sarabjit seminar
TRANSCRIPT
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MODERATOR-MRS PARMEES KAUR
LECTURER
RPCON
PRESENTED BY-SARABJIT KAUR
M.SC 1
ST
YEARRPCON
SEMINAR ON OXYGEN
INSUFFICIENCY,
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INTRODUCTION
Oxygen is required to sustain life.Blood is oxygenated through
the mechanisms of ventilation,perfusion and transport of
respiratory gases
Oxygenation is the addition of oxygen to any
system,includingthe human body
It also refers to the process of treating a patient with oxygen
Oxygenation is the process by which concentration of oxygen
increased in a tissue.
Oxygen insufficiency is defiency in the amount of oxygen
reaching blood
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PHYSIOLOGY OF OXYGENATION
Oxygenation results from the co-operative function of three majorsystems
Pulmonary
Haematological
Cardiovascular system
Anatomy of system involved in oxygenation process
The main organs involved in process of oxygenation are heart andlungs. blood from heart enters to the heart through superior and
inferiorvenacava to right atrium
During atrial systole the blood is ejected to right venriclethroughtricuspid valve
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PHYSIOLOGY OF OXYGENATION
From right ventricle pulmonary artery takes the blood to lungs foroxygenation
Oxygenated blood return to left atrium and then ventricle via pulmonary
vein
Left ventricle then supplies oxygenated blood to whole body via artery
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PHYSIOLOGY OF OXYGENATION
HOW LUNGS HELPS IN OXYGENATION
Respiratory system is divided into two parts-
1.Upper respiratory tract including mouth,nose ,pharynx and
larynx
2.Lower respiratory tract trachea and lungs along
bronchi,alveoli,pulmonary capillary network and pleural
membranes
Pathway of air: nasal cavities (or oral cavity) > pharynx > trachea
> primary bronchi (right & left) > secondary bronchi > tertiary
bronchi > bronchioles > alveoli (site of gas exchange)
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PHYSIOLOGY OF OXYGENATION
ALEVOLAR GAS EXCHANGE
The exchange of gases (O2 & CO2) between the alveoli & the blood occurs by
simple diffusion:
O2 diffusing from the alveoli into the blood & CO2 from the blood into the
alveoli. Diffusion requires a concentration gradient. So, the concentration (or
pressure) of O2 in the alveoli must be kept at a higher level than in the blood &
the concentration (or pressure) of CO2 in the alveoli must be kept at a lower
lever than in the blood.
, by breathing - continuously bringing fresh air (with lots of O2 & little CO2)
into the lungs & the alveoli.
Breathing is an active process- requiring the contraction of skeletal muscles.
The primary muscles of respiration include the external intercostal muscles
(located between the ribs) and the diaphragm
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PHYSIOLOGY OF OXYGENATION
The external intercoastal plus the diaphragm contract to bring
about inspiration:
Contraction of external intercostal muscles > elevation of ribs &
sternum > increased front- to-back dimension of thoracic cavity >
lowers air pressure in lungs > air moves into lungs
Contraction of internal intercoastal muscles > ribs moves
downward > decraese dimension of thoracic cavity > air moves
out of lungs:
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PHYSIOLOGY OF OXYGENATION
HYPOXIA
Hypoxia can occur from either severe pulmonary disease or from
extrapulmonary disease affecting gas exchange at the cellular
level.The four general types of hypoxia are;
1.HYPOXIC HYPOXIA- It is a decreased oxygen level in the
blood resulting in decreased oxygen diffusion into the tissues. It
may be caused by hypoventilation, high altitudes, ventilation-
perfusion mismatch and pulmonary diffusion defects. It iscorrected by increasing alveolar ventilation or provide adequate
oxygen
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PHYSIOLOGY OF OXYGENATION
2.CIRCULATORY HPOXIA-
It is resulting from inadequate capillary circulation. It may be
caused by decreased cardiac output. local vascular obstruction,
low flow states such as shock or cardiac arrest. It is corrected by
identifying and treating the underlying cause.
3. ANEMIC HYPOXIA-
It is a result of decreased effective haemoglobinconcentration,which causes deacrease in oxygen carryingcapacity of the blood
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PHYSIOLOGY OF OXYGENATION
4.HISTOTOXIC HYPOXIA-
It occurs when anoxic substance such as cyanide,interferes with
the ability of tissues to use available oxygen.
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PATHOPHYSIOLOGY OF HYPOXIA
Due to any factors such as anemia
Cell can switch to anaerobic Less oxygen supply to cells resulting in
availability of less
Metabolism energy for cellular functions
Result in accumulation of acids
Distruction of tissues and organs
Imbalance in chemical environment of cells
Release of lysosomal enyzymes
Tissue distruction
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FACTORS AFFECTING OXYGENATION
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Oxygen is influenced by three types of factors;
1 Physiological Factors
Any condition that affects cardiopulmonary functioning directly
affects the bodys ability to meet oxygen demands.
The general classification of cardiac disorders include
disturbances in conduction, impaired valvular
function,myocardial hypoxia,cardiac myopathic conditions and
peripheral tissue hypoxia.
Respiratory disorders include hyperventilation,hypoventilation
and hypoxia
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FACTORS AFFECTING OXYGENATION
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Some more physiologic processes are
1.Anaemia
2.Pregnancy
3. Fever 4.Infection
5. CNS alteration
6.Influences of chronic diseases
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FACTORS AFFECTING OXYGENATION
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2. DEVELOPMENTAL FACTORS-
The developmental stage of the client and the normal aging
process can affect tissue oxygenation
1.I nfants and toddlers-are at greater risk for upper respiratorytract infections
2.School age chi ldren and adolescents-are exposed to
respiratory infections and respiratory risk factors such as
smoking 3.Young and middle age adul ts-are exposed to multiple
cardiopulmonary risk factors like unhealthy diet,lack of
exercise ,stress and drug uses.
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FACTORS AFFECTING OXYGENATION
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4.Older adults-Thephysiologic changes occurs.Ventilation andtransfer of respiratory gases decline with age,leading to loweroxygenation levels
3. LIFE STYLE FACTORS
Life style factors which lead to oxygen imbalance- Cigarette smoking
Junk foods
Spicy and fatty foods
No exercise Stress
Substance abuse
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FACTORS AFFECTING OXYGENATION
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ENVIRONMENTAL FACTORS
Alttitude, heat,cold and air pollution affect oxygenation.
Air pollution cause stinging of eyes and chocking even in healthypeople.
MEDICATIONS-
Certain medications including sedatives, hypnotics can causerespiratory deprression and narcotics including morphine
SYMPTOMS OF OXYGEN INSUFFICIENCY
Body weakness
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FACTORS AFFECTING OXYGENATION
Cont--15-
Loss of memory
Muscle ache
Depression
Dizziness Irritability
Infection
Fatigue
Acidity Lowered immunity
Bronchial problems
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FACTORS AFFECTING OXYGENATION
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Irrational behaviour
INTERVENTIONS
1.OXYGEN THERAPY
2.SUCTIONING
3.NEBULIZATION
1.OXYGEN THERAPY
Oxygen therapy is used for paitient who suffer from
hypoxaemia. The decision to administer oxygen,the amountto deliver and the method to be used depend on thepurpose for which it is being administered
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INTERVENTIONS
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The effectiveness of oxygen in the treatment of the patientdepends on the pathologic process present.The physicianindicates the method by which oxygen is to be given and thenumber of liters per minute.
The nurse responsible for carrying out the directive shouldact promptly and remember that although oxygen may bebeneficial,it may also be dangerous.
Therefore the nurse should carefully observe any patient
who is receiving oxygen.
INDICATIONS-
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INTERVENTIONS
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COPD
Hypoxaemia
Pulmonary embolism
Pneumonia Tension pneumothorax
Asthma
Pulmonary edema
2. GOALS OF OXYGEN THERAPY
To relieve hypoxaemia
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INTERVENTIONS
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To reduce work of breathing
To decrease the work of myocardium
To relieve tissue hypoxia
3. OXYGEN DEL IVERY METHODS
1 NASAL CANNULA-
A nasal cannula is used when the patient requires a low tomedium concentration of oxygen .
This method is relatively simple and allows the patient to moveabout bed in bed ,talk,cough and eat without interrupting oxygenflow .
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INTERVENTIONS
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Flow rate in excess of 6 to 8 L/min may lead to swallowing of air
or may cause irritation and drying of the nasal and pharyngeal
mucosa.
2. FACE MASK
Oxygen masks are comfortable and are used when higher
concentrations of oxygen is given.
A simple oxygen mask provides concentration of oxygen from
40% to 60% depending on the patients ventilator pattern.
