1)Posterior Chest (Thorax)
3) Anterior Chest (Thorax)
Auscultation
1) Posterior Chest (Thorax)
o
Normal Breath sounds
n
Bronchial breath
sounds—characteristics
n
Bronchovesicular
breath sounds—characteristics
n
Vesicular breath
sounds—characteristics
o
Abnormal Breath Sounds
o
Adventitious sounds
n
Crackles
n
Rhonchi
n
Wheeze
n
Pleural Friction Rub
2) Lateral Chest (Thorax)
3) Anterior Chest (Thorax)
o
Normal Breath sounds
n
Bronchial breath
sounds—characteristics
n
Bronchovesicular
breath sounds—characteristics
n
Vesicular breath
sounds—characteristics
o
Abnormal Breath Sounds
o
Adventitious sounds
n
Crackles
n
Rhonchi
n
Wheeze
n
Pleural Friction Rub
Altered Breathing Patterns
See next
slide…..
Ventilation/O2 Studies
ü
Pulmonary
Function Tests (PFT’s)
ü
Arterial
Blood Gases (ABG’s)
ü
Pulse
Oximetry
Lab Diagnostics
o
CBC
(Hgb & Hct)
o
Cardiac
enzymes (CK-MB)
o
Troponin
o Electrolytes
o
Cholesterol
o
Triglycerides
Pulmonary Visualization
o
CXR
(to right)
o Bronchoscopy (shown below)
o Lung Ventilation- Perfusion
Scan
o
/CT
Scan of Lungs
More Chest X-Ray Photos
Diagnosing
Abnormal Organisms in the Respiratory Tract (refer to Pagana Lab
Diagnostic text)
o Throat Cultures (C&S)
o Sputum collection
ü
AFB
(Acid Fast Bacillus - for Tuberculosis (TB) diagnosis)
ü
Cytology
(for cancer)
o Skin Testing (PPD for TB diagnosis)
o Thoracentesis
Nursing Process:
Planning: Care for the Client with Altered Oxygenationo ABCs
n Airway patency
n Adequate ventilation
n Circulation
o Vital signs
o Promote Lung Expansion
o Promote Mobilization of
secretions
o Review Lab Values
o Psychosocial interventions
Nursing Process:
Nursing Interventions for Optimal Oxygenationo Health Promotion: vaccines
o Education on risk factors
o Dependent Nursing
Interventions (with physician’s order)
n Oxygen (O2)Therapy
n Medications
Psychosocial Interventions
o
Develop a trusting
Nurse/Client relationship. Use open ended, non-judgmental approach
o
Teach diaphragmatic
breathing and pursed lip breathing
o
Teach relaxation
techniques and meditation
o
Use motivational
interviewing techniques to assess client's readiness to change health habits http://motivationalinterview.org/clinical/index.html
Oxygen
Therapies
(Table
27-10: will be reviewed in NAL)o Nasal Cannula
o Simple Face Mask
o Venturi Mask
o Plastic Face Mask with inflated
reservoir bag
n
(Non-Rebreather
Mask)
Nursing Process:
Nursing Interventions for Optimal Oxygenationo Promoting Lung Expansion:
ü
Positioning
ü
Coughing
and Deep Breathing
ü
Incentive
Spirometry with Physician’s Order (shown at right)
o Promoting Mobilization of
Secretions
•
Hydration
•
Dependent Nursing Interventions:
1) Chest PT: percussion and vibration (Chest Physiotherapy)
2) Postural
Drainage (next slide)
3) Relaxation
Techniques
Nursing Process:
Additional Dependent Nursing Interventions for Optimal Oxygenation
o Airway Maintenance: humidification, nebulization
o
Suctioning:
oral,
nasotracheal, nasopharyngeal,
o
Artificial
Airways: oral/tracheal
o
Ventilators
Nursing
Process:
Evaluation of Careo Reassess client’s oxygenation
status after interventions
o Ask client to rate breathing
on a scale
o Notify MD if client’s O2
status impaired
o Revise care plan prn
o Documentation!!!!
