N105: Essentials of Nursing Care - Health Differences

Essentials of Nursing Study Guide

©2017 Achieve Test Prep Page 68 of 160 is the body’s attempt to compensate for metabolic acidosis by blowing off CO2 with deep and rapid breathing. Cheyne-stokes is marked waxing and waning of respirations from very deep to very shallow (CHF, ICP and drug overdose). Apneusis is prolonged gasping inspiration followed by a very short inefficient expiration (CNS disorders). Biot’s (cluster) respirations are shallow breaths interrupted by apnea (CNSdisorders). • Obstructed Airway : Obstruction of the airway can occur anywhere in the upper or lower airway tract. Secretions, foreign bodies, or blockage by food or liquids can cause partial or complete obstruction and is an immediate nursing priority. Stridor is a harsh, high-pitched sound, heard on inspiration. • Altered oxygen intake and supply : Nursing intervention is to maintain a patent airway. Administer O2 via face mask/tent/cannula. Encourage deep breathing and coughing. Use percussion, vibration, and postural drainage. Encourage use of incentive spirometry. • Lifestyle (individual preferences/patterns) : Physical exercise increases the rate and depth of oxygenation. Cigarette smoking causes vasoconstriction and can cause impaired tissue oxygenation. Excessive alcohol intake is a respiratory depressant, slowing respirations. These factors increase the risk of hypertension, anemia, and infection for thepatient. • Health status (physical condition): Any impairment in the health of anindividual will reduce oxygen transport. • Age/developmental level: Infants rely on diaphragmatic movement for breathing (abdominal breathing). With aging, the chest wall becomes more rigid and the lungs less elastic. More air is retained in the lungs at the end of each breath the vital capacity decreases. • Gender : There is a predominance of abdominal breathing in males, while women tend to be diaphragmaticbreathers. • Cultural and spiritual/religious practices : Some cultures and religious groups refuse to accept blood transfusions when necessary to improveoxygenation. • Psychological factors : Stress and coping mechanisms, hyperventilation in response to stress, and impaired emotional status andanxiety effect oxygenation. • Alternative/complementary treatments: Relaxation breathing, acupuncture for smoking cessation, andhypnosis can improve oxygenation. Common Oxygen Disturbances • Hypoxia : Hypoxia is insufficient oxygen anywhere in the body. Acute hypoxia is evidenced by rapid pulse, rapid, shallow respirations and dyspnea, increased restlessness/light- headedness, flared nares, substernal/intercostal retractions, and cyanosis. Chronic hypoxia is evidenced by fatigue, lethargy, “clubbed” fingers and toes, or nail beds that appear slightly swollen. Hypoventilation is inadequate alveolar ventilation. Hypercarbia is an accumulation of carbon dioxide in the blood. Cyanosis is a bluish discoloration of the skin, nail beds, and mucous membranes. • Altered breathing patterns : Tachypnea, bradypnea, apnea, hyperventilation, hypoventilation are all altered breathing patterns. Dyspnea is difficult or labored breathing. Orthopnea is an inability to breathe except in an upright or standing position. Kussmaul’s breathing