Flow rate of 5 to 8Lmin are normally required.This system is
particularly useful in individuals with COPD.
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INTERVENTIONS
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3.PARTIAL REBREATHING MASK
Have a reservoir bag that must remain inflated during both
inspiration and expiration.
The nurse adjust the oxygen flow to ensure that the bag does not
collapse during inhalation.
A high concentration of oxygen can be delivered ,because both
the mask and the bag serve as reservoirs for oxygen.
Oxygen enter the mask through small-bore tubing that connects at
the junction of the mask and bag.
As the patient inhales ,gas is drawn from the mask,from the bag
and potentially from room air through the exhalation
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PARTIAL REBREATHER
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ports.As the patient exhales,the first third of the exhalation fills
the reservoir bag .This mainly dead space and does not
participate in gas exchange in the lungs.
3.NON BREATHER MASK
Non breather mask consist of a mask and reservoir that are
separated by a oe-way valve that prevents expired air from
mixing with supplement oxygen.Exhaled air is directed out of
the mask through exhalation ports.If the mask conforms tightly
to the face ,100% oxygen concentration can be delivered.
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NON-BREATHER MASK
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INTERVENTIONS
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4.VENTURI MASK
Venturi mask is the most reliable and accurate method for
delivering precise concentrations of oxygen through non invasive
means.The mask is constructed in a way that allows a
concentration constant flow of room air blended with a fixed flowof oxygen .It can accurately used for patients with COPD because
it can accurately provide appropriate levels of supplemental
oxygen,thus aviding the risk of suppressing the hypoxic drive
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VENTURI MASK
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INTERVENTIONS
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6.TRANS TRACHEAL OXYGEN CATHETER
It is inserted directly into trachea and is indicated forpatients with chronic oxygenation therapy needs.
These cathetars are more comfortable,lessdependent on breathing patterns.Because no oxygenis lost into the surrounding environment,the ptientachieves adequate oxygenation at lower rates,making
this method less expensive and more efficient.
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INTERVENTIONS
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7.FACE TENTS
Facial tents can be used in clients who cannottolerate masks.
O2 concentration at a flow rate of 4 to 8 L/min. METHODS USED IN CASE OF PAEDIATRICS
IN CASE OF INFANTS
OXYGEN HOOD
Rigid plastic dome that encloses on infanthead
It provides precise oxygen levels and high humidity
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OXYGEN HOOD
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INTERVENTIONS
IN CASE OF CHILDREN
OXYGEN TENT
Made up of rectangular, clear,plastic canopy with outlets that
connect to an oxygen source.
Flow rate is adjusted at 10 to 15 L/min after flooding the tent for
5 minutes
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INTERVENTIONS
HAZRARDS OF OXYGEN IHALATION Infection
Combustion
Drying of mucous membrane of the respiratory tract
Oxygen toxicity
Atelectasis
Oxygen induced apnoea
Retrolental Fibroplasia
Asphyxia
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OXYGEN INSUFFIEIENCY
NURSING RESPONSIBLITIES FOR ADMINISTRATION OF OXYGEN
Check the name ,bed number and other identification dateof patient.
Confirm diagnosis and the need of oxygen therapy
Assess the patient for any sign of anoxia e.g cyanosis andalso assess the breathing pattern
Monitor for results of ABG
Monitor the signs of oxygen toxicity
Check that the oxygen is properly humidified
Every precaution should be taken to prevent entry ofinfection to patient
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OXYGEN INSUFFIEIENCY
Place a calling bell near the patient in case if nurse is not near
him.
Pay attention to kinks in tubing ,loose connection and faulty
humidifying apparatus as it may interfere with flow of oxygen
For fear of retrolental fibroplasias, give oxygen to newborn
babies for a short period at very low concentration.
Since oxygen supports combustion, fire precautions are to be
taken when oxygen is on low.Give proper instructions to the
relatives of client regarding this.
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MECHANICAL VENTILATION
In case of oxygenation failure mechanical ventilationis used to restore and maintain lung volumes.Conditions such as thoracic or abdominal surgery,drug overdose, neuromuscular disorders,multipletrauma, shock, and coma may lead to respiratoryfailure and the need for mechanical ventilation
Normal respiration begins with the contraction of
the diaphragm and respiratory muscles to createnegative pressure in the chest. A vacuum is created
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MECHANICAL VENTILATION
and air flows in.When a ventilator is used ,positivepressure (rather than negative pressure)forces airinto the lungs .The positive pressureis necessary forgas exchange and to keep alveoli open.Unfortunatelypositive pressure forces can damage the alveoli andmay retard venous return and cardiac output.
INDICATIONS-
Continuous decrease in Pao2 Increase in arterial CO2 levels
Persistent acidosis
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MECHANICAL VENTILATION
GOALS OF MECHANICAL VENTILATION
To maintain adequate ventilation
To deliver precise concentrations of FiO2
To deliver adequate tidal volumes to maintain anadequate minute ventilation and oxygenation
To lessen the work of breathing in those clients whocannot sustain adequate ventilation on their own.
To prevent complications from the underlyingproblems
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MECHANICAL VENTILATION
POSITIVE PRESSURE VENTILATION
Positive pressure ventilation inflate the lungs by exerting positive
pressure on the airway ,forcing the alveoli to expand during
inspiration.Expiration occurs passively. Endotracheal intubation
or tracheostomy is necessary in most cases.There are three types
of positive pressure ventilatiors; pressure- cycled ,time-cycled,and volumecycled.
1.PRESSURE CYCLED VENTILATORS
Delivers a volume of gas to the airway using positive pressureduring inspiration.The positive pressure is delivered until the
preselected pressure has been reached .When the preset pressure
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MECHANICAL VENTILATION
has been reached , the ventilator will cycled into passive
exhalation.A disadvantage to this type of ventilator is
that the volume delivered may not be sufficient
depending on the compliance of the lung and the
integrity of the ventilator circuit (_e.g kinking tube)
2. VOLUME- CYCLED VENTILATORS(volume-
controlled or volume
limited)-
Delivers a preset tidal volume of inspired gas .The tidal
volume has been preselected based on the ideal weight
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MECHANICAL VENTILATION
and is delivered to the client regardless of the pressure required todeliver this volume.The ventilator will automatically adjust the
pressure needed to deliver the preset volume ..If the clients
breathing is shallow ,the ventilator will increase pressure to
continue delivering the preset volume . A pressure limit can beset to prevent the occurrence of dangerously high airway
pressures.
3.TIME
CYCLED VENTILATORS
Timecycled ventilators terminate or control inspirations after a
preset time .
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MECHANICAL VENTILATION
MODES OF VENTILATION
ASSIST CONTROLLED VENTLATION
Mode of mechanical ventilation in which the patients breathing
pattern may trigger the ventilator to deliver a preset tidal volume
;in the absence of spontaneous breathing , the machine delivers acontrolled breath at a preset minimum rate and tidal volume.
SYNCHRONIZED INTERMITTENT MANDATORY
VENTILATION(SIMV)-
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MECHANICAL VENTILATION
Mode of mechanical ventilation in which the ventilator allows thepatient to breathe spontaneously while providing a preset number
of breaths to ensure adequate ventilation ;ventilated breaths are
synchronized with spontaneous breathing.
INTERMITTENT MANDATORY VENTILATION-
Mode of mechanical ventilation that provides acombination of mechanically assisted breaths and
spontaneous breaths.
CONTINUOUS POSITIVE AIRWAY PRESSURE-(CPAP)
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MECHANICAL VENTILATION
Positive pressure applied through out the respiratory cycle to aspontaneously breathing patient to promote alveolar and airway
stability ;may be administered with endotracheal or tracheostomy
tube, or by mask.
POSITIVE END EXPIRATORY PRESSURE (PEEP)-
Positive pressure maintained by the ventilator at the end ofexhalation to increase functional residual capacity and open
collapsed alveoli ,improves oxygenation with lower FiO2.
PRESSURE SUPPORT VENTILATION-
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MECHANICAL VENTILATION
Mode of mechanical ventilation in which preset positive pressureis delivered with spontaneous breaths to decrease work of
breathing
PROPORTIONAL ASSIST VENTILATION-
Mode of mechanical ventilation that provides partialventilator support in which the ventilator generatespressure in proportion to the patients inspiratory efforts;
decrease the work of breathing.the more inspiratorypressure the patient generates ,the more pressure theventilator generates ,amplyfying the patient,s inspiratoryeffort.
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SUCTIONING
SUCTIONING
Definition
Removal of secretions from the oral cavity and pharynx
Purposes
To remove secretions that obstruct the airway.
To facilitate ventilation
To obtain secretions for diagnostic purposes
To prevent infection that may result from accumulated secretions.
