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Ventilation Movement of air into and out of the lungs
Delivery of fresh air to the lungs aveoli
Regulated by the medulla (respiratory control center)
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Alveolar Gas Exchange
- Oxygen uptake (external respiration) is the
exchange of oxygen from the alveolar space into
the pulmonary capillary blood.
- Carbon dioxide diffuses from the blood to thealveolar space.
Cellular Respiration (internal respiration)
- Oxygen diffuses from the blood to the tissues
- CO2 diffuses moves from the tissues to the blood
- The blood is then reoxygenated.
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Oxygen transport and delivery
Oxygen transport in the blood
PaO2- O2 dissolved in the plasma, normal PaO2 of arterial
blood is 80-100 mmHg
SaO2- amount of O2 bound to the hgb. Also called O2
saturation (92% to 100%)
O2 is delivered to the cells by process of circulation- the
heart pumps oxygenated blood to the cells
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Age Environmental and lifestyle factors
Disease Processes
Obstructive pulmonary disease
Restrictive pulmonary disease: pneumonia, pulmonary fibrosis(scarring), traumatic injury to the thorax.
Diffusion defects: decrease in the efficiency of gas diffusion fromthe alveolar space into the pulmonary capillary blood.
Ventilation-perfusion mismatching
Atherosclerosis Heart Failure
Anemia Alterations in oxygen uptake (cyanide poisoning andsevere sepsis)
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Health History
The health history should begin with a thoroughexploration of the presenting problem; ask howlong has it been present and if it has gotten worse
Explore the medical history, impact of illness onactivities of daily living, clients knowledge leveland coping abilities
Physical Examination
General observation of clients efforts at ventilation Count respiratory rate, note the rhythm
Signs of hypoxia - cyanosis, clubbing of fingers
Adventitious breath sounds - crackles, rhonchi,wheezes, pleural friction rub, stridor
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Mental status changes are often the first signs of respiratoryproblems and may include restlessness and irritability.
Cyanosis is a late sign of hypoxia. Central cyanosis is the
most serious finding because it indicates hypoxemia
Central cyanosis is observed in the tongue, soft palate, and
conjunctiva of the eye, where blood flow is high
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Diagnostic and Laboratory Data
Pulse oximetry
Arterial blood gases (ABGs)
Lactic acid, H&H Sputum collection
Ventilatory function tests
Chest x-ray
Computerized tomography, MRI
Bronchoscopy, thoracentesis
Ekg, echo, stress test
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Primary Nursing Diagnoses
Ineffective Airway Clearance
Ineffective Breathing Patterns
Impaired Gas Exchange
Decreased Cardiac Output Altered Tissue Perfusion
Secondary Nursing Diagnoses Knowledge Deficit
Activity Intolerance Sleep Pattern Disturbance
Altered Nutrition
Pain
Anxiety
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The goals should be individualized to reflect the
clients capabilities and limitations.
Outcomes may be based on physiological
parameters such as respiratory rate or arterialblood gas values
The outcomes should be based upon the
assessment findings that led to the nursing
diagnoses at hand
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Interventions to promote airway clearance
Teach effective coughing
Initiate postural drainage and chest physiotherapy
Monitor hydration
Administer medications
Monitor environmental and lifestyle conditions
Suction the airway
Teach controlled breathing exercises
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Interventions to improve O2 uptake and delivery
Administer oxygen
Administer blood components
Interventions to increase cardiac output and tissueperfusion
Manage fluid balance
Suggest activity restrictions and assistance with
activities of daily living Position client properly
Administer medications
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The nurse caring for theclient with a nasal cannula
should plan to assess the
clients nares and superior
surface of both ears for skin
breakdown every 6 hours.
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Restoration of cardiopulmonary
functioning- CPR (remember
ABC!!)
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Body weight
Diet
Exercise
Stress reduction
Occupational safety
Smoke-free
Regular physical exams
Vaccinations/immunizations Influenza
pneumonia
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Hydration
Coughing techniques
Respiratory muscle training
Breathing exercises
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In many instances, the evaluation of the success of
the specific interventions will be based on the
degree to which the client is or can be returned to a
satisfactory state of respiratory function
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