cyanosis, rate and depth, coughing with or without sputum (color, blooding)

inspect mucous membranes, pulse ox, use of accessory muscles, nasal flaring, position of trachea, pt chest shape

palpate for masses, tenderness, crepitis, thoracic excursion, tactile fremitus (area of consolidation transmits sounds differently, may vibrate)

bronchial: hollow, high pitched sound; inspitory phase shorter than expitory

bronchvesicular: bronchi, over sternum and b/t scapula; inspitory = expitory

vescicular: softer quality low pitched sounds, heard in peripheral; inspiratory longer than expiratory

restore and maintain a patent airway and cardiopulmonary function with

- aggressive airway managment

- fluid replacement

- chest tube placement

enlarged lymph nodes, tumors

hilar adonopathy: enlarged lymph nodes at hilam

- diagnostic: tissue sample, deep sputum sample, check for cancer cells

-therapeautic: retrieve something aspirated, remove secretions

BEFORE

- NPO 6-12 hours

- IM injection to suppress cough reflex with anticholinergic to dry up secretions and protect against drops in HR

- number throat

AFTER

- chest X-ray to check ofr pneumothorax

- NPO until check for gag reflex

- procedure to avoid major surgery

- diagnostic, or to perform a wedge resection

- pain after should be managed

- get fluid, drain a large collection of fluid

- check for cancer cells

- culture fluid

- drain plueral effusion

- pt sits on side of bed, leans onto overbed table

- area is numbed and prepped, needled is inserted b/t ribs, fluid is sucked into a bottle

- monitor pt, asses amount of fluid, make sure fluid gets sent to proper place

- chest Xray afterwards

- listen to lungs, look for bilateral sounds

- look for drainage

- palpate area for crepitus

- smoking

- bronchodilators

- ribs 1-3: rare, can lacerate major vessels

- ribs 5-10: most common

- fibs 10-12: can injure liver or spleen

- pain (defining feature)

- muscle tenderness (tender to palpation), muscle spasm

- echhymosis

- shallow breaths perferred by pt

- pain control: analgesics, nerve block, ice

- detect and treat underlying injuries

- paradoxical movement (defining feature)

- tachypnea, shallow resp, tachycardia, cyanosis

- atelectasis

- hypoexemia, hypercarbia

- possible lung contusion

- open results from from a hole in the chest wall with atmospheric air flowing in and out

- closed occurs when air enters pleral space from lung

- air flows in and out

- guaze over hole, tape on three sides

- blunt chest trauma

- sever COPD

- ventilating someone on high pressure

- lungs get squished, heart gets squished

- trachial deviation

- decreased CO (decreased urine, increased pulse, decrease BP)

- 12-14 guage needle inserted into 2nd intercostal space, mid clavicular line

- air will rush out

- rupture of blood vessels from trauma

- inflammation

- malignant tumors

- similiar to pneumothorax

- tachycardia, hypotension, palloe

- possible s&s of hypovolemic shock

- chest tube: carefully monitor amount of drainage

- thoractomy

exudative: caused by inflammation processes, dark yellow/amber color

transudatative: fluid overload, clear yellow/straw yellow

- CHF

- renal failure

- infection

- tumor

- s&s of underlying disease

- resp symptoms based on size of fluid collection

- thoracentesis: significant drainage (725ml-1000ml), may require chest tube

- treat cause

- plerodesis: injection to irritate laters of pleura and not allow fluid to accumulate

- increased RR

- dyspnea

- increased HR

- pleuratic pain

- blood tinged secretions (defining feature)

- support airway

- oxygenation

- pain control

- bruised heart, usually r/t steering wheel injury

- can interfere with contractile and electrical events within heart

- chest pain

- increased HR

- dysrhythmias (defining feature)

- EKG changes

- increased cardiac enzymes

-serial enzymes

- cardiac monitoring

- compression of heart due to fluid (blood) within pericardial sac

- pericardial effusion

- squishing chambers of heart

- impedes ventricular filling l/t decreased CO

- Beck's triad: decreased BP, distended neck veins, distant muffled heart sounds

- increased pulsus paradox (difference in systolic BP during insp/exp, abnormal is greater than 10 mm/Hg)

- dyspnea

-restlessness

- pericardiocentesis

- pericardial window: cut through subxyphoid and pericardia, drains into media sternum or hooked up to drainage

