Exam 1 study guide
Older Adult
• Explain respiratory changes associated with aging
Laryngeal cartilage ossifies
Atrophy of vocal muscles
Increased diameter of trachea and upper bronchioles
Decreased number of cilia
Increased anterior-posterior diameter (kyphosis)
Decreased chest wall flexibility
Intercostal muscle atrophy
Progressive loss of elasticity
Flattening of alveoli and decreased alveolar surface area
Decreased response to changes in O2 and CO@ levels, decreased PaCO2
Increased dead space, air trapping
Increased risk for atelectasis
Decreased cough reflex, section clearance
Respiratory Diagnostic procedures
• Interpret ABG results
Normal
pH 7.35-7.45
PaO2 80-100
PaCO2 35-45
HCO3 22-26
O2 88-100
• Discuss diagnostic procedure for TB.
TB skin test-induration of 5+ at risk, induration of 10=no risk
Interferon gamma release assay-QuantiFERON/TB T-spot TB (blood tests)
Sputum culture-how dx is discovered
Chest x-ray-holes from destroyed lung tissue, consolidation, enlarged lymph nodes
o Explain Mantoux test interpretation
Skin test-if there is a hard and raised bump with swelling, then test is positive
TB antibodies in body but not active infection
No reaction-no tb, negative result
o Identify how TB is confirmed
• Describe the nursing responsibilities and potential complications related to caring for a
client following a bronchoscopy
Pre-procedure-obtain consent, instruct pt. to be NPO for 6-12hr before procedure
Post-procedure-keep pt. NPO until gag reflex returns. Monitor for recovery from
sedation. Blood tinged mucus is not abnormal. If biopsy was done, monitor for
hemorrhage and pneumothorax.
• Describe the nursing responsibilities and potential complications related to caring for a
client undergoing thoracentesis
Pre-procedure-explain procedure to pt., obtain consent
Intra-procedure-usually performed in pt. rm, position pt. upright with elbows on overbed
table and feet supported, instruct pt. to not talk or cough
,Exam 1 study guide
Post-operative-observe for s/sx of hypoxia and pneumothorax, verify breath sounds in all
fields. Encourage deep breathing exercises. Send labeled specimens to lab promptly.
o Identify priority assessments after a thoracentesis
Upper Respiratory
• Influenza
o Identify expected findings
Malaise, fatigue, fever, chills, body aches, cough, congestion, n/v, resp. failure
o Identify signs of pulmonary complications related to influenza
Pneumonia, resp failure
• Head and neck cancer
o Identify clients at risk for head and neck cancer
Tobacco and alcohol use, GERD, environmental factors, genetics, damaged DNA
from carcinogens cause mutation of cells
o Surgical therapy: identify post-operative interventions for laryngectomy
and radical neck dissection
Focus on airway management, wound care, nutrition, communication,
psychosocial issues r/t body issues
Maintenance of patent airway
Keep pt. in semi fowlers to decrease edema and inflammation
Frequent suction r/t increase in secretions
Deep breathing and coughing exercises
Frequent pain, VS assessment
Wound care, drainage assessment
Check patency of drainage tubes q4h
Frequent oral care
o Identify reportable complications related to a
laryngectomy Increased risk of infection, hemorrhage
Monitor patency of airway
R/T edema and
inflammation
• Tracheostomy care (recommend ATI airway management
(tracheostomy) skills module)
o Identify safe care of the client with a tracheostomy
▪ Identify priority assessments
VS, including heart rate, RR, BP, O2, ensure patency of IV and drainage
tubes, place obturator inside outer cannula after insertion, remove
obturator, auscultate lung sounds after the cuff is inflated, note and
record ventilator settings, observe amount of blood at insertion site,
redness, inflammation, edema, ulcerations
▪ Identify priority interventions
Provide means for communication, teach tracheostomy management,
tracheostomy care, position to facilitate ventilation (HOB 30-45),
aspiration precautions, tube feedings, nutritional consultation,
psychosocial needs, suctioning
▪ Explain when and how to suction
Assess need for suctioning hourly. Indications include visible coughing,
course crackles or wheezes, moist cough
