Medical-Surgical Nursing

• Larynx


  Houses vocal cords
• Hyoid bone


  Holds up the tongue
• Right lung


  • 3 lobes
• Left lung


  • 2 lobes
• Respiratory system


  Regulates the amount of CO2 in blood
• Alveoli


  Site of gas exchange between air & circulatory blood
• Respiratory acidosis


  Blood pH low, Cause: hypoventilation
• Respiratory alkalosis


  Blood pH high, Cause: hyperventilation
• Acid-base balance occurs when the levels of CO2 & O2 in the blood aren't balanced
• The body needs oxygen to function properly. Inhale oxygen into the lungs. Exhale release carbon dioxide=waste product. Normally, the respiratory system keeps these 2 gases in balance.
• Respiratory alkalosis


  Occurs when you breathe too fast/too deep (hyperventilation) & CO2 levels drop too low, pH of the blood rises & becomes too alkaline
• Respiratory acidosis


  Occurs when the lungs can't remove enough CO2, may be due to a decrease in respiratory rate or air movement due to an underlying condition like asthma, COPD, Pneumonia & Sleep Apnea (OSA)
• Aging


  • Changes affect lung tissue, muscles and bones, which all impact breathing
  • Maximum amount of air lungs can hold (total lung capacity) is about 6 liters
  • Lungs mature by 20-25 years old
  • After 35, lung function declines
  • Changes are due to cardiovascular and muscle changes, not changes to the lungs themselves
• Body changes that happen as you get older that may cause a decline in lung capacity

  • Alveoli can lose their shape and become baggy
  • Diaphragm can become weaker, decreasing the ability to inhale and exhale
  • Ribcage bones become thinner and change shape, altering the ribcage so that it is less able to expand and contract with breathing
  • Nerves in airways that trigger coughing become less sensitive to foreign particles
  • Immune system may weaken, leaving you more vulnerable to infections like influenza and pneumonia
• Pack-years


  Example: if a patient has smoked two packs of cigarettes per day for 20 years, he has a 40 pack-year smoking history
• WHAT'S UP? - Use to Gather Additional Data

  • Where is it?
  • How does it feel?
  • Aggravating and alleviating factors
  • Timing
  • Severity
  • Useful other data
  • Patient's perception
• Inspection findings


  • Symmetry
  • Dyspnea
  • Use of accessory muscles
  • Retraction
  • Color
  • Cyanosis
  • Respiratory rate and rhythm
  • Apnea
  • Chest shape
  • Retractions
• Palpation findings


  • Sinuses
  • Tenderness
  • Respiratory excursion
  • Chest expansion on inspiration
  • Crepitus
  • Subcutaneous emphysema (air leak into SQ tissue from pneumothorax or chest tube)
  • Feels like Rice Krispies under the skin when palpated
• Percussion


  Performed by experienced nurse, tap anterior and posterior chest, each intercostal space, compare from side to side, Normal: equal bilaterally except over the heart
• Auscultation


  Listen to anterior, lateral, and posterior sides, With inspiration AND expiration, Compare bilaterally
• Adventitious breath sounds


  • Crackles: Coarse or fine
  • Wheezes
  • Stridor
  • Pleural friction rub
  • Diminished
  • Absent
• Crackles


  Coarse cause- fluid or secretions in airways, Fine cause- alveoli popping open on inspiration, Moist bubbling sound heard on inspiration or expiration
• Wheezes


  Cause- narrowed airways, Fine high-pitched violin sound, mostly on expiration
• Stridor


  Cause- airway obstruction, Loud crowing noise heard without stethoscope
• Pleural friction rub


  Cause- inflamed pleura rubbing together, Sound of leather rubbing together; grating sound
• Diminished breath sounds


  Cause- decreased air movement, Faint lung sounds
• Absent breath sounds


  No air movement, No sounds heard
• Laboratory tests


  • Complete blood count
  • Arterial blood gases
  • D-dimer
• Complete blood count


  Low RBC/Hgb decreased oxygen carrying capacity of blood; can cause dyspnea, High WBC may indicate infection
• Arterial blood gases


  Determine effectiveness of gas exchange
• 1. dimer


  Elevation- indicates blood clot; can help diagnose blood clot in pulmonary artery
• Culture and sensitivity tests

  • Sputum
  • Throat
  • Nasal
• Sputum culture


  Deep breaths then cough sputum into sterile collection container; do not spit saliva; best collected first thing in the morning
• Throat culture


  Swab to reach into posterior pharynx behind the uvula; swab red areas or lesions; may use tongue blade
• Nasal culture


  Must be obtained in first few days of symptom onset
• Other tests


  • Oxygen saturation
  • Capnography
• Oxygen saturation


  Measures arterial oxygenation, Sensor on finger or ear, Measures % of Hgb that is saturated with oxygen, Normal 95% or greater, Some chronic lung diseases may maintain 90-92%
• Capnography


  Measures exhaled carbon dioxide, Used on intubated patients, Used when patient on PCA pump
• Diagnostic tests


  • Chest x-ray
  • Computed tomography (CT) scan
  • Ventilation-perfusion scan
  • Pulmonary function studies
  • Pulmonary angiography
  • Bronchoscopy
• Ventilation-perfusion scan


  "Lung scan" or "VQ scan"; shows blood flow to lungs; diagnose pulmonary embolism (PE)