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SUCTIONING
NURSING ACTIONS
1.Assess for sign and symptoms indicating presence of upper
airway secretions
2.Explain to the client that suctioning will stimulate the
cough,gag reflex
3.Explain importance of and encourage coughing during
procedure
4.Assemble articles
5.Adjust bed to comfortable working position.Lower side rails
closer to you ,place the patient in a semi-fowlers position if
conscious.An unconscious patient should be placed in lateral
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lateral position facing you
6.Place towel or waterproof pad across patients chest
7.Wear mask or face shield
8.Turn on suction and adjust to appropriate pressure
a)Wall unit
Adult-100-120 mm of Hg
Child -95-110mm of Hg
Infant-50-95mm of Hg b)Portable unit
Adult-10-15mm of Hg
SUCTIONING
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SUCTIONING
Child-5-10mm of Hg
Infant-2-5mm of Hg
9.Wash hands
10.Perform oropharngeal suctioning
11.Reassess clints respiratory status
12.Remove towel,place in laundary bag
13.Reposition client;Sims position encourages drainage and
should be used if client has decreased level of consciousness 14. Wash and rinse used articles
15. Place catheter in clean dry area
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16.Document the procedures in nurses record
3)NEBULISATION THERAPY-
It is the process of dispersing liquid medication into microscopic
particles(aerosol) and delivering into lungs as patient inhales
PURPOSES
1.To administer medication directly into the respiratory tract for
sputum expectoration.
2.To reduce difficulty in bringing out thick tenacious repiratory
secretions
3.To increase vital capacity
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NEBULISATION THERAPY
3.To increase vital capacity
4.To relieve dyspnoea
NURSES ACTIONS
1.Identify patient and check physicians instructions
2.Monitor heart rate before and after the treatment for patients
using bronchodilators drug
3.Explain the procedure to the patient
4.Place the patient in a comfortable sitting or a semifowlersposition.
5.Add the prescribed amount of medication and saline or sterile
water to the nebulizer.
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NEBULISATION THERAPY
6.Place mask on patients face to cover his mouth and nose andinstruct him to inhala deeply and slowly through the mouth,hold
breath and then exhale several times.
7.Oberve expansion of chest to ascertain that patient is taking
deep breaths. 8.Instruct the patient to brathe slowly and deeply until all the
medication is nebulized.
9.On completion of the treatment encourage the patient to cough
after several deep breaths 10.Record medication used and descriptions of secrtions
expectorated
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3)NEBULISATION THERAPY-
11.Disassemble and clear nebuliser after each use .Keep theequipment in patients roomThe tubing is changed every 24 hrs.
12.Wash hands.
Diagnostic studies-
A] PFT
Pulmonary function tests are routinely used in patients with
chronic respiratory disorders.They are performed to assess
respiratory function and to determine the extent of
dysfunction.Such tests include measurenents of lung
volumes.ventilatory function and the mechanics of
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HISTORY
Health History- The health history focuses on the physical and functional
problems of the patient and effect of these problems on the
patient,including his or ability to carry out activities of daily
living 1.DYSPNOEA-Difficult or labored breathing or shortness of
breath is a symptom common to many pulmonary and cardiac
disorders,particularly when there is decrease lung compliance or
increased airway resistance
2.ORTOPNOEA-
Inability to breathe in an upright posit
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HISTORY
It is important to ask the patient the following questions-
1.How much exertion triggers shortness of breath?
2.Is there is an associated cough?
3.Is the shortness of breath related to other symptoms?
4.At what time of day or night does the shortness of breath occur?
5.Is the shortness of braeth worse when the patient is flat in bed?
6.Does the shortness of breath occur at rest?with
exercise?Running?climbing stairs? 3.Pain
4.Hemoptysis
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HISTORY
5.Edema of the ankles and feet,cough and general fatigue andweakness
6.Obtains information about precipitating factors,duration,s
everity and associated factors and symptoms and also assess for
risk factors and genetic factors that contribute to the patientslung condition
7.Assess the impact of sign and symptoms on the patient,s ability
to perform activities of daily living and to participate in usual
work and family activities 8.Cough
Cough results from irritation of mucus membranes anywhere in t
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HISTORY
The respiratory tract.The stimulus that produces cough may arisefrom an infectious process or from an airway irritant such as
smoke ,dust or a gas.Cough may indicate serious pulmonary
disease,but it may caused by a variety of other problems as well
including cardiac disease,smoking and GERD Clinical significance
A dry ,irritative cough is characterstic of an upper respiratory
tract infection of viral origin or it may be side effect of ACE
inhibitor therapy Laryngotracheitis causes an irritative ,high pitched cough.
A severe or changing cough indicate bronchogenic carcinoma
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HISTORY
The time of coughing is noted
Coughing at night indicate the onset of left sided heart failure or
bronchial asthma
A cough in the morning with sputum production may indicate
bronchitis
A cough that worsens when the patient in supine suggests
sinusitis
Coughing after food intaake aspiration of material into the
trcheobronchial tree
9.Sputum
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HISTORY
A patient who coughs long enough almos invariably producessputum
Sputum production is the reaction of the lungs to any constantly
recurring irritant.
CLINICAL SIGNIFICANCE
The nature of the sputum is indicative of the causal condition
A profuse amount of purulent sputum or a change in color of the
sputum is a common sign of bacterial infection
Thin mucoid sputum results from viral bronchitis
A gradual increase of sputum over time may indicate the presence
of chronic bronchitis or bronchiectasis
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HISTORY
Pinktinged mucoid sputum suggests a lung tumor
Foul smelling sputum and bad breath indicate the presence of
lung abcess ,bronchiectasis or an infection caused by anerobic
organisms
10. CHEST PAIN
Chest pain or discomfort may be associated with pulmonary
conditions may be sharp, stabbing and intermittent or it may be
dull, aching and persistent. The pain is usually felt on the sidewhere the pathologic process is located ,but it may be reffered
elsewheree.g,to the neck,back or abdomen
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HISTORY
The nurse assess the quality,intensity and radition of pain andidentifies and explores precipitating factors and their relationship
to the patient condition
11.WHEEZING-
It is a high- pitched musical sound heard only on expiration .It is
heard with or without stethoscope,depending on its location
Oral or inhalant bronchodilator medications reverse wheezing in
most instances.
12.CLUBBING OF THE FINGERS-
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CLUBBING OF FINGERS
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HISTORY
The nurse considers the following points
Bloody sputum from the nose or the nasopharynxx is usually
preceded by considerable sniffing,with blood possibly appear
from the nose
Blood from the sputum is usually bright red ,frothy and mixedwith sputum.
If the haemorrhage is in the stomach ,the blood is vomited rather
than coughed up.Blood that has been in contact with gastric juice
is sometimes so dark that it is refferded to as coffee grounds
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HISTORY
It is a sign of lung disease that is found in patients with chronichypoxic conditions,chronic lung infections or malignancies of the
lung.
This finding may be manifested intially as sponginess of the nail
bed and loss of the nail bed angle.
12.HEMOPTYSIS
Expectoration of blood from the respiratory tract is a symptom of
both pulmonary and cardiac disease.
It is important to determine the source of the bleedingthe
gums,nasopharnyx,lungs or stomach
S O
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HISTORY
13.CYANOSIS- A bluish coloring of the skin is a very late indication of hypoxia
The presence or absence of cyanosis is determined by the amount
of unoxygenated hemoglobin in the blood .
Cynosis appears when there is at least 5g/dl of unoxygenated
hemoglobin
Assessment of cynosis is affected by room lighting ,the patients
skin color
Central cyanosis is assessed by observing the color of the tongue
and lips.This indicates a decrease in oxygen tension in the blood.
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Peripheral cyanosis results from decreased blood flow to a certainarea of the body,as in vasoconstriction of the nail beds or earlobes
from exposure to cold, and does not indicate a central systemic
problem
PHYSICAL ASSESSMENT OF THE UPPER
RESPIRATORY TRACT STRUCTURES
1.NOSE AND SINUSES
The nurse inspects the external nose for lesions,asymetry orinflammation and then ask the patient to tilt the head backward
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PHYSICAL ASSESSMENT
Gently pushing the tip of the nose upward ,the nurse examinesthe internal structures of the nose,inspecting the mucosa for
color,swelling,exudate or bleeding
The nasal mucosa is normally redder than the oral mucosa.It may
appear swollen and hyperemic if the patient has a commoncold,but in allergic rhinitis the mucosa appears pale and swollen.