Explain procedure, gather supplies
Adjust suction to no greater than 125mmHg
, Exam 1 study guide
Assess baseline HR and rhythm, SpO2
Use sterile technique to open equipment, full cup with sterile H2O,
designate 1 hand for connecting/disconnecting suction tubing, using
manual resuscitation bag and operating suction control
Provide preoxygenation for a min of 30 sec
Insert catheter without suctioning to the point where pt. coughs. Apply
suction while gently removing
Continuous suction for 10-15 seconds
D/C suctioning if HR decreases by 20bpm from baseline, increase by
40bpm, dysrhythmia or SpO2 decreases to 90%
Hyper-oxygenate between suctioning
▪ Explain essential discharge teaching for a client with a tracheostomy
Observe tracheostomy site for s/sx of infection
Sterile technique to clean tracheostomy
Suctioning techniques
Changing of tracheostomy tapes
Lower Respiratory
• Review oxygen therapy: indications for and how to choose appropriate equipment
Low flow delivery-nasal cannula-O2 up to 2L/min, simple face mask-O2
concentration
35-50% flow up to 6-12L, partial and non-breather mask-60-90% O2 concentration 10-
15L, O2 conserving cannula-log term O2 therapy, 30-50% O2 at 8L/min
High flow delivery-tracheostomy collar-can deliver high humidity and O2 via
tracheostomy, tracheostomy T Bar-has vent and T shaped connector that allows for
inline catheter to be connected, venturi mask-delivers precise, high flow O2 with
concentration of 24%, 28%, 31%, 36%, 40%, 50%, High flow nasal cannula-blends O2
with compressed air to generate FiO2 of 1 at flow rate of 60L min, provides 100% body
humidity
• Explain criteria used when evaluating effectiveness of respiratory
interventions VS-BP, HR and rhythm, temp, RR, SpO2
Auscultate lung sounds
Assess respiratory secretions; color, consistency,
odor Skin temp and color
Sputum culture
ABGs
I/O
• Identify risk factors for developing pneumonia
Pneumonia-complication of flu
Risk factors-advanced age, long term care resident, smoking, respiratory disease,
immune-deficiency, altered mental status, prolonged immobilization, aspiration,
hospitalization, communal living
• Pneumonia: explain the changes in the lung tissue and the effect these changes have on
airway clearance, breathing pattern, and gas exchange
Pathophysiology-offending organisms-virus, bacteria, fungi
Inhaled via cough, sneeze, aspirate
Functional changes-increases inflammation, blood flow, vascular permeability,
airway edema, consolidation, increased mucous production, decreased gas exchange
Complications-atelectasis, pleural effusion, sepsis, resp. failure
Older Adult
• Explain respiratory changes associated with aging
Laryngeal cartilage ossifies
Atrophy of vocal muscles
Increased diameter of trachea and upper bronchioles
Decreased number of cilia
Increased anterior-posterior diameter (kyphosis)
Decreased chest wall flexibility
Intercostal muscle atrophy
Progressive loss of elasticity
Flattening of alveoli and decreased alveolar surface area
Decreased response to changes in O2 and CO@ levels, decreased PaCO2
Increased dead space, air trapping
Increased risk for atelectasis
Decreased cough reflex, section clearance
Respiratory Diagnostic procedures
• Interpret ABG results
Normal
pH 7.35-7.45
PaO2 80-100
PaCO2 35-45
HCO3 22-26
O2 88-100
• Discuss diagnostic procedure for TB.
TB skin test-induration of 5+ at risk, induration of 10=no risk
Interferon gamma release assay-QuantiFERON/TB T-spot TB (blood tests)
Sputum culture-how dx is discovered
Chest x-ray-holes from destroyed lung tissue, consolidation, enlarged lymph nodes
o Explain Mantoux test interpretation
Skin test-if there is a hard and raised bump with swelling, then test is positive
TB antibodies in body but not active infection
No reaction-no tb, negative result
o Identify how TB is confirmed
• Describe the nursing responsibilities and potential complications related to caring for a
client following a bronchoscopy
Pre-procedure-obtain consent, instruct pt. to be NPO for 6-12hr before procedure
Post-procedure-keep pt. NPO until gag reflex returns. Monitor for recovery from
sedation. Blood tinged mucus is not abnormal. If biopsy was done, monitor for
hemorrhage and pneumothorax.