- 2nd highest cause of accidental death

- rib cage is more flexible

- pulmonary contusions are common

- diminished ventilation

- atelectasis

- pnemonia

- hypoxemia

- respiratory insufficiency and failure

- remove air and fluid from pleural space

- prevent air from re-entering

- re-establish negative pressure

- facilitate rexplansion

- sedated with pain meds

- jam into chest

- sutured into place

- vaseline guaze around surface

- occlusive dressing

- intrapleural pressure becomes more negative during inspiration

- air and fluid in pleural space prevent negative pressure during inspiration

- CT re-establishes negative pressure

- observe drainage system: tidaling and bubbling

- never clamp chest tube unless changing collecting unit or checking for air leaks

- change dressing using vaseline guaze as ordered

- check for subcutaneous emphysema

- administer analgesics are needed

- place in sterile saline if discovered chest tube that has been disconnteced for a long time

- hemoglobin holds tightly to oxygen

-ph increases (alkoline)

- hemoglobin more readily releases

- pH decreaes (acidic)

- tape connections

- keep drainage unit below chest

- keep drainage system upright

- reconnect tubing immeadiatley if disconnected

- if chest tube pulled out, cover site with occulusive materials

- do not strip or milk tubes

- encourage activity

- ongoing resp. assessments

pH: 7.35-7.45

p02: 80-100

pCO2: 35-45

HCO3: 22-26

- hyperventilation

 - anxiety

- high altitudes

- pregnancy

- fever

- hypoxia

- initial stages of PE

- loss of gastric juices

- over use of antacids

- potassium wasting diuretics (loss of H+)

- hypoventilation

- drug overdose

- airway obstruction

- COPD

- chest trauma

-neuro muscular disease

- pulmonary edema

- drug overdose

- salicylate OD (ASA)

- sock

- sepsis

- diarrhea

- renal failure

- diabetic ketoacidosis

- rapid shallow respirations

- dyspnea

- disorientation

- muscle weakness

- tingling of extremeties

- confusion

- deep, rapid breathing

- seizures

- disorientation

- Kussmaul respirations

- muscle twitching

- chances in LOC

- n&v

- diarrhea

- restlessness

-slow respirations

- arrhythmias

adv: ease of insertion

dis: may stimulate gag reflex

- frequent mouth care

- remove tid and clean with 1/2 strength H202

- avoid taping

adv: ease of insertion, easily tolerated by pt

dis: does not prevent occlusion of upper airway by tongue

- observe for necrosis and irritation

- check for development of sinusitis

- tube placed orally or nasally through larynx into trachea

- adult tubes are cuffed to provide tracheal seal to allow artificial ventilation and prevention of aspiration

- direct communication with trachea, relative ease of insertion

- oral: easier insertion, can use larger tube

nasal: blind insertion, smaller tube, bleeding, easily stabilized, can mouth words

- potential for infection

- potential for tracheal and laryngeal damage

- inability to speak

- increased airway resistance d/t diameter and length of tube

- oral tube easily dislodged and difficult to anchor

- nasal smaller diameter and can cause sinus obstruction

- ausculate for bilateral breath sounds

- inflate cuff to provide seal (20-25 mmHg)

- CXR for placement

- CO2 detector for placement

- work out method of communication

- change anchoring tapes daily

- oral airway may be needed to prevent biting

- may need sedation for mech vent

- note cm level at lips

- tube inserted directly through trachea through an incision in the neck

- bypasses the pharynx, epiglottis, and larynx

- long term managment

- manage secretions

- long term mech vent

- direct communication with trachea

- avoids trauma to larynx

- can swallow

- decreased airway resistance d/t small diameter tube

- tube can get dislodged easily

- can cause trach damage

- infection risk

- if plug trach, deflate cuff

- same size new trach in the room

- 20-25 mmHg of inflation

- work out method of communication

- secure trach ties at least every 24 hrs - 1 week

- bag pt if trach removed, call rapid response

- hypoxemia secondary to intrapulmonary shunting of blood (atelectis, pulm embolism)

- hypoventilation w/ resp acidosis

- specific rep conditions: psot thoraci surgery, drug OD, COPD, multiple trauma, shock, MSOF, inhalation injury, coma

- non-invasive

- creates pressure gradints that mimic normal physiologc ventilation

- iron lung, poncho suit

- most widely used

- during inspiration a pressure is generated by the ventilator that pushes air into lungs

