NUR2502: Multidimensional Care III / MDC
3 Exam 2
MDC 3 EXAM 2
hyperventilation, if someone is blowing off too much CO2 they become more
(ANS- Alkaline, respiratory alkalosis
if a patient’s lung are not functioning very well and they are unable to remove or
blow off CO2 very well, the CO2 will build up in their system becoming
(ANS- acidic, respiratory acidosis
Perfusion
(ANS- is adequate arterial blood flow through the peripheral tissues (peripheral
perfusion) and blood that is pumped by the heart to oxygenate major body organs
(central perfusion)
upper respiratory tract
(ANS- nose, sinuses, pharynx, larynx
Lower respiratory tract (ANS- Lungs,Trachea, two mainstem bronchi, lobar,
segmental, and subsegmental bronchi; bronchioles; alveolar ducts; alveoli
common cause of respiratory ailments
(ANS- Cigarette smoke
Nursing care of a patient experiencing upper respiratory system disorders
(ANS
- maintaining a patent airway to allow adequate ventilation and oxygenation.
Along with a focused respiratory assessment, the nurse will utilize information
obtained from the patient and family during the admission history interview.
Information regarding the patient’s history of upper respiratory disorders, smoking,
and environmental exposures will be utilized to determine the necessary testing
and treatment
Normal Changes in Aging Adults
(ANSAlveoli function decreases
Ability to cough decreases
Lungs loose residual volume, vital capacity and gas exchange decreases.
Respiratory muscles atrophy
Vascular resistance increases, capillary flow decreases
Susceptibility to infection increases.
The turbinates
(ANSthree bones that protrude into the nasal cavities from the internal portion of the
nose
increase the total surface area for filtering, warming, and humidifying inspired air
before it passes into the nasopharynx.
The paranasal sinuses
(ANSair-filled cavities within the bones that surround the nasal passages
Lined with ciliated membrane, the sinuses provide resonance to speech, decrease
the weight of the skull, and act as shock absorbers in the event of facial trauma..
Fremitus refers to vibratory tremors that can be felt through the chest by palpation,
Increased fremitus may indicate
(ANScompression or consolidation of lung tissue, as occurs in pneumonia.
Lung sounds
(ANSBronchial
Bronchovesicular
Vesicular
Adventitious sounds
(ANSCrackles
Wheezes
Rhonchus
Pleural friction rub
Other Indicators of Respiratory Adequacy
(ANSCyanosis, decreased capillary refill, clubbing of nails in fingers, level of
consciousness, Chest Circumference, Anxiety, Dyspnea Orthopnea, General
Appearance
Diagnostic Assessment of lungs
(ANS-
Laboratory assessment
- RBC
- ABG- is a blood gas and this tells us the acid base balance of the patient
- Sputum- can tell us if microorganisms are growing in the lung – describe color,
clarity, and any odor
Imaging assessment - x-rays-Xrays show us areas of opaque which usually indicate
pneumonia/consolidation of fluid
-CT- computed tomography. Lung nodules, areas of fluid buildup
Other noninvasive diagnostic assessments - Pulse oximetry-circulating O2- tells us oxygen levels in the tissues- usually
fingers, toes, or earlobes - Capnometry and capnography-how much CO2 is leaving the lungs.
-PFTs-Lung function- tell us how well the lungs function at moving air in and out - Exercise testing-Exercise tolerance
Invasive Diagnostic Assessment
(ANS-
-Endoscopic examinations
-Bronchoscopy- is a camera that looks at the airway passages
-Thoracentesis- can remove fluid buildup from the lung
-Lung biopsy- is used to diagnose some lung diseases or cancer
Which assessment finding for an older adult patient does the nurse ascribe to the
natural aging process?
A.Tightening of the vocal cords
B.Decrease in residual volume
C.Decrease in the anteroposterior diameter
D.Decrease in respiratory muscle strength
(ANS D-.
As a person ages, vocal cords become slack, changing the quality and strength of
the voice; the anteroposterior diameter increases; respiratory muscle strength
decreases; and the residual volume increases.
The nurse knows that under normal physiologic conditions of tissue perfusion, a
patient will have what percent of oxygen dissociate from the hemoglobin
molecule?
A.25%
B.50%
C.75%
D.100%
ANS: B
Oxygen dissociates with the hemoglobin molecule based on the need for oxygen to
perfuse tissues. Under normal conditions, 50% of hemoglobin molecules
completely dissociate their oxygen molecules when blood perfuses tissues that
have an oxygen tension (concentration) of 26 mm Hg. This is considered a
“normal” point at which 50% of hemoglobin molecules are no longer saturated
with oxygen.
Which assessment finding does the nurse interpret that is associated most closely
with lung disease?
A.Cough
B.Dyspnea
C.Chest pain
D.Sputum production
ANS: A
Cough is a main sign of lung disease. Dyspnea (difficulty in breathing or
breathlessness) is a subjective perception and varies among patients. A patient’s
feeling of dyspnea may not be consistent with the severity of the presenting