• Describe the nursing responsibilities and potential complications related to caring for a
client undergoing thoracentesis
Pre-procedure-explain procedure to pt., obtain consent
Intra-procedure-usually performed in pt. rm, position pt. upright with elbows on overbed
table and feet supported, instruct pt. to not talk or cough
,Exam 1 study guide
Post-operative-observe for s/sx of hypoxia and pneumothorax, verify breath sounds in all
fields. Encourage deep breathing exercises. Send labeled specimens to lab promptly.
o Identify priority assessments after a thoracentesis
Upper Respiratory
• Influenza
o Identify expected findings
Malaise, fatigue, fever, chills, body aches, cough, congestion, n/v, resp. failure
o Identify signs of pulmonary complications related to influenza
Pneumonia, resp failure
• Head and neck cancer
o Identify clients at risk for head and neck cancer
Tobacco and alcohol use, GERD, environmental factors, genetics, damaged DNA
from carcinogens cause mutation of cells
o Surgical therapy: identify post-operative interventions for laryngectomy
and radical neck dissection
Focus on airway management, wound care, nutrition, communication,
psychosocial issues r/t body issues
Maintenance of patent airway
Keep pt. in semi fowlers to decrease edema and inflammation
Frequent suction r/t increase in secretions
Deep breathing and coughing exercises
Frequent pain, VS assessment
Wound care, drainage assessment
Check patency of drainage tubes q4h
Frequent oral care
o Identify reportable complications related to a
laryngectomy Increased risk of infection, hemorrhage
Monitor patency of airway
R/T edema and
inflammation
• Tracheostomy care (recommend ATI airway management
(tracheostomy) skills module)
o Identify safe care of the client with a tracheostomy
▪ Identify priority assessments
VS, including heart rate, RR, BP, O2, ensure patency of IV and drainage
tubes, place obturator inside outer cannula after insertion, remove
obturator, auscultate lung sounds after the cuff is inflated, note and
record ventilator settings, observe amount of blood at insertion site,
redness, inflammation, edema, ulcerations
▪ Identify priority interventions
Provide means for communication, teach tracheostomy management,
tracheostomy care, position to facilitate ventilation (HOB 30-45),
aspiration precautions, tube feedings, nutritional consultation,
psychosocial needs, suctioning
▪ Explain when and how to suction
Assess need for suctioning hourly. Indications include visible coughing,
course crackles or wheezes, moist cough
Explain procedure, gather supplies
Adjust suction to no greater than 125mmHg
, Exam 1 study guide
Assess baseline HR and rhythm, SpO2
Use sterile technique to open equipment, full cup with sterile H2O,
designate 1 hand for connecting/disconnecting suction tubing, using
manual resuscitation bag and operating suction control
Provide preoxygenation for a min of 30 sec
Insert catheter without suctioning to the point where pt. coughs. Apply
suction while gently removing
Continuous suction for 10-15 seconds
D/C suctioning if HR decreases by 20bpm from baseline, increase by
40bpm, dysrhythmia or SpO2 decreases to 90%
Hyper-oxygenate between suctioning
▪ Explain essential discharge teaching for a client with a tracheostomy
Observe tracheostomy site for s/sx of infection
Sterile technique to clean tracheostomy
Suctioning techniques
Changing of tracheostomy tapes
Lower Respiratory
• Review oxygen therapy: indications for and how to choose appropriate equipment
Low flow delivery-nasal cannula-O2 up to 2L/min, simple face mask-O2
concentration
35-50% flow up to 6-12L, partial and non-breather mask-60-90% O2 concentration 10-
15L, O2 conserving cannula-log term O2 therapy, 30-50% O2 at 8L/min
High flow delivery-tracheostomy collar-can deliver high humidity and O2 via
tracheostomy, tracheostomy T Bar-has vent and T shaped connector that allows for
inline catheter to be connected, venturi mask-delivers precise, high flow O2 with
concentration of 24%, 28%, 31%, 36%, 40%, 50%, High flow nasal cannula-blends O2
with compressed air to generate FiO2 of 1 at flow rate of 60L min, provides 100% body
humidity
• Explain criteria used when evaluating effectiveness of respiratory
interventions VS-BP, HR and rhythm, temp, RR, SpO2
Auscultate lung sounds
Assess respiratory secretions; color, consistency,
odor Skin temp and color
Sputum culture
ABGs
I/O
• Identify risk factors for developing pneumonia
Pneumonia-complication of flu
Risk factors-advanced age, long term care resident, smoking, respiratory disease,
immune-deficiency, altered mental status, prolonged immobilization, aspiration,
hospitalization, communal living
• Pneumonia: explain the changes in the lung tissue and the effect these changes have on
airway clearance, breathing pattern, and gas exchange
Pathophysiology-offending organisms-virus, bacteria, fungi
Inhaled via cough, sneeze, aspirate
Functional changes-increases inflammation, blood flow, vascular permeability,
airway edema, consolidation, increased mucous production, decreased gas exchange
Complications-atelectasis, pleural effusion, sepsis, resp. failure
