Chapter 027 - Iggy test bank PDF

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Ignatavicius: Medical-Surgical Nursing, 9th Edition Chapter 27: Assessment of the Respiratory System Key Points Priority concept applied in this chapter is GAS EXCHANGE. The most important interrelated concept for this chapter is PERFUSION. •

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GAS EXCHANGE is the oxygen transport to the cells and carbon dioxide transport away from cells through ventilation and diffusion. Once ventilation and diffusion exchange these gases in the lungs, blood oxygen is then available to cells by perfusion and diffusion. PERFUSION is the arterial blood flow through the tissues (peripheral perfusion) and blood that is pumped by the heart (central perfusion).

HEALTH PROMOTION AND MAINTENANCE • Because lung and breathing problems are so prevalent in the United States, the nurse must assess habits and behaviors that can be changed to promote overall better respiratory function. • Screen for smoking and tobacco-related health behaviors in teens, adults, and older adults. • Screening for smoking and tobacco-related health conditions is especially important when working with LGBTQ patients as this group has higher rates of smoking when compared with their heterosexual counterparts. • Concern exists that the LGBTQ community may not focus enough attention on prevention and smoking cessation programs. Thus many LGBTQ individuals who smoke are highly susceptible to smoking-related health problems, such as chronic lung disease and throat and lung cancers. • Assess smoking habits and provide education about cessation programs. The Joint Commission requires documentation of screening for tobacco use and that a tobacco treatment program be offered or provided, as part of their quality measures. ANATOMY AND PHYSIOLOGY REVIEW • The respiratory system includes the upper airways, lungs, lower airways, and alveolar air sacs. • The respiratory system is vital in helping the body meet its need for GAS EXCHANGE and tissue PERFUSION. • The two purposes of breathing are to provide oxygen for tissue PERFUSION so that cells have enough oxygen to take part in metabolism, and to remove carbon dioxide, the major waste product of metabolism. • The upper airways consist of the nose, the sinuses, the pharynx, and the larynx. • The lower airways consist of the trachea; two mainstem bronchi; lobar, segmental, and subsegmental bronchi; bronchioles; alveolar ducts; and alveoli.

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GAS EXCHANGE takes place in the lung tissue between the alveoli and the lung capillaries, not in the airways. The lungs are sponge-like, elastic, cone-shaped organs located in the pleural cavity in the chest. The apex (top) of each lung extends above the clavicle; the base of each lung lies just above the diaphragm. Breathing occurs through contraction and relaxation of specific chest muscles and the diaphragm, which cause changes in the size and pressure of the chest cavity. Accessory muscles help in this process. Tissue oxygen delivery through dissociation or unloading from hemoglobin is based on tissues’ need for oxygen.

ASSESSMENT METHODS Patient History • Obtaining accurate information from the patient is important for identifying the type and severity of breathing problems that may interfere with GAS EXCHANGE and to assess the impact of pulmonary function. • Age, gender, and race can affect the physical and diagnostic findings related to breathing. • Many changes in older patients result from heredity and a lifetime of exposure to environmental stimuli such as cigarette smoke, bacteria, air pollutants, and industrial fumes and irritants. • Women have greater bronchial hyperreactivity and larger airways than men. This factor increases the risk for a more rapid decline in lung function as an older adult, especially in smokers. • Compared with white or light skin color, individuals with dark skin usually show lower oxygen saturation as measured by pulse oximetry. This results from deeper coloration of the nail bed and does not reflect true oxygen status. • Explore the home, community, and workplace for environmental factors that could cause or worsen lung disease. Occupational lung diseases include pneumoconiosis. • Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled substances. • Ask whether the patient has any known allergies to substances such as drugs, foods, dust, molds, pollen, bee stings, trees, grass, or animal dander and saliva. • Ask the patient to describe specific allergic responses such as wheezing, trouble breathing, coughing, sneezing, or rhinitis. • Document any known specific allergies that have respiratory manifestations. • Obtain a family history to assess for respiratory disorders with a genetic component, such as asthma, cystic fibrosis, some lung cancers, and alpha1-antitrypsin deficiency. • Whether the breathing problem is acute or chronic, the current health problem usually includes cough, sputum production, chest pain, and shortness of breath at rest or on exertion. • Since chest pain can occur with other health problems as well, provide a detailed description to determine whether the pain is pleural, musculoskeletal, cardiac, or gastrointestinal in origin.

