When preparing for the admission of a client diagnosed with bronchiectasis, the nurse will
put a sputum cup and a box of tissues on the bedside table.
A major risk factor for the development of active pulmonary tuberculosis (TB) disease is
immunosuppression.
Immunosuppressed individuals, such as those with HIV, are at high risk for active _____ _______.
TB disease
Copious amounts of foul-smelling sputum are generally associated with
bronchiectasis.
Obstructive sleep apnea would most likely be found in a patient diagnosed with
Pickwickian syndrome.
Pickwickian syndrome is _________ ________ ____ ________.
Hypoventilation caused by obesity.
A restrictive respiratory disorder is characterized by
decreased residual volume.
Obstructive disorders are associated with
Low expiratory flow rates and high residual volume.
Accumulation of fluid in the pleural space is called
pleural effusion.
Pleural effusion is accumulation of
fluid in the pleural space.
The hallmark manifestation of acute respiratory distress syndrome is
hypoxemia.
The hallmark of acute respiratory distress syndrome is hypoxemia caused by
intrapulmonary shunting of blood.
A patient has been hospitalized several times in 6 months with severe ECV depletion and hypokalemia resulting from chronic laxative abuse. Which blood gas results should be relayed to the physician?
pH in high part of normal range, PaO2 normal, PaCO2 high, bicarbonate high
A major cause of treatment failure in tuberculosis is
noncompliance.
Individuals who have chronic bronchitis most often have
A productive cough.
(for at least 3 months)
Airway obstruction in chronic bronchitis is because of
thick mucus, fibrosis, and smooth muscle hypertrophy.
After evaluation, a child’s asthma is characterized as “extrinsic.” This means that the asthma is
associated with specific allergic triggers.
To best prevent emphysema, a patient is instructed to stop smoking since cigarette smoke.
impairs α1-antitrypsin, allowing elastase to predominate.
Viral pneumonia is characterized by
a dry cough.
Cystic fibrosis is associated with
bronchiectasis.
Which complication of asthma is life threatening?
Status asthmaticus
Status asthmaticus is a
severe attack unresponsive to routine therapy and can be life threatening if not reversed.
Early manifestations of a developing metabolic acidosis include
headache.
A patient with a productive cough and parenchymal infiltrates on x-ray is demonstrating symptomology of
bacterial pneumonia.
A common characteristic of viral pneumonia is
dry cough.
Clinical manifestations of severe symptomatic hypophosphatemia are caused by
deficiency of ATP.
What age group has a larger volume of extracellular fluid than intracellular fluid?
Infants
Fully compensated respiratory acidosis is demonstrated by
pH 7.36, PaCO2 55, HCO3 – 36.
A person who has hyperparathyroidism is likely to develop
hypercalcemia.
A patient, who is 8 months pregnant, has developed eclampsia and is receiving intravenous magnesium sulfate to prevent seizures. To determine if her infusion rate is too high, you should regularly
check the patellar reflex; if it becomes weak or absent, her infusion rate probably is too high and she is at risk for respiratory depression or cardiac arrest.
Hypermagnesemia causes
decreased neuromuscular excitability
A person who overuses magnesium-aluminum antacids for a long period of time is likely to develop
hypophosphatemia.
A patient has a positive Chvostek sign. The nurse interprets this as a sign of
increased neuromuscular excitability.
A known cause of hypokalemia is
insulin overdose.
Insulin overdose causes hypokalemia by
shifting potassium into cells.
Emesis causes
metabolic alkalosis
The body compensates for metabolic alkalosis by
hypoventilation.
Clinical manifestations of extracellular fluid volume deficit include
weak pulse, low blood pressure, and increased heart rate.
The major buffer in the extracellular fluid is
bicarbonate.
Signs and symptoms of clinical dehydration include
decreased urine output.
Diarrhea causes
metabolic acidosis.
Diarrhea causes metabolic acidosis as the intestinal fluids are rich in
bicarbonate ions.
Clinical manifestations of moderate to severe hypokalemia include
muscle weakness and cardiac dysrhythmias.
The process responsible for distribution of fluid between the interstitial and intracellular compartments is
osmosis.