The nurse inspects the septum for deviation,perforation or
bleeding
The nurse may palpate the the frontal and maxillary sinuses fortendreness
The frontal or maxillary sinuses is inspected by translumination
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PHYSICAL ASSESSMENT
If the light fails to penetraate ,the cavity likely to contain fluid orpus
2.PHARYNX AND MOUTH
After nasal inspection ,the nurse assess the mouth and pharynx,
instructing the patient to open the mouth wide and take a deep
breath .
Allows a full view of the anterior and posterior pillars
,tonsils,uvula and posterior pharynx
The nurse inspects these structures for color,symmetry and
evidence of exudate ,ulceration or enlargement
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PHYSICAL ASSESSMENT
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PHYSICAL ASSESSMENT
3.Trachea The position and mobility of trachea are noted by direct palpation
This performed by placing the thumb and index finger of one
hand on either side of trachea just above the sternal notch
The trachea is highly sensitive and palpating too firmly may
trigger a coughing or gagging response
Pleural or pulmonary disorders, such as pneumothorax,may also
displace the trachea
PHYSICAL ASSESSMENT OF THE LOWER
RESPIRATORY STRUCTURES AND BREATHING
PHYSICAL ASSESSMENT
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PHYSICAL ASSESSMENT
1.THORAX Inspection of the thorax provides information about the
musculoskeletal structure ,the patients nutritional status and the
respiratory system
Observe the skin over the thorax for color and turgor and forevidemce of subcutaneous tissue
CHEST CONFIGURATION
Normally the ratio of the anteriorposterior diameter to the lateral
diameter is 1..2There are four main deformities of the chestassociated with respiratory disease that alter this relationship-
1.Barrel chest-
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PHYSICAL ASSESSMENT
Occuras as a result of overinflation of the lungs.There is anincrease in the anteriorposterior diameter of the thorax.
2.Funnel chest(Pectus excavatum)
Occurs when there is depression in the lower portion of thesternum.This may compress the heart and great vessels,resulting
in murmurs
It may also occurs as a result with rickets os Marfan syndrome
3.Pigeon chest(Pectus Carinatum)-
It occurs as a result of displacement of the sternum.
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PHYSICAL ASSESSMENT
There is an increaes in the anterior posterior d iameter
BREATHING PATEERNS AND RESPITATORY RATES
The normal adult who is resyting comfortably takes 12 to 18
braeths per minute(Eupnea)
BRADYPNEA OR SLOW BREATHING
TACHYPNOEA OR RAPID BREATHING
HYPERPNEA OR INCREASE IN THE DEPTH OF
RESPIRATIONS
APNEA OR CESSATION OF BREATHING
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Cheyen Stokes:
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Cheyen-Stokes:
Bi t' B thi ("Cl t " b thi )
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Biot's Breathing ("Cluster" breathing)
Kussmaul's Breathing
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Kussmaul's Breathing
Ataxic Breathing:
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Ataxic Breathing:
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PHYSICAL ASSESSMENT
KUSSMAUL;S RESPIRATION OR INCREEASE IN RATE ORDEPTH OF RESPIRATIONS
CHEYNE STOKES RESPIRATION(Alternating episodes of
apnoea and periods of deep breathing
BIOTS RESPIRATION OR CLUSTER BREATHING are cyclesof breath that vary in depth and having periods of apnoea
THORACIC PALPATION
For tenderness,massess,lesions,respiratory excursion and vocalfermitus
RESPIRATORY EXCURSION
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PHYSICAL ASSESSMENT
It is an estimation of thoracic expansion and may dislodgesignificant information about thoracic movement during
breathing
The patient is instructed to inhale deeply while the movement of
the nurses thumbs during inspiration and expiration is observed This movement is normally symmetric
Decreased chestexcursion may be caused by chronic fibrotic
disease
Asymmetric excursion may be due to fracturedribs,trauma,unilateral bronchial obstruction
RESPIRATORY EXCURSION
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RESPIRATORY EXCURSION
PHYSICAL ASSESSMENT
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PHYSICAL ASSESSMENT
TACTILE FERMITUS-The detection of the resulting vibrationon the chest wall by touch
The vibrations are detected with the palmer surfaces of the
fingers and hands or the ulner aspect of the extented hands on the
thorax
Air does not conduct sound well,but a solid substance such as
tissue doe, provied that it has elasticity and is not compressed
A patient with consolidation of a lobe of lung from pneumonia
has increased tactile fermitus.
TACTILE FERMITUS
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TACTILE FERMITUS
PHYSICAL ASSESSMENT
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PHYSICAL ASSESSMENT
THORACIC PERCUSSION It is used to estimate the size and location of certain structures
within the thorax
Percussion sounds
Flaatness-Large pleural effusion
Dulness-Lobar pneumonuia
Resonance-Simple chronic bronchitis
Hyperesonance-Emphysema
BREATH SOUNDS
THORACIC PERCUSSION
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THORACIC PERCUSSION
PHYSICAL ASSESSMENT
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PHYSICAL ASSESSMENT
CRACKLES- 1Crackles in general-Soft,high-pitched ,discontinous
popping sounds that occur during inspiration
Coarse crackles-Discontinous popping sounds heardin early inspiration;harsh,moist sound orginated inthe large bronchi
Fine crackles-Discontinous popping sounds heard in
late inspiration,orginates in the alveoli
WHEEZING
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PHYSICAL ASSESSMENT
SONOROUS WHEEZES Deep low pitched rumbling sounds heard primarily
during expiration,caused by air moving throughnarrowed tracheobronchial passages
Sibilant wheezes
Continuous ,musical,high pitched ,whistle like
sounds heard during inspiration and expiration
PLEURAL FRICTION RUB
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PHYSICAL ASSESSMENT
Harsh ,crackling sound like two pieces of leatherrubbed together
TERM USED SYMBOL DESCRIPTION REMARKS
FORCED VITAL FVC Vital capacity FVC is often
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CAPACITYp y
performed with amaximum forcedexpiratory effort
reduced in COPDbecoz of airtrapping
FORCEDEXPIRATORYVOLUME
FEV1 Volume of airexhaled in thespecified timeduring theperformance ofFVC
A valuable cue toof the expiratoryairway obstructionthe severity
Ratio of timedforced expiratory
volume to forcedvital capacity
FEV/FVC It is expressedpercentage of
forced vitalcapacity
Presence of airwayobstruction
FORCEDEXPIRATORYFLOW
FEF200-1200 Mean forceexpiratory flowb/w 200-1200 ml
of FVC
Large airwayobstruction
Oxyhemoglobin dissociation curve
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Oxyhemoglobin dissociation curve
It shows the relationship between the partial pressure of oxygenand the percentage of saturation of oxygen
The percentage of oxygen can be affected by the following
factors-carbondioxide,hydrogen ion concentration,temperature
and 2,3diphosphoglycerate An increase in these factors shifts the curve to the right ,so that
more oxygen is released to the the tissues at the same Pao2
A decrease in thes e factors cause the curve to shift to left,making
the bond between oxygen and hemoglobin stronger.The unusualshape of the curve is a distinct advantage to the patient for two
reasons
Oxyhemoglobin dissociation curve
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Oxyhemoglobin dissociation curve
If the Pao2 decraese from 100 to 80 mm Hg as aresult of lung or heart disaese,the hemoglobin of thearterial blood remains almost maximally saturated(94%), and the tissues do not suffer from hypoxia
When the arterial blood passess into tissuecapillaries and is exposed to the tissue tension ofoxygen of oxygen9about 40 mm Hg )hemoglobingives up large quantities of oxygen for use by thetissues.
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ALLEN TEST
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ALLEN TEST
The blood supply to hand normally comes from 2 arteries, theradial artery and the ulnar artery. Before drawing blood for an
arterial blood gas test, physician will make sure that both arteries
are open and working correctly. A procedure called the Allen test
may be used to find out if the blood flow to your hand is normal.
For the Allen test, the health professional drawing the blood will
apply pressure to the arteries in the wrist for several seconds. This
will stop the blood flow to your hand, and your hand will become
cool and pale. Blood is then allowed to flow through the
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artery that will not be used to collect the blood sample. This isusually the ulnar artery, which is found on the outer (little finger
side) of your wrist. Arterial blood gases are usually taken from
the radial artery, which is found on the inner (thumb side) of the
wrist.
Allen testNormal (positive) hand quickly becomes warm and
returns to its normal color. This means that one artery alone will
be enough to supply blood to the hand and finger.
Abnormal (negative)the hand remains pale and cold. This means
that one artery is not enough to supply blood to your hand and
fingers. Blood will not be collected from an artery in this hand.
DIAGNOSTIC TESTS
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DIAGNOSTIC TESTS
of breathing,diffusion and gas exchange PFTS are performed bytechnician using a spirometer that has a volume collectin device
attached to a recorder that demonstrates volume and time
simultaneously.