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o Ask the patient whether the pain is continuous or made worse by coughing, deep breathing, or swallowing. o Ask the patient to measure the intensity of the pain on a pain scale. Paroxysmal nocturnal dyspnea is intermittent dyspnea during sleep. Orthopnea is shortness of breath that occurs when lying down but is relieved by sitting up. Ask the patient about recent travel. Ask the patient how many pillows he or she uses when sleeping. Assess the degree to which breathing problems interfere with the patient’s ability to perform activities of daily living (ADLs) and provide appropriate teaching. Chronic respiratory disease may cause changes in family roles and relationships, social isolation, financial problems, and unemployment or disability. Determine psychosocial factors, including coping mechanisms and support systems.

Physical Assessment • Following a detailed history, begin the physical assessment. • Assess the airway and breathing effectiveness for any patient who has shortness of breath or any change in mental status. • Inspect the patient’s external nose for deformities or tumors, and inspect the nostrils for symmetry of size and shape. Inspect for color, swelling, drainage, and bleeding. • Also assess nostrils for patency by closing first one nostril, then the other, and asking the patient to exhale. • Nasal flaring may indicate increased respiratory effort. • Inspect the internal structures of the mouth, using a tongue depressor to press down one side of the tongue at a time to avoid stimulating the gag reflex. • Inspect trachea to determine if there is any deviation, which is a sign of pneumothorax. • Inspect the chest by assessing the front and back of the thorax. • Examine the shape of the patient’s chest. • Observe the rate, rhythm, and depth of inspirations as well as the symmetry of chest movement. • Observe the type of breathing, noting pursed-lip or diaphragmatic breathing and the use of accessory muscles. • Auscultate for normal breath sounds, adventitious sounds, and voice sounds. • Palpate the chest after inspection to assess respiratory movement symmetry and observable abnormalities, to identify areas of tenderness, and to check vocal or tactile fremitus. • Use percussion to assess for pulmonary resonance, the boundaries of organs, and diaphragmatic excursion. • Breathing difficulty from any cause often induces anxiety. The patient may be anxious because of reduced oxygen to the brain or because the sensation of not getting enough air is a frightening experience • Explain diagnostic procedures, restrictions, and follow-up care to patients scheduled for tests. • Because GAS EXCHANGE affects all body systems, assess other indicators of respiratory and PERFUSION adequacy including skin and mucous membrane changes, general

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appearance, endurance, and the ability to talk and breathe at the same time. Diagnostic Assessment • Laboratory/diagnostic testing assists in revealing the extent of pulmonary dysfunction. • Laboratory tests may include red blood cell count for hemoglobin level while arterial blood gas analysis assesses GAS EXCHANGE and PERFUSION as oxygenation, alveolar ventilation, and acid–base balance. • Chest x-rays are used for patients with respiratory tract disorders to evaluate the status of the chest and to provide a baseline for comparison with future changes. Standard chest xrays are performed from posteroanterior and left lateral views. • Digital imaging is especially useful to assess lung and chest lesions. • Computed tomography is useful when an x-ray reveals a suspicious lesion because pulmonary soft tissue densities, tumors, and blood clots can be seen. • Ventilation and PERFUSION scanning can identify the areas of the lung being ventilated and the distribution of blood within the lungs. • Pulse oximetry identifies hemoglobin saturation with oxygen. • Pulmonary function tests evaluate lung function and breathing problems and include lung volumes and capacities, flow rates, diffusion capacity, GAS EXCHANGE, airway resistance, and distribution of ventilation. • Exercise testing assesses the patient’s ability to work and perform ADLs, differentiates reasons for exercise limitation, evaluates disease influence on exercise capacity, and determines whether supplemental oxygen is needed during exercise. • Skin tests are used with other diagnostic data to identify various infectious diseases such as tuberculosis, viral diseases, and fungal diseases. Allergies and the status of the immune system also can be checked through skin testing. • Endoscopic studies to assess breathing problems include bronchoscopy, laryngoscopy, and mediastinoscopy. o In accordance with The Joint Commission’s National Patient Safety Goals, verify the patient’s identity with two types of identifiers before a bronchoscopy. o Assess the patient’s respiratory status every 15 minutes for at least the first 2 hours after undergoing an endoscopic test for respiratory disorders. • Thoracentesis is the aspiration of pleural fluid or air from the pleural space for diagnosis or treatment. • Teach the patient the manifestations of a pneumothorax and to go to the nearest emergency department immediately for treatment if these symptoms develop. • A lung biopsy is performed to obtain tissue for histologic analysis, culture, or cytologic examination to make a definite diagnosis about the type of cancer, infection, inflammation, or lung disease. • Encourage all people to use masks and adequate ventilation when exposed to inhalation irritants.

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