Filtration is responsible for the distribution of
fluid between the vascular and interstitial compartments
A person who experiences a panic attack and develops hyperventilation symptoms may experience
numbness and tingling in the extremities.
Numbness and tingling in the extremities occurs in alkalosis as a result of
increased neuromuscular irritability.
What is the most likely explanation for a diagnosis of hypernatremia in an elderly patient receiving tube feeding?
Inadequate water intake
What form of oral rehydration, bottled water or salty broth, is best suited for a patient who is demonstrating signs of clinical dehydration?
Salty soup, because it will provide some sodium to help hold the fluid in his blood vessels and interstitial fluid
Vomiting of stomach contents or continuous nasogastric suctioning may predispose to development of
Metabolic acid deficit.
Empyema is defined as an
Infection in the pleural space.
Air that enters the pleural space during inspiration but is unable to exit during expiration creates a condition called
tension pneumothorax.
An increase in the resting membrane potential (hyperpolarized) is associated with
hypokalemia.
The assessment findings of a 5-year-old with a history of asthma include extreme shortness of breath, nasal flaring, coughing, pulsus paradoxus, and use of accessory respiratory muscles. There is no wheezing and the chest is silent in many areas. How should you interpret your assessment?
The child may be having such a severe asthma episode that the airways are closed, so start oxygen and get the doctor immediately.
A patient exhibiting respiratory distress as well as a tracheal shift should be evaluated for
pneumothorax.
The most definitive diagnostic method for active tuberculosis is acquired via
sputum culture.
When exposed to inhaled allergens, a patient with asthma produces large quantities of
IgE.
Emphysema results from destruction of alveolar walls and capillaries, which is because of
release of proteolytic enzymes from immune cells.
COPD leads to a barrel chest, because it causes
air trapping.
When a client diagnosed with COPD type A asks, “Why is my chest so big and round?”, the nurse responds that
“Loss of elastic tissue in your lungs allows your airways to close and trap air, which makes your chest round.”
What is likely to lead to hyponatremia?
Frequent nasogastric tube irrigation with water
Respiratory alkalosis is caused by
hyperventilation.
How do clinical conditions that increase vascular permeability cause edema?
By allowing plasma proteins to leak into the interstitial fluid, which draws in excess fluid by increasing the interstitial fluid osmotic pressure
The primary cause of infant respiratory distress syndrome is
lack of surfactant.
The finding of ketones in the blood suggests that a person may have
metabolic acidosis.
When a parent asks how they will know if their 2-month-old baby, who is throwing up and has frequent diarrhea, is dehydrated, the nurse’s best response is
“If the soft spot on the top of his head feels sunken in and his mouth is dry between his cheek and his gums, then he is probably dehydrated.”
The nurse provides teaching regarding dietary intake of potassium to avoid an electrolyte imbalance when a patient
has chronic heart failure that is treated with diuretics.
A patient diagnosed with chronic compensated heart failure reports that, “My feet swell if I eat salt but I don’t understand why” The nurse’s best response is
“Salt holds water in your blood and makes more pressure against your blood vessels, so fluid leaks out into your tissues and makes them swell.”
Which electrolyte imbalances cause increased neuromuscular excitability?
Hypocalcemia and hypomagnesemia
How is a patient hospitalized with a malignant tumor that secretes parathyroid hormone–related peptide monitored for the resulting electrolyte imbalance?
Serum calcium, bowel function, level of consciousness
The fraction of total body water (TBW) volume contained in the intracellular space in adults is
two thirds.
Signs and symptoms of extracellular fluid volume excess include
bounding pulse
The ________ system compensates for metabolic acidosis and alkalosis.
respiratory
The arterial blood gas pH = 7.52, PaCO2 = 30 mm Hg, HCO3 – = 24 mEq/L demonstrates
respiratory alkalosis
The person at highest risk for developing hypernatremia is a person who
receives tube feedings because he or she is comatose after a stroke.
The increased anterior-posterior chest diameter associated with obstructive lung disease is caused by
Increased residual lung volumes.
What is the normal ratio for FEV1/FVC diagnostic test?
____% or ______%
75% or 80%
What do arterial blood gas (ABG) testing access?
oxygenation and acid-base status.
If the pH is <7.35 is it alkalosis or acidosis?
Acidosis
If the pH is >7.45 is it alkalosis or acidosis?
