the method of assessment? |
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Percussion
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allows nurse to detect the presence of abnormal fluid or air in lungs it also determines diaphragmatic excursion.
What is the method of assessment? |
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Percussion
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It involves tapping the body with finger tips to evaluate organs and discover fluid in body cavities.
Used if nurse hears abnormal breathing when ausculating, percussion could rule out the presence of consolidated fluid or air in the pleural space. What is the method of assessment? |
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1. Nursing history
2. Respiratory rate 3. Physical exam 4. Lab tests 5. environmental factors |
Identify methods and data to be included in making an assessment in gas exchange.
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Nursing history
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focus on pt ability to meet O2 needs. The characteristics for cardiac function include pain and dyspnea, fatigue, circulation, cardiac risk factors, and the presence of past or current cardiac conditions.
What method or data is this in making assessment of gas exchange? |
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Nursing history
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respiratory function include presence of cough, shortness of breath, wheezing, pain, environment, frequency of respiratory tract infection, pulmonary risk factors, past problems, current meds, smoking.
What method or data is this in making assessment of gas exchange? |
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Respiratory rate
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nurse assesses by inspection 12-18 breaths per min.
What method or data is this in making assessment of gas exchange? |
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Physical exam
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inspection, palpation, auscultation, percussion
What method or data is this in making assessment of gas exchange? |
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environmental factors
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Pulmonary disease is elevated in smoggy urban areas. Also some jobs.
altitude- increases making effective breathing more difficult at higher altitudes. Humidity- causes shortness of breath because it increases the density of the air, also when humidity increases the prevalence of airborne allergens increase. What method or data is this in making assessment of gas exchange? |
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tachypnea
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above 24 breaths per minute
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bradypnea
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below 10 breaths per minute
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Depth
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how far air travels into lungs
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Rhythm
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Normal or abnormal respiratory rate
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Breath sounds
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are heard by air flow low pitched with swishy, breezy, quality, abnormal sounds are crackles, rhonchi, and pleural friction rub
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pao2
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80-100 mmhg
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paCO2
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35-45 mmhg
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ph
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7.35-7.45
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Hco2
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20-29 meg/liter
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o2 saturation
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95-100 %
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sputum
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normal or negative meaning no signs of microorganisms.
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CBC
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Hemoglobin
Hematocrit RBC WBC |
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14-18 g/100ml males
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Hemoglobin in males?
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12-16 g/100ml
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Hemoglobin in females?
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4.7-6.1 million/ml
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RBCs in males?
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4.2 - 5.4 million/ml
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RBCs in females?
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fatigue
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in a pt with cardiopulmonary alterations is often an early sigh of worsening chronic underlying process
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dyspnea
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is a sign of hypoxia and manifests as breathlessness. Its explained as difficult or uncomfortable breathing. Its associated with pulmonary disease cardiovascular disease, neuromuscular condition and anemia.
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cough
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cough is sudden audible expulsion of air from the lungs this is done to clear the trachea, bronchi, and lungs of irritants and secretions. Pt with chronic sinusitis may cough only in am or right after sleeping.
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pain
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the presence of pain needs to be thourhly evaluated with regard to location, duration, radiation, and frequency. Cardiac pain doesn’t occur with respiratory variations.
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fatigue
dyspnea cough pain |
What are the behaviors that indicate respiratory comprimise?
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Cardiac
pericardial pleuritic musculoskeletal |
What are the different types of pain associated with respiratory comprimise?
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Adventitious breathing sounds
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occurs with collapse of a lung segment, fluid in a lung, or narrowing of obstruction of an airway.
often occur superimposed over normal sounds are crackles, rhonchi, wheezing, and pleural friction rub. |
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environmental factor
exercise emotions developmentals stage health status/lifestyle metabolism increased temperature poor posture culture family history adaptive modes from roy hydration head injury coughing wheezing sneezing |
What are the stimuli (factors) affecting gas exchange?
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noxious environment like tobacco , allergens and irritating fumes can be considered individually as stimuli affecting oxygen.
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What are the environmental factors affecting gas exchange?
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it increase the body’s metabolic activity and O2 demand. The rate and depth of respiration increase enabling the person to intake more O2 and exhale more co2. people increase O2 consumption by 10% to 20% because of increases cardiac output and increase efficiency of the myocardial muscle.
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What are the exercize factors affecting gas exchange?
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stress
anxiety which increase metabolic rate and demand for o2 demand. this increases respiratory rates. most can adapt, but some who are immunosuppressive, can lead to MI. |
What are the emotional factors (stimuli) that can affect gas exchange?
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