A number of tests are carried out , because no singlemeasurement provides a complete picture of pulmonary
function.The most frequently used PFTs are Forced vital capacity.
,FEV 1,FEVI/FVC%,MW
B] ABG(Arterial Blood Gas Analysis) -
Meaurement of blood pH and of arterial oxygen and
DIAGNOSTIC TESTS
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DIAGNOSTIC TESTS
carbondioxide tensions are obtained whenmanaging patients with respiratory problems andadjusting oxygen therapy as needed.
The arterial oxygen tension (PaO2) indicates thedegree of oxygenation of blood and the arterialcarbondioxide tension (PaCO2) indicates theadequacy of alveolar ventilation
.ABG studies aid in assessing the ability of thelungs to provide adequate oxygen and emovecarbondioxide and the ability of the kidneys to
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DIAGNOSTIC TESTS
reabsorb or excrete bicarbonate ions to maintain normal body PH
C) PULSE OXIMETRY
It is a non invasive method of continuously monitoring
the oxygen saturation of haemoglobin(SaO2)When oxtgen
saturation is measured with pulse oximetry it is referred to
as SpO2A probe or sensor is attached to the finger tipforehead,earlobe, or bridge of the nose
.The sensor detects changes in oxygen saturation levels by
DIAGNOSTIC TESTS
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G OS C S S
monitoring light signals generated by the oximetre and reflectedby blood pulsing through the tissue at th probe
Normal Spo2 values are 95% to 1005 Values less than 85%
indicate that the tissues are not receiving enough oxygen and
further evaluation is needed. d) SPUTUM STUDIES-
Sputum is obtained for analysis to identify pathogenicorganisms and to determine malignancy or hypersensitivity
which in turn helpful ito determine causes of oxygeninsufficiency.
Expectoration is the usual method for collecting a sputum
DIAGNOSTIC TESTS
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specimen.The patient is instructed to clear the nose and throat andrinse the mouth to decrease contamination of the sputum.After
taking a few breaths,the patient coughs(rather than spits),using
the diaphragm and expectorates into a sterile container.
The specimen is delivered to laboratory within 2 hours by the
patient or nurse.Allowing the specimen to stand for several hours
in a warm room results in the overgrowth of contaminant
organisms and may make it difficult to identify the pathogenic
organisms.
D) CHEST X- RAY-
To assess fluids,tumors,foreign bodies and other pathologic
DIAGNOSTIC TESTS
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conditions.Chest rays are usually taken after fullinspiration,because the lungs are best visualized when they are
aerated.
E) Computed tomography
It is an imaging method in which the lungs are scannedinsucessive layers by a narrow beam x-ray.The images produced
provide a cross-sectional view of the chest .
CT may be used to define pulmonary nodules and small tumors
adjacent to peural surfaces that are not visible on routine chest xrays
DIAGNOSTIC TESTS
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It is an imaging method in which the lungs are scanned in
sucessive layers by a narrow beam x-ray.
The images produced provide a cross-sectional view of the chest
CT may be used to define pulmonary nodules and small tumors
adjacent to peural surfaces that are not visible on routine chest xrays
G) BRONCHOSCOPY-
It is the direct inspection and examination of the larynx,
trachea and bronchi through either a fixed fibroopticbronchoscope or a rigid bronchoscope.
The purpose of diagnostic bronchoscopy are;
DIAGNOSTIC TESTS
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To examine tissues or collect secretions To determine the location and extent of the pathologic process
and to obtain a tissue sample for diagnosis.
To determine whether a tumour can be resected surgically
To diagnose bleeding sites(source of hemoptysis)
Therapeutic bronchoscopy is used to
1.Remove foreign bodies from the tracheobronchial tree
2.Remove secretions obstructing the traceobronchial tree
3. Destroy and excise lesions
DIAGNOSTIC TESTS
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. Destroy and excise lesions NURSES ROLE-
Obtain informed written consent
Withheld foods and fluids 6 hr prior to bronchoscopes
Explanation of procedure to the patient and administration of
preoperative medications(e.a atropine) to inhibit vagal
stimulation,suppress cough reflex, sedate the patient and relieve
the anxiety
Dentures must be removed
Instruct the patient to take nothing by mouth till the cough
reflexes returns after the procedure.
DIAGNOSTIC TESTS
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Assess the confusion and lethargy in patient because of ananaesthesia
Instruct the family and caregivers to report any shortness of
breath or bleeding immediately.
I) THORACENTESIS-
A sample of pleural fluid is obtained by thoracentesis forboth diagnostic and therapeutic purposes.It may be used
for 1.Removal of fluid and air from the pleural caviy
2. Aspiration of pleural fluid for analysis
THORACENTESIS-
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DIAGNOSTIC TESTS
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3. Pleural biopsy 4. Instillation of medication into the pleural space.
NURSES ROLE
Assess the patient for allergy to local anesthetics
Position the patient comfortably with adequate supports
Support and ressure the patient during procedure
Encourage the patient to refrain from coughing.
Record the total amount of fluid obtained during thoracentesis
and sends it to laboratory for evaluation.Also record nature of
fluid,color and its viscosity.
DIAGNOSTIC TESTS
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Monitor respiratory status of patient afterwards. Hematocrit and hemoglobin are also measured in order to assess
effectiveness of bodys oxygen delivery to the tissues.
G) PULMONARY ANGIOGRAPHY- It is most common used to investigate thromboembolic
disease of the lungs, such as pulmonary emboli andabnormalities of vascular tree.It involves rapid injection of
a radioopaque agent into the vasculature of the lungs forradiographic study of the pulmonary vessels
NURSING MANAGEMENT OF CLIENTS WITH
OXYGEN INSUFFICIENCY
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OXYGEN INSUFFICIENCY
History, physical assessment and results of diagnosticexamination. Prioritize the problem on the basis of :
A-airway
B-breathing
C- circulation
FOLLOWING ARE THE POSSIBLE NURSING DIAGNOSIS
1 Ineffective airway clearance may be related to
Retained secretions
Airway spasm
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Presence of artificial airway
MANIFESTED BY-
Feeling of shortness of breath
Use of accessory muscles
Difficulty in speaking
Cyanosis
NURSING INTERVENTIONS
1 Assess the respiratory pattern of the patient
2.Elevate head of the bed /change position every 2 hours
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INSUFFICIENCY
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3.Insert oral airway as appropriate to maintain anatomic position
of tongue and natural airway
3. Assist with procedures (e.g bronchoscopy) to maintain clear
airway.
4.Encourage deep breathing and coughing exercises
4.Monitor hydration status of client as it will help in thining of
pulmonary secretions
5. Administer medications e.gMucolytic/Expectorant(Mucomyst)
,Methylxanthine(Aminophylline),Beta-adrenergic
sympathomimetic(albuterol,Terbutaline),Mast cellinhibitor(Cromolin sodium),
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INSUFFICIENCY
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Corticosteroid(Betamethasone,Prednisone).
6. Oberve for signs of respiratory distress
7. Evaluate changes in sleep pattern
8.N ote color and amount of sputum
9.Monitor serial chest x-rays /ABG/Pulse oximetry
2.Ineffective breathing patternrelated to-
Restrictive pulmonary disease
Neuromuscular disease that can weaken respiratory musclese.e.g
myasthenia gravis
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INSUFFICIENCY
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GOAL- TO PROMOTE LUNG EXPANSION
Nursing Interventions-
1.Auscultate chest,noting presence/character of breath
sounds,presence of secretions
2. Monitor rate and depth of respirations 3.Administre oxygen indicated for underlying pulmonary
condition,respiratory distress
4.Suction airway as needed to clear secretions
5. Proper postioning like fowler position by supporting the clientwith elevation of the head of the bed.
6.Encourage deep breathing exercises to the patient
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INSUFFICIENCY
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7. Assist client in the use of relaxation techniques
Impaired gas exchangerelated to
Ventilation perfusion mismatch,
overall decrease in the amount of alveolar capillary surface areaavailable for gas exchange in case of emphysema
Manifested by altered findings on ABG or pulse oximetry
GOAL-Maintain and promote tissue oxygenation
Nursing Interventions-
Note respiratory rate ,depth,use of accesory muscles for braething
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INSUFFICIENCY
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Auscultate breath sounds Monitor vital signs
Evaluate pulse oximetry to determine oxygenation
Elevate head of bed Encourage frequent position changes
and deep braething and coughing exercises Provide supplement oxygen at lowest concentration
Encourage adequate rest and limit activities to within clienttolerance
Administer medications as indicated
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INSUFFICIENCY
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4. Decreased Cardiac output related to
Congestive heart failure causing pulmonary edema,heart failure
or shock
Manifested by
Low BP,cool clammy skin, weah threay pulse,low urie output anda diminishing level of consciousness,crackles in case of of
pulmonary edema,pink frothy sputum
Nursing interventions 1 Monitor the vital signs of the patient
2.Maintain intake and outout of the patient
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INSUFFICIENCY
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3.Monitor the weight of the patient 4.Limited sodium and reduced fluid intake in case of congestive
heart failure.