Alkalosis
What is the normal pH range?
7.35-7.45
What is the range considered lethal in pH?
Bellow 6.9 (too much acidity); higher than 7.6 (too much base).
What is acidosis?
_________ _______ _________.
Retaining carbon dioxide.
What is alkalosis?
________ __________ __________ ___________.
Too little carbon dioxide. -hyperventilating
Diagnosis of obstructive disorders
___________ FEV1
_____ FE V/FVC ratio.
__________ in FEV1 after use of bronchodilator (asthma).
____________ residual volume.
____________ functional residual capacity.
When
bronchodilator is given there will be ___________ bronchodilator response.
Decreased
Low (<70%)
Improvement
Increased
Increased
Positive
Diagnosis of restrictive disorders
FEV1/FVC ratio could be ________ since both of them are reduced.
__________ in vital capacity (VC).
__________ in total lung capacity (TLC)
__________ in functional residual capacity (FRC)
__________ in residual volume (RV)
Normal
Decrease
Decrease
Decrease
Decrease
The greater the _________in the lung volume, _________ the severity of disease.
decrease, greater
Obstructive pulmonary disorders are manifested by ______________ ___________ _____ __________.
Increased resistance to airflow
TRUE or FALSE
In asthma, an airway obstruction is not reversible.
False, in asthma, airway obstruction could be reversible, but not completely in some patients.
What type of asthma?
-Non-allergic, adult-onset.
-Develops in middle age w/ less favorable prognosis.
-Respiratory infection/psychological factors.
Intrinsic
What type of asthma?
- Allergic, pediatric-onset.
-1/3 to 1/2 of asthma cases
-An IgE-mediated response- Mast cell activation (histamine)- inflammation cell infiltration (neutrophils, eosinophils, and lymphocytes)
extrinsic
Wheezing is a clinical manifestation of asthma. Is wheezing seen in the inspiratory or expiratory stage?
expiratory.
What are the clinical manifestation of asthma?
Wheezing, feeling tightness of chest, dyspnea, cough (dry or productive), hyperinflated chest seen in an x-ray, and decreased breath sounds on physical exam.
Important Clinical manifestations seen in a severe asthma attack are....
(4)
Orthopnea, agitation, tachypnea: >30 beats per/min, tachycardia >120 beats per/min.
What are the X-ray findings in asthma?
Hyperinflation with flattening of the diaphragm.
What are sputum examination findings that can indicate that someone has asthma? (3)
-Charcot-Leyden crystals (from crystalized enzymes from eosinophilic membranes)
-Eosinophils
-Curschmann spirals (mucus casts of bronchioles)
What are pulmonary function test findings in someone who has asthma?
-Forced expiratory volume decrease
-Peak expiratory flow rate (PEFR)
In asthma the ratio of FEV1/FVC before and after administration of short-acting bronchodilator will change >_____%.
greater than 15%
In asthma
ABG:
___________ during mild attack.
_________ __________ and hypoxemia as bronchospasm increases in intensity.
PaCO2__________: sign that patient is getting worse,
Normal
Respiratory alkalosis
elevation
In asthma:
CBC
____________ WBCs and eosinophils
Elevated
What is treatment/medications used for asthma-anti-type 1 hypersensitivity
Oxygen therapy, small-volume nebulizers, B2 agonists, corticoid steroids, leukotriene modifiers, and mast cell inhibitors.
Etiology of chronic bronchitis:
How long must the patient have a chronic or recurrent productive cough to be diagnosed with chronic bronchitis?
greater than 3 months, over two successive years.
What is type A COPD?
emphysema
What is type B COPD?
chronic bronchitis
TRUE or FALSE
Chronic bronchitis is irreversible when paired with emphysema.
True
What is the male to female ratio for chronic bronchitis?
1:2 male to female ratio
Pathogenesis of chronic bronchitis:
Chronic ___________________ and swelling of the bronchial mucosa resulting in _________________.
inflammation, scarring
TRUE or FALSE
Hypertrophy of bronchial mucuos gland/goblet cells happen in chronic bronchitis.
False; hyperplasia of bronchial mucous gland/goblet cells happen in chronic bronchitis.
In chronic bronchitis, pulmonary hypertension causes inflamation where?
