The patient's arterial blood gas results show the PaO2 at 65 mmHg and SaO2 at 80%. What other manifestations should the nurse expect to observe in this patient?
-Restlessness, tachypnea, tachycardia, and diaphoresis
-Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis
-Combativeness, retractions with breathing, cyanosis, and decreased output
-Coma, accessory muscle use, cool and clammy skin, and unexplained
fatigue
Restlessness, tachypnea, tachycardia, and diaphoresis
Rationale:
With inadequate oxygenation, early manifestations include restlessness, tachypnea, tachycardia, and diaphoresis, decreased urinary output, and unexplained fatigue. Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis; combativeness, retractions with breathing, cyanosis, and decreased urinary output; coma, accessory muscle use, cool and clammy skin, and
unexplained fatigue are later manifestations of inadequate oxygenation.
Gather patient history. Insert chart on pg 502
Gather information on nutrition status, family history and genetic history, current health problems.
You would then perform a physical assessment. Assess the nose and sinuses. assess the pharynx, trachea, and larynx. Inspect the mouth. Inspect the neck for symmetry, alignment, masses, swelling, bruises, and the use of accessory neck muscles in breathing. Palpate lymph nodes for size, shape, mobility with palpation, consistency, and tenderness. Gently palpate the trachea for position, mobility, tenderness, and masses. Inspect the front and back of the thorax with the patient sitting up. Observe the rate, rhythm, and depth of inspirations as well as the symmetry of chest movement. Examine the shape of the patient's chest, and compare the antero-posterior diameter with the lateral diameter. Normally the ribs slope downward. Patience with air trapping in the lungs caused by emphysema have ribs that are more horizontal. How paint the chest after inspection to assess respiratory movement symmetry and observable abnormalities. Palpation also can help identify areas of tenderness and check local or tactile fremitus or vibration. Use percussion to assess for pulmonary residence, the boundaries of organs comment and diaphragmatic excursion. Auscultation includes listening with a stethoscope for normal breath sounds, abnormal sounds, and voice sounds. assess those aspects of the patients lifestyle that either can affect respiratory function or are affected by it. Some respiratory problems may become worse with stress. Ask about current life stresses and usual coping mechanisms. Complete a laboratory assessment. Insert chart 27-3. chest xrays with digital images are used for patients with pulmonary problems to evaluate the status of the chest and to provide a baseline for comparison with future changes. These chest x rays are performed from posteroanterior and left lateral positions. Chest x rays are used to assess lung pathology such as with pneumonia, atelectasis, pneumothorax, and tumor. They also can detect pleural fluid and the placement of an endotracheal tube or other invasive catheters.
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2
A pleural effusion involves the build-up of fluid in the pleural cavity around the lungs. Presence of fluid in the pleural cavity may result in decreased tactile fremitus, dullness on percussion, and absence of breath sounds. The patient may also have unequal chest movement due to fluid collection. Therefore, Patient B is likely to have a pleural effusion. Patient A is likely to have asthma, as evidenced by pursed-lip breathing, use of
accessory muscles for breathing, increased AP diameter of chest, and presence of wheezing. Patient C is likely to have chronic obstructive pulmonary disease (COPD), as evidenced by the tripod position, use of accessory muscles for breathing, hyperresonance on percussion, and presence of coarse crackles. Patient D is likely to have cystic fibrosis, as evidenced by an increased AP diameter of the chest, finger clubbing, presence of rhonchi, and a history of repeated pulmonary infections.
Text
Reference - p. 489
2
Asthma involves bronchospasms, which can be triggered by many factors including pollens inhaled during outdoor activities such as gardening. Wheezes are continuous, high-pitched squeaking or musical sounds caused by the rapid vibration and narrowing of bronchial walls. If the patient has wheezing sounds during auscultation, it indicates the patient may have asthma. Rhonchi sounds are continuous rumbling, snoring, or rattling sounds
caused by obstruction of large airways with secretions. This would be seen in instances of cystic fibrosis. Fine crackles are series of short-duration, discontinuous, high-pitched sounds heard just before the end of inspiration, as seen in cases of pulmonary fibrosis and interstitial edema. Coarse crackles are long-duration, discontinuous, and low-pitched and they are usually caused by air passing through an airway intermittently occluded by mucus, unstable bronchial walls, or folds of mucosa.
Coarse crackles can be heard in conditions such as heart failure and pulmonary edema.
Text Reference - p. 489
1, 3, 5
Changes in the respiratory system in the older adult include thickened mucus, decreased chest wall movement, and diminished breath sounds, especially at the lung bases. The PaO2 and SaO2 levels are decreased.
Test-Taking Tip: Come to your test prep with a positive attitude about yourself, your nursing knowledge, and your
test-taking abilities. A positive attitude is achieved through self-confidence gained by effective study. This means (a) answering questions (assessment), (b) organizing study time (planning), (c) reading and further study (implementation), and (d) answering questions (evaluation).
Text Reference - p. 481