5. Restrict the activity of the patient and assist the patient with
activities of daily living in order to decrease oxygen demand onbody.
6.Proper positiong preferably sitting or semi-sitting in order to
decrease fluid load to heart and pulmonary edema.
7. Administer medications to improve cardiac output includingcardiac glycosides and other inotropic agents.
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INSUFFICIENCY
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5.Activity intolerance related to dyspnoea and hypoxiamanifested by fatigue
GOAL- To improve the activity of the patient of the patient
Nursing Interventions 1.Assess the level of activity performed by patient
2.Assist the patient in daily activities
3.monitor the vital signs before and arter activity
4.Monitor the severity of dyspnoea and oxygen saturation
5.Maintain supplemental oxygen therapy as needed
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INSUFFICIENCY
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6.Advise the client to avoid conditions that increase oxygendemand such as stress,smoking
7.Instruct the client energy conversation techniques e.g adequate
rest period.
FLUID AND ELECTROLYTE IMBALANCE
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INTRODUCTION Fluid and electrolyte balance within the body are necessary to
maintain health and function in all body systems.
These balances are maintain by the intake and output of water
and electrolytes and regulation by the renal and pulmonarysystems.
Body fluids are regulated by fluid intake ,hormonal control and
fluid output .This physiological balance is termed homeostasis.
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Amount and composition of body fluids Approximately 60% of weight of a typical adult consists of
fluid(water and electrolytes).Factors that influence the amount of
body fluid are age,gender and body fat,.
1.Age-younger peope have a higher percentage of bogy fluid thanolder people
2.Gender-Men have proportionate more body fluid than women.
3.Body fat-People who are obese have less fluid than those are
thin,because fat cells contain little water
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Body fluid is located in two fluid compartments;theintracellular(fluid in the cells) and the extracellular space(fluid
outside the cells).
Approximately two thirds of body fluid is in the intracellular
fluid(ICF)compartment The ECF compartment is further divided into the
intravascular,interstitial and transcellular fluid spaces.
The intravascular space(the fluid within the blood
vessels)contains plasma . Approximately 3L of the average 6L of blood volume is made up
Of plasma
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The remaining 3L is made up of erythrocytes,leukocytes andthrombocytes.
The interstial space contains the fluid that sorrounds the cell and
totals about 11 to 12 L in an adult.
Lymph is an interstitial fluid .The transcellular space is thesmallest division of the ECF compartment and contains
approximately 1L.Examples of transcellular fluids are
cerebrospinal,pericardial,synovial,intraocular and pleural
fluids;sweat and digestive secretions.
Loss of ECF into a space that does not contribute to equilibrium
between the ICF and the ECF is referred to as a thirdspace fluid
shift,or third-spacing for short.
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Early evidence of a third space fluid shift is a decrease in urineoutput despite adequate fluid intake
.Urine output decreases because fluid shifts out of the
intravascular space;the kidneys then receive less blood and
attempt to compensate by decreasing urine output .Other sign and symptoms of third spacing that indicate an
intravascular fluid volume deficit include increased heart
rate,decreased blood pressure,decreased central venous
pressure,edema,increased body weight and imbalances influid intake and output
Third space shifts occurs in ascites,burns,peritonitis ,bowelobstruction and massive bleeding into a joint or body
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cavity. ELECTROLYTES
Electrolytes in body fluids are active chemicals?(cations that
carry positive charges and anions that carry negative charges).The
major cations in body fluid aresodium,potassium,calcium,magnesium and hydrogen ions.The
major anions are chloride,bicarbonate,phosphate,sulphate .
REGULATION OF BODY FLUID COMPARTMENTS 1.OSMOSIS AND OSMOLALITY
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When two different solutions are separated by a membrane thatis impermeable to the dissolved substances,fluid shifts through
the membrane from the region of low solute concentration to the
region of high concentration until the solutions are of equal
importance.
This diffusion of water caused by a fluid concentration gradient is
known as osmosis
2.DIFFUSION Diffusion is the central tendancy of a substance to move
from an area of higher concentration to one of
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Lower concentration.It occurs through the random movement ofions and molecules.examples of diffusion are the exchange of
oxygen and carbon dioxide between the pulmonary capillaries
and alveoli.
3.FILTRATION
Hydrostatic pressure in the capillaries tends to filter fluidout of the intravascular compartment into the interstitial
fluid.Movementof water and solutes occurs from an area ofhigh hydrostatic pressure to an area of low hydrostaticpressure.Filtration allows the kidneys to filter 180L of
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plasma per day
4.Sodium-Potassium pump
The sodium concentration is greater in the ECF than in theICF and because ofthis,sodium tends to enter the cell bydiffusion.
This tendancy is offset by the sodium-potassium
pump,which is located in the cell membrane and activelymoves sodium from the cell into the ECF.
.Active transport implies tha t energy must be expended for
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the movement to occur against a concentration gradient.
ROUTES OF GAINS AND LOSSESS
Water and electrolytes are gained in various ways.Ahealty
person gains fluids by drinking and eating.Fluids may beprovided by the parenteral route(intravenously andsubcutaneously)or by means of an enteral feeding tube inthe stomach or intestine.
1.KIDNEYS The usual daily urine volume in the adult is 1 to 2L.A
general rule is that the output is approximately 1 ml of
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urine per kilogram of body weight pr hpur(1ml/kg/h) in allage groups.
2.SKIN
Sensible perception refers to water and electrolytes lossthrough skin(sweating).
The chief solutes in sweat are sodium,chloride andpotassium.
Actual sweat loss can vary from 0 to 1000ml or more everyhour,depending on the environmentaltemperature.Continous water loss by evaporation (
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approximately 600 ml/day). Occurs through the skin.Fevergreatly increases insensible water loss through the lungsand the skin ,as does loss of the natural skinbarrier(e.G,through major burns)
.LUNGS
The lungs normally eliminate waer vapour(insensible loss)ata arate of approximately 400 ml eyery day.The loss ismuch greater with increased respiratory rate or depth, or ina dry climate
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HOMEOSTATIC MECHANISMS The body is equipped with remarkable homeostatic
mechanisms to keep the composition and volume of bodywithin narrow limits of normal.Organs involved inhomeostasis include the kidneys,lungs,heart,adrenalglands,parathyroid glands and pituitary gland
1.KIDNEY FUNCTIONS
Vital to the regulation of fluid and electrolytebalance,the kidney normals filters 170L of plasmaevery day in the adult,while excreting only 1.5 L of
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urine. They act both autonomously and in response to bloodborne
messengers,such as aldosterone and antidiuretic hormone
Renal failure results in multiple fluid and electrolyte
abnormalities.
2.HEART AND BLOOD VESSEL FUNCTIONS
The pumping action of the heart circulates bloo through thekidneys under sufficient pressure to allow for urineformation.Failure of this pumping action interferes with
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renal perfusion and thus wuth water and electrolyteregulation
3.LUNG FUNCITONS
The lungs also vital in maintaining homeostasis.Throughexhalation, the lungs remove approximately 300 ml ofwater daily in the normal adultAbnormal conditions suchas hyperpnea(abnormally deep respirations) or continouscoughing,increase this loss;mechanical ventilation withexcessive moisture decrease sit.
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4.PITUITARY FUNCTIONS The hypothalamus manufactures ADH,which is stored in
the posterior pituitary gland and released as needed.
ADH is sometimes called the water conserving hormone
because it causes the body to retain water. Functions of ADH include maintaining the osmotic
pressure of the cells by controlling the retention orexcretion of water by the kidneys and by regulating bloodvolume
. ADRENAL FUNCTIONS
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Aldosterone, a mineralocorticoid secreted by the zonaglomerulosa(outer zone) of the adrenal cortex,has aprofound effect on fluid balance..
Increased secretion of aldostrerone causes sodiumretention and potassium loss.Decreased secretion ofaldosterone causes sodium and water loss and potassiumretention.
6.PARATHYROID FUNCTIONS
The parathyroid glands.embedded in the thyroid gland,regulate calcium and phosphate balance by means of
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parathyroid hormone(PTH).PTH influences boneresorption,calcium absorption from the intestines and calcium
resorption from the renal tubules.