In bronchial walls with vasoconstriction of pulmonary vessels and arteries.
In chronic bronchitis, pulmonary hypertension causes high pulmonary resistance that may lead to ________-_________ _________ ____________.
Right-sided heart failure
In chronic bronchitis, pulmonary hypertension causes inflammation in bronchial walls with vasoconstriction of pulmonary vessels and arteries, due to _______________ and activation of _________ ________ ________.
Autoregulation and activation of the sympathetic nervous system.
Clinical manifestations of chronic bronchitis:
- The typical patient is _____________.
- Commonly associated with ____________.
-____________ sputum.
- (more severe in the morning) ______________ _____________.
- evidence of excess ________ _______________.
Overweight, emphysema, excessive, chronic cough, body fluids.
What is a clinical manifestation of chronic bronchitis seen in late stages?
Cyanosis
SOB is a clinical manifestation of chronic bronchitis, why does it typically happen on expiration?
Because its an exhaling problem
Diagnosis of Bronchitis:
Chest X-Rays show:
____________ bronchial vascular markings
___________ lung fields
____________ horizontal cardiac silhouette
____________ of previous pulmonary infection
Increased, congested, enlarged, evidence.
Diagnosis of Bronchitis:
What are the three things seen in pulmonary function tests for a patient with chronic bronchitis?
Normal total lung capacity (TLC), Increased residual volume (RV), Decreased FEV1 and Decreased FEV1/FVC
Diagnosis of Bronchitis:
In a patient with chronic bronchitis what will be found in their ABG results?
Elevated PaCO2, decreased PO2
Treatment for chronic bronchitis includes a low dose O2 therapy, why?
A low dose is necessary to prevent the retention of carbon dioxide.
What etiological changes does emphysema cause?
Destructive changes of the alveolar walls without fibrosis.
TRUE or FALSE
In emphysema damage is irreversible.
True
Pathogenesis of emphysema:
Release of ____________ _______________ from _____________ and __________ leading to alveolar damage.
proteolytic enzymes, neutrophils, macrophages
Pathogenesis of emphysema:
Smoking causes alveolar damage that causes inflammation.
Inflammation leads to _________ of __________ ____________.
release of proteolytic enzymes
Pathogenesis of emphysema:
Smoking causes alveolar damage by inactivating what?
a1 -antitrypsin
Pathogenesis of emphysema:
What is lost in tissue in a patient who has emphysema?
Loss of elastic tissue in the lung, that usually holds the airway open.
What causes barrel chest in patients with emphysema?
Air that has become trapped in distal alveoli.
Clinical manifestations of emphysema
Progressive ________ ____________.
exertional dysnea
Clinical manifestations of emphysema
Will the patient be thin or overweight?
Thin; due to the increased respiratory effect, increased caloric expenditure and decreased ability to consume adequate calories.
What does barrel chest cause?
*not what causes barrel chest.
Increased total lung volume to compensate the lost lung capacity due to dead space.
What will be seen in pulmonary function tests in an emphysema patient?
(3)
Increased functional residual capacity
increased RV, TLC
Decreased FEV1, FVC
What will be seen in the X-Ray of a patient with emphysema?
Hyperventilation, low flat diaphragm, presence of blebs, narrow mediastinum, normal or small vertical heart.
In patients with emphysema what will be seen in their ABG test?
Which one is elevated in late stages?
mild decrease in PaO2 and normal PaCO2
What are the two important physical findings in a patient with emphysema?
Decreased breath sounds, lack of crackles and rhonchi, and decreased heart sounds.
Restrictive pulmonary disorders result from __________ __________ ___________.
Decreased lung expansion.
What are the two classification of restrictive pulmonary disorders?
Pulmonary and extrapulmonary
In acute (adult) respiratory distress syndrome (ARDS) damage to the alveolar capillary membrane causes _______ _______-__________ __________ ___________ and __________ ____________.
Widespread protein-rich alveolar-infiltrates and severe dyspnea.
Aveoli type II cells produce surfactants, why are surfactants important?
For fighting against surface tension to prevent lungs from collapsing.
ARDS is associated with a decline in the _______ ______ _____ ___________.
the PaO2 that is refractory.