- exhaltion is passive

- requires artificial airway

- tidal volume and minimal ventilatory rates are pre-set

- allows patient to initate breaths

- ventilator delivers the same tidal volume with a machine-initiated breath and a patient intiated breath

- pt can increased # of breaths above the preset rate

- ventilator delivers a present tidal volume at a pre-set rate and allows the pat to breathe spontaneously at his own tidal volume b/t ventilator breaths

- ventilator senses pt spontaneous breaths and synchs pt breath with pre-set breath

- frequently used for weaning

- ventilator delivers a pre-set amount of positive pressure as the pt inhales and maintains it throughout insp phase

- give a litle boost at the beginning of pt own breaths during SIMV

- allows pt to overcome resistance of artificial airway and ventilator demand valve

- a positive pressure exerted during the expiratory phase of ventilation

- improves oxygenation by enhancing gas exchange and preventing atelectaiss

- back pressure at end of exp

- all breaths are controlled by ventilator

- patient is unable to initiate any breaths

- all breaths are at a predetermined volume, delivered by ventilator

- pt is able to initate the ventilator delivered breaths

- if no spontaneous effort is sensed by ventilator, a ventilator delivered breath will be give, thus a minimum mandatory ventilation rate is set

- pt is able to increase RR as needed

- ventilator delivers a preset volume at a preset rate, time to be dlivered in conjunction with pt's own resp effort

- if no effort, ventilator provides breath

- pt is able to breath spontaneously b/t ventilator delivered breaths at their own tidal volume and rate

- pt's inspiratory efforts is augmented by a predeterminded pressure assis from ventilator

- used in spont breathing pt or in combo w/ SIMV

- overcomes airway resistance

- used in spon breathing pt

- postive pressure is applied t/o resp cycle

- keep alveoli open

- RR

- oxygen perfusion

- lung sounds

- barotrauma fomr pressure (ruptured alveoli, pneumothorax)

- head nodding

- letter board

- can be very difficult, usually pts are kept well sedated

- anxiety producing from vent

- COPD pts may be glad for it, pyschological dependance

- usually pt is sedated

- usually decreased CO until body adjusts

- when breathing normally, intrathoracic pressure sucks blood to heart

- sight impediment of blood to heart

- transiet hypotension

- PEEP can also decrease CO

- monitor settings

- maintain artificial airway

- be aware of alarm (pressure limit, low exhaled volume)

- maintain humidification

- DVT prophalaxis (seq, lovenox)

- hypotension considerations

- prevent barotrauma from too much pressure

- prevent overdoing O2, which can create stiff or non-compliant lungs

- oral gastric tube

- protonix

- TPN

- head of bed elevated 30 degrees to prevent microaspiration

- extrordinary mouth care

- suction as needed

- ROM

- PT

- original problem that caused need for ventiliation has been corrected

- measure parameters: vital capicity, neg insp force

- well rested

- stable

- SIMV

- pressure support

- CPAP

- T-piece (oxygen straight to trach)

- suction down endotrachial tube

- suctiona around orapharynx

- suction as pull tube out

- give pt humidified air, don't want pt talking too much so you don't aggrevate vocal cords

- watch for s&s that they are tolerate extubation

- clinical syndrome characterized by progressive hypoexemia occuring after a serious illness or injury

- oxygen doesn't seem to help

- underlying cause injures alveolor capillary membrane

- fluid leaks into alveoli and interstitial spaces

- results is extremely impaired gas exchange

- non cardiogenic pulmonary edema

white out

fluffy white things all over chest xray

- inhalation of smoke or corrosive substances

- prolonged inhalation of hi conc. of 02

- trauma

- fat or air embolism

- sepsis

- shock

- aspiration

- trauma

- surgery

- drug OD

- DIC

- massive transfusion

- pacreatitis

- uremia

white out chest Xray

progressive hypoexemia despite O2

- acute resp failure

- bilateral pulm infiltrates

- hypoexemia

- decreased lung compliance

- ventilation

- resp support: 02, high fowlers

- circ supprt: iv fluids, vasopressors

- nutritional support

- prone positioning

- takes quite a few nurses

- fluid collects in dependent areas, better perfusion in dependent areas

- unable to clear secretions with cough

- induced sputum

- frequency is based on assessment: auscultate lung fields