OTHER MECHANISMS BARORECEPTORS
The baroreceptors are small nerve receptors that directchanges in pressure within blood vessels and transmit this
information to the central nervous system. They are responsible for monitoring circulatory volume,
and they regulate the sympathetic and parasympathetic
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neural activity .. They are categorized as either low-pressure or
high-pressure baroreceptors.
Low-pressure baroreceptors are in the cardiacatria,particularly the left atrium.
High-pressure baroreceptors are nerve endings inthe aortic arch and carotid sinus,as arterial
pressure decreases ,baroreceptors transmit fewerimpulses from the carotid sinus and the aortic archto the vasomotor center.
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A decrease in impulses stimulate the sympathetic nervous systemand inhibits the parasympathetic nervous .The outcome is an
increase in cardiac rate ,conduction and contractibility and an
increased circulatory volume.
RENIN-ANGIOTENSIN ALDOSTERONE SYSTEM
Renin is an enzyme that converts angiotensinogen,an inactivate
substance formed by the liver ,into angiotensin 1.Renin is
released by the juxtaglomerular cells of the kidney in response to
decreased renal perfusion .Angiotensin converting enzyme
converts angiotensin 1 to angiotensin 11.Angiotensin 11,with
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its vasoconstrictive properties, increases arterial perfusionpressure and stimulates thirst.
ANTIDIURETIC HORMONE AND THIRST
ADH and the thirst mechanism have important roles inmaintaining sodium concentration and oral intake of fluids.
Oral intake is controlled by the thirst center located in thehypothalamus.
As serumconcentration or osmolality increases or bloodvolume decreases ,neurons in the hypothalamus arestimulated by intracellular dehydration;thirst then occurs
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and the person increases his or her intake of fluids.Waterexcretion is controlled by ADH,aldosterone and baroceptors
RELEASE OF ATRIAL NATRIURETIC PEPTIDE-
ANP ,also called atrial natriuretic factor, is a 28 aminoacidpeptide that is synthesized, stored and released by musclecells of the atria of the heart in response to severalfactors.These factors include increased arterialpressure,angiotensin 11 stimulation and sympatheticstimulation
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LABORATORY VALUES USED IN EVALUATING FLUIDAND ELETROLYTE STATUS
1 Serum sodium 135-145mEq/L
2.Serum potassium 3.5-5.0mEq/L
3.Total serum calcium 8.6-10.2mg/dl 4.Ionized calcium 4.5-5.0mg/dl
5.Serum magnesium 1.3-2.5mEq/L
6.Serum phosphorous 2.5 -4.5mg/dl
7.Serum osmolality 275-300mOsm/kg
8.BUN 10 -20mg/dl
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9.Serum creatinine 0.7-1.4mg/dl 10.Hematocrit Males 42-52%, Females -35-47%
11.Serum glucose 60-110mg/dl
12.Serum albumin 3.5-5.0g/dl
13. Urine specific gravity 1.003-1.030
14.Urinary pH
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1 FLUID VOLUME DEFICIT(Hypovolemia) Decrease in intravascular and interstitial fluids.
CONTRIBUTING FACTORS
1.Loss of water and electrolytes, as in
vomiting,diarrhea,fistulas,fever,excess sweating,burns,blood loss,gastrointestinal suction, and third space fluid shifts
2. Decreased intake as in anorexia, nausea and inability to gain
acess to fluid.
3. Diabetes insipidus and uncontrolled diabetes mellitusalso contribute to a depletion of extracellular fluid volume
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SIGN AND SYMPTOMS 1.Acute weight loss
2.Decreased skin turgor
3.Oliguria,concentrated urine
4.Weak rapid pulse.prolonged capillary refill time 5.Low CVP,decreased BP,flattened neck veins,tacycardia
6.Dizziness,weakness,thirst and confusion
7. Muscle cramps
8. Sunken eyes
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LAB indications 1.Increased haemoglobin and hematocrit
2. Increased serum and urine osmolality and specific gravity
3.Increased BUN and creatine level
4. Increased urine specific gravity and osmolality
MEDICAL MANAGEMENT-
Pharmacologic Management
1.Isotonic electrolyte solutions(e.g lactated ringerssolution,o.9% sodium chloride) are frequently used to treathypotensive patient because they expand plasma volume.
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2. As soon as the patient becomes normotensive, ahypotonic electrolyte solution (e.g 0.45% sodiumchloride) is often used .
3. Accurate and frequent assessment of intake and
output, weight,vital signs,CVP,level ofconsciousness,breath sounds and skin color shouldbe performed
NURSING DIAGNOSIS
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Nursing diagnosis Fluid volume deficit related to insufficient fluid
intake,vomiting,diarrhea, haemorrhageNURSINGINTERVENTIONS
1.Check the weight of the patient 2.Monitor intake and output of the patient
3.Administer IV fluids to the patient
4.Administer medications e.g antiemetics to prevent the
patient from vomiting 5.Assist the patient to protect from any kind of injury
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2.EXTRA CELLULAR FLUID VOLUME EXCESS-(HYPERVOLEMIA)
Increased fluid retention in the intravascular & interstial spaces.
CONTRIBUTING FACTORS
1.Compromised regulatory mechanisms such as renalfailure,heart failure, and cirrhosis
2.Over-zealous administration of sodium containing fluids and
fluid shifts(burns)
3.Prolonged corticosteroid therapy,severe stress, andhyperaldosterism augment fluid volume excess
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SIGN AND YMPTOMS 1.Acute weight gain
2.Peripheral edema and ascites
3.Distented juglar veins
4..Crackles 5.ELevated CVP,Shortness of breath
6.Incresed BP,Bounding pulse and cough
7.Increased respiratory rate
LABORATORY FINDINGS
1.Decreased Hb and hematocrit
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2.adaecreased serum and urine osmolality 3.Decreased serum sodium and specific gravity
MEDICAL MANAGEMENT
Pharmacological management 1.Diuretics are prescribed when dietary restriction of
sodium alone is insufficient to reduce edema by inhibitingthe reabsorption of sodium and water by the kidneys.Loop
diuretics such as furosemide(Lasix),torsemide, cancausea greater loss of both sodium and water because theycan block sodium resorption in the ascending limb of the
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loop of henle.Thiazide diuretics such ashydrochlorthiazide or metalazone, are prescribedfor mild to moderate hypervolemia and loopdiuretics for severe hypervolemia
Electrolyte imbalances may result from the effectof the diuretic.Hypokalemia can occur with all thediuretics except potassium sparingdiuretics(sprinolactone) .Potassium supplementscan be prescribed to avoid thiscomplication.Decreased magnesium levels occur
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with administration of loop and thiazide diuretics due todecreased resorption and increased excretion ofmagnesium by the kidney
2.Hemodialysis Azotemia can occur with FVE when urea and creatinine are
not excreted due to decreased perfusion by the kidneys anddecreased excretion of wastes.High uric acidlevels(hyperuricemia) can also occur from increasedresorption and decreased excretion of uric acid by thekidneys.
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Hemodialysis or peritoneal dialysis may be used toremove nitrogenous waste and control potassiumand acid-base balance, and to remove sodium andfluid
NUTRITIONAL THERAPY
A low sodium diet is prescribed in order to reduce
fluid retention.
NURSING MANAGEMENT
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Clients vital signs should be assessed every 1 -8 hrs. IV fluid replacement should be monitored . If fluids
are administered too rapidly, hypervolaemia(fluidoverload ) may occur .
Frequent checks for chest crackles ,difficult inbreathing 7 neck vein engorgement are essential toprevent pulmonary edema with fluid volume excess.
The abdominal girth of client with ascites should bemeasured every 8 hrs.
If the extremities are involved , the circumference of
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the extremities and the peripheral pulses should bemeasured every hour.
Level of consciousness should be monitored
Prevent the breakdown of the skin.
Monitored the urine output of the patient
NURSING DIAGNOSIS
Fluid volume excess related to compromisedregulatory mechanisms of kidneys.