(does not respond to supplemental oxygen therapy).
ARDS is _____________+___________________.
inflammation + fibrosis
In ARDS, atelectasis and decrease lung compliance is caused from a lack of _______________.
Surfactant
What are the important clinical manifestations in late ARDS?
Tachycardia, tachypnea, hypotension frothy secretions, crackles, and rhonchi on auscultation.
What is >40% of causes of ARDS?
What is >30% of causes of ARDS?
sepsis and aspiration of gastic acid
In ARDS, protein-rich fluids are found where? an example?
hyaline membrane, fibrosis
In ARDs Hallmark is _________ __________ to _________ levels of supplemental O2.
Hypoxemia refractory, increased
What is seen in the ABGs in a patient with ARDS?
Hypoxia, acidosis, hypercapnia
What is seen in the X-ray in a patient with ARDS?
Normal with progression to diffuse "whiteout"
ARDS Diagnosis:
PFTs:
______________ in FVC
______________ lung volume
______________ lung compliance
VA/Q ___________ with __________ right-to-left shunt.
Decreased
Decreased
Decreased
mismatch; large
What are the 4 findings from an open lung biopsy of a patient with ARDS
Atelectasis, hyaline membranes, cellular debris, interstitial and alveolar edema.
In ARDS what causes reduced oxygen usage in the heart; vasodilation-increase tissue oxygenation until inflammation resolves.
inhaled nitric oxide
TRUE/FALSE
The only treatment for ARDS are only supportive measures.
True
What type of supplemental O2 is given to patients with ARDS?
High-frequency jet ventilation (HFJV)
Inverse ratio ventilation (IRV)
PEEP- mechanical ventilation w/ positive end-expiratory pressure
What type of atelectatic disorder:
-Also called hyaline membrane disease
-syndrome of premature neonates
-associated w/ a1-antitrypsin deficiency
-Atelectasis and decrease in lung compliance from lack of surfactant
Infant respiratory distress syndrome (IRDS).
What are clinical manifestations seen in late occupational lung diseases?
Chronic hypoxemia, cor pulmonale, respiratory failure
Pneumothorax is accumulation of.....
air in the pleural space
What are 4 important clinical manifestations of pneumothorax?
Hypotension (shock), tracheal shift to contralateral (opposite) side, neck vein distension, hyperresonance.
What type of occupational lung disease:
-Caused by inhalation of inorganic dust particles.
Pneumoconiosis
What type of occupational lung disease:
-"coal miner's" lungs or "black lungs"
anthracosis
What type of occupational lung disease:
Silica inhalation
Silicosis
What type of occupational lung disease:
Asbestos inhalation
asbetosis
What findings are seen in the ABGs of a patient with pneumothorax?
Decreased PaO2, acute respiratory alkalosis (due to tachypenia)
What X-ray findings are seen in a patient with pneumothorax?
Depression of hemidiaphragm on the side of pneumothorax.
In pleural effusion is pathologic collection of .....
fluid or pus in pleural cavity as result of another disease process.
What are impotant clinical manifestations of pleural effusion?
Pleuritic pain (sharp, worsens with inspiration), dry cough, dyspnea, absence of breath sounds, contralateral trachea shift (massive effusion),
TRUE/FALSE
Is pneumothorax a medical emergency?
True
Patient with plural effusion show what sign in their X-ray?
signs of CHF
In pneumothorax a sudden chest pain on affected side is it angina or MI?
Angina - no signs of MI
TRUE/FALSE
You will hear loud sounds on the affected side in pneumothorax patients.
False, you will hear a decrease or absent breath sounds.
How are CT and Ultrasonograph test helpful to diagnose plural effusion?
Assist in complicated effusions and distinguish mass from large effusion.
Death can occur if pH falls or rises
pH falls below 6.9 and pH rises above 7.8
Normal laboratory values for acid-base parameters
PaCO2 (aterial blood) =
HCO3- (serum) =
pH (arterial blood) =
PaCO2 (aterial blood) = 36-44 mm Hg (adults), average 40
HCO3- (serum) = 22-26 mm Hg (adults), average 24
pH (arterial blood) = 7.35-7.45 (adults), average 7.40
What measures lung (respiratory) function
PaCO2
if it falls or rises < 40 >, it means that there is a problem with your lungs. It is an indicator for lung function.