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Nursing Interventions 1.Check the weight of the patient
2.Monitor intake output of the patient
3.Restrict the fluid intake of the patient
4.Administer diuretics to the patient
5.Instruct the patient to take low sodium
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3. HYPONATREMIA
Is a serum sodium level below 135mqL
ETIOLOGY
Renal disease resulting in salt wasting
Adrenal insufficiency
GI loss(Diarrhea)
Incresed sweating
Diuretics
Burns Liver cirrhosis
SIADH
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Vomiting
SYMPTOMS
1.Anorexia
2.Nausea
3. Vomiting
4.Convulsions
5.Fatigue
6. Headache
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7.Irritability 8.Muscle Cramps
9.Muscle weakness
10.Restlessness
11.Dry skin
12.Incraesed pulse
13.Decraesed BP
14.Weight gain
15.Edema
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LABORATORY FINDINGS 1.Decreased serum and urine sodium
2.Decreased urine specific gravity and osmolality
MEDICAL MANAGEMENT 1.SODIUM REPLACEMENT-The obvious traeatment for
hyponatremia is careful administration of sodium bymouth,nasogastric tube or a parenteral route.For patients
who cannot consume sodium,lactated Ringers solutionor isotonic saline(0.9%
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sodium chloride)solution may be prescribed 2.WATER RSTRICTION-Hyponatremia is treated by
restricting fluid to a otal of 800 ml
4. HYPERNATREMIA Serum sodium level over 145meq/L
ETIOLOGY
1.Diabetes inspidus
2.Heat stroke 3.Hyperventilation
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4.Watery diarrhea
5. Burns 6.Diaphoresis
7.Excess sodium bicarbonate and sodium chlorideadministration
8.Salt water near drowning
SYMPTOMS
1.Thirst 2.Elevated body temperature
3. Swollen dry tongue and sticky mucous membranes
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4.Hallucinations,lethargy,restlessness,irritability,seizures
5.Pulmonay edema
6.Nausea and vomiting,anorexia,Increased pulse
and deacreased BP
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LABORATORY FINDINGS
1.Increased serum sodium and decreased urine sodium
2.Increased urine specific gravity and osmolality
MEDICAL MANAGEMENT Treatment of hypernatremia consisits of a gradual lowering
of the serum sodium level by the infusion of a hypotonicelectrolyte solution(e.g 0.3% sodium chloride) or an
isotonic solution(Dextrose 5% in water{D5W} Desmopressin acetate(DDAVP),a synthetic antidiuretic
hormone may be prescribed to treat diabetes insipidus if it
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is the cause of hypernatremia
5.HYPOKALEMIA
Serum potassium level less than 3.5meq/L
ETIOLOGY 1.Diarrhoea,vomiting,nasogastric suctioning
2.Corticosteroid administration
3.Hyperaldosteronism
4.OSMOTIC diuretics
5.Alkalosis
6.Starvation,Diuretics and digitalis toxicity
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CLINICAL MANIFESTATIONS
1.Anorexia,vomiting,diarrhea
2. Muscle weakness,paraesthesia,leg cramps
3.Dysrhythmia,vertigo,postural hypotension,flattened T wave.
4.Shallow respiration,shortness of breath 5.Fatigue,lethargy,decreased tendon reflexes,confusion
INVESTIGATIONS
ECG-Flattened T waves, ,Prominent U waves.ST depression
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MEDICAL MANAGEMENT
Determining & correcting the cause of imbalance.
Extreme hypokalemia requires cardiac monitoring
PHARMACOLOGIC MANAGEMENT Oral potassium replacement therapy is usually prescribed for
mild hypokalemia
Potassium is extremely irritating to gastric mucosa,therefore the
drug must be taken with glass of water or during meals. Potassium chloride can be administered intravenously for
moderate to severe hypokalemia & must be diluted in IV
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fluids.
Administration of potassium by IV push may result in cardiac
arrest .Potassium can be given in doses of 10 to 20 meq/hour
diluted in IV fluid if the client is on heart monitor.
High concentration of potassium is irritating to heart muscle.Thus
correcting a potassium deficit may take several days.
DIETARY MANAGEMENT
The administration of foods that are high in potassium help to
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correct the problem as well as prevent further potassium
loss. The adult recommended allowance of potassium is
1875 to 5625mg
.Common food source containing potassium-
Cabbage,Carrot,Cucumber,Spinach,Tomato,Fruits,Bana
na,Guava,Orange
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6)HYPERKALEMIA
Elevated potassium level over 5.0meq/L
ETIOLOGY
1.Retention of Potassium Renal insufficiency, renal
failure, decreased urine output, potassium sparig diuretics. 3 Infection , metabolic acidosis
4.Excessive IV infusions or oral administration ofpotassium
CLINICAL MANIFESTATIONS
First tachycardia then bradycardia,electro cardiographic
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changes.Peak narrow T waves, wide QRS complex,depressed ST SEGMENT,Widened PR interval
Nausea,diarrhea,hyperactive bowel sounds.
Muscle weakness, muscle cramps, tinglingsensation(Paresthesia)
Oliguria & later anuria
.MEDICAL MANAGEMENT
When serum potassium level is 5.0 to 5.5 meq/l restrictionof dietary potassium intake.
If potassium excess is due to metabolic acidosis , correcting
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the acidosis with sodium bicarbonate promotes potassiumuptake into the cells.
Improve urine output decreases elevated serum potassiumlevel.
When hyperkalemia is severe , immediate actions areneeded to be taken to avoid severe cardiac disturbances.
Intravenous calcium gluconate infusions to decrease theantagonistic effect of potassium excess on the myocardium.
Infusion of insulin and glucose or sodium bicarbonate topromote potassium uptake
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.)HYPOCALCEMIA
Serum calcium below 8.5mg/dl
ETIOLOGY
1.Inadequate dietary calcium intake ,vitamin D defiency 2.Malabsorption of fat in intestine.
3.Metabolic alkalosis( less ionized calcium)
4.Renal failure with hyperphsophatemia, acute
pancreatitis,burns,cushing disease, hypoparathyrodism.
5.ALKALOSIS`
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SIGN AND SYMPTOMS
1.Numbness tingling of fingers,toes
2.Positive Trousseausign and chovesteksigns
3.Hyperactive deep tendon reflexes
4.irritabiliy 5.Impaired clotting time
INVESTIGATIONS
1.ECG- prolonged QT INTERVAL AND LENTHENED ST
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MEDICAL MANAGEMENT
Determining & correcting the cause of hypocalcaemia.
Asymptomatic hypocalcaemia is usually corrected with oral
calcium gluconate, calcium lactate or calcium chloride.
Administer calcium supplements 30 minutes before meals forbetter absorption and with glass of milk because vitamin D is
necessary for absorption of calcium from the intestine.
Intravenous calcium chloride or calcium gluconate (10%)nis
given slowly to avoid hypertension,bradycardia & other
arrhythmias.
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DIETARY MANAGEMENT Chronic or mild hypocalcaemia can be treated in part by
having the client consume a diet high in calcium e.g.
cheese, milk ,spinach
If hypocalcaemia is secondary to parathyroid deficiencythe client must avoid high phosphate foods e.g. milk
products , carbonated beverages
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.)HYPER CALCEMIA
Serum calcium leve l over 1O.5meq mg/dl
ETOLOGY
Metastatic malignancy- lung,breast,ovarian,prosatic,bladder,leumekia.
Hyperparathyroidism
Thiazide diuretic therapy
Prolonged immobilization
Excessive intake of calcium supplements and vitamin D.
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CLINICAL MANIFESTATIONS
- Anorexia,vomiting,constipation,decreased peristalsis.
- Mild to moderate- Weakness,fatigue,difficulty to conc
Severe hypercalcemic state-extreme lethargy, confusion ,coma
-Dysrhythmias,heart block. Polyuria,kidney stones , renal failure.
Bone pain, fracture
MEDICAL MANAGEMENT
Treatment consists of correcting the underlying cause.
Intravenous normal saline(0.9%Nacl) given rapidly with
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furosemide to prevent fluid overload,promote urinary calcium
excretion.
Calcitonin decreases serum calcium level by inhibiting the effects
of PTH(Parathyroid hormone) on the osteoclasts and increasing
urinary calcium excretion.
Corticosteroid drugs decrease calcium levels by competing with
vitamin D thus resulting in decreased intestinal absorption of
calcium.
If the cause is excessive use of calcium or vitamin D supplements
or calcium containing antacids these agents should be either
avoided or used in reduction dosage.
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A newer form of drug therapy is etidronate disodium.This drug
reduces calcium by reducing normal and abnormal bone
resorption of calcium and secondarily by reducing bone
formation.
.)MAGNESIUM DEFICIT(HYPOMAGNESMIA)
Serum magnesium
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3.Insomnia,mood changes
4.Anrexia,vomiting and increased BP
TREATMENT
Mild magnesium deficiency is treated by diet alone .Principal dietary sources of magnesium, which is a
component of chlorophyll, are gren leafyvegetables,nuts,seeds,legumes,whole grains and sea food.If
necessary magnesium salts can be administered orally in anoxide or gluconate form to replace continous excessivelosses.
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Diabetic ketoacidosis
Chronic laxative use
Diarrhea
Acute MI,heart failure
Certain pharmacologic such as gentamicin,cisplatin andcyclosporine
SIGN AND SYMPTOMS
1.Neuromuscular irritability 2.Positive Trousseau and chovessteks signs
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