What measures renal (metabolic) function
HCO3 -
If it falls or rises < 24>, it means that there is a problem with your kidneys. It is an indicator for kidney function.
What are the three major mechanisms that regulate the body's acid-base status?
- Buffers (first line of defense)
- Respiratory system (compensatory mechanism)
- Renal system (compensatory mechanism)
What chemicals help control pH of body fluids
Base: Bicarbonate ions (HCO3 -) takes up hydrogen when fluid is too acidic
Weak acid: Carbonic acid (H2CO3) release hydrogen ions when a fluid is too alkaline
What are the four types of buffers
- Bicarbonate buffers (most important )
- phosphate buffers
- hemoglobin buffers
- Protein buffers
respiratory response
Metabolic reponse
- The lungs can excrete only carbonic acid (Volatile acid)
- Lactic acid and acetoacetic acid: nonvolatile acids get excreted through the metabolic response (compensatory)
What is the respiratory response, and is it acidosis or alkalosis
Increased Paco2, decreased pH
Decreased Paco2, increased pH
Decreased pH from excess of metabolic acids
Increased pH from deficit of metabolic acids
- Acidosis, hyperventaltion
- Alkalosis, hypoventaltion
- Acidosis, hyperventilation
- Alkalosis, Hypoventilation
Renal contribution
- third line of defense against acid-base disorders
- can excrete any acid from the body except carbonic acid (solely excreted by the lungs)
- excrete metabolic acids produced continuously during normal metabolism
what does decreased HCO3 - indicate
- Indicates a relative excess of metabolic acids
What does increased HCO3 - indicate
- Indicates a relative deficit of metabolic acids
- in other words, a relative excess of base
What are the renal compensatory responses to carbonic acids imbalances
- For high carbonic acid levels, increase the excretion of metabolic acids and H+
- For low carbonic acid levels, decrease the excretion of metabolic acids and H+, excrete HCO3 -
- requires several days to be fully operative
What is the renal response, and is it acidosis or alkalosis
Decreased pH from excess of metabolic acids
increased pH from deficit of metabolic acids
Decreased pH from excess of carbonic acid
Increase of pH from deficit of carbonic acid
- Acidosis, secrete more H+ into renal tubules and make more ammonia
- Alkalosis, secrete fewer H+ into renal tubules, and excretes HCO3 -, make less ammonia
- Acidosis, Secrete more H+ into renal tubules, and make more ammonia
- Alkalosis, secrete fewer H+ into the renal tubules, excrete HCO3 -, make less ammonia
What are the (3) reasons why someone might have respiratory acidosis
- Impaired gas exchange
- inadequate neuromuscular function
- Impairment of respiratory control in the brainstem
Chronic Obstructive pulmonary disease (COPD), Pneumonia, severe asthma, Pulmonary edema, and ARDS are examples of what reason for respiratory acidosis
Impaired gas exchange
Guillian-Barre syndrome, Chest injury or surgery (pain limits breathing), Hypokalemic respiratory muscle weakness, sever kyphoscoliosis, respiratory muscle fatigue are examples of what reason for respiratory acidosis
Inadequate Neuromuscular Function
Respiratory-depressants drugs (opioids, barbiturates) are examples of what reason for respiratory acidosis
Impaired respiratory control (Brainstem)
What condition causes respiratory alkalosis
- any condition that tends to cause a carbonic acid deficit
- e.g Hyperventilation
Metabolic acidosis is caused by
Relative excess of any acid except carbonic acid
- May be caused by
- Increase in acid
- excess removal or decrease in base
- combination of increase in acid and decrease in base
What are some examples of metabolic acidosis
Example: starvation ketoacidosis
- caloric and glucose intake is insufficient, body begins to use fat stores for energy, fat metabolizes incompletely, ketoacids accumulate in blood, causing metabolic acidosis
Hyperkalemia =
Metabolic acidosis
What causes metabolic acidosis
any condition that tends to cause a relative deficit of any acid (except carbonic acid)
causes
- increase in base (bicarb)
-decrease in acid
-combination of the two
What are some examples of decrease in acid
Emesis, gastric suction, Hyperaldosteronism, Hypokalemia