sarabjit seminar

5/24/2018 Sarabjit Seminar

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MODERATOR-MRS PARMEES KAUR

LECTURER

RPCON

PRESENTED BY-SARABJIT KAUR

M.SC 1

ST

YEARRPCON

SEMINAR ON OXYGEN

INSUFFICIENCY,


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INTRODUCTION

Oxygen is required to sustain life.Blood is oxygenated through

the mechanisms of ventilation,perfusion and transport of

respiratory gases

Oxygenation is the addition of oxygen to any

system,includingthe human body

It also refers to the process of treating a patient with oxygen

Oxygenation is the process by which concentration of oxygen

increased in a tissue.

Oxygen insufficiency is defiency in the amount of oxygen

reaching blood


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PHYSIOLOGY OF OXYGENATION

Oxygenation results from the co-operative function of three majorsystems

Pulmonary

Haematological

Cardiovascular system

Anatomy of system involved in oxygenation process

The main organs involved in process of oxygenation are heart andlungs. blood from heart enters to the heart through superior and

inferiorvenacava to right atrium

During atrial systole the blood is ejected to right venriclethroughtricuspid valve


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From right ventricle pulmonary artery takes the blood to lungs foroxygenation

Oxygenated blood return to left atrium and then ventricle via pulmonary

vein

Left ventricle then supplies oxygenated blood to whole body via artery


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HOW LUNGS HELPS IN OXYGENATION

Respiratory system is divided into two parts-

1.Upper respiratory tract including mouth,nose ,pharynx and

larynx

2.Lower respiratory tract trachea and lungs along

bronchi,alveoli,pulmonary capillary network and pleural

membranes

Pathway of air: nasal cavities (or oral cavity) > pharynx > trachea

> primary bronchi (right & left) > secondary bronchi > tertiary

bronchi > bronchioles > alveoli (site of gas exchange)


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ALEVOLAR GAS EXCHANGE

The exchange of gases (O2 & CO2) between the alveoli & the blood occurs by

simple diffusion:

O2 diffusing from the alveoli into the blood & CO2 from the blood into the

alveoli. Diffusion requires a concentration gradient. So, the concentration (or

pressure) of O2 in the alveoli must be kept at a higher level than in the blood &

the concentration (or pressure) of CO2 in the alveoli must be kept at a lower

lever than in the blood.

, by breathing - continuously bringing fresh air (with lots of O2 & little CO2)

into the lungs & the alveoli.

Breathing is an active process- requiring the contraction of skeletal muscles.

The primary muscles of respiration include the external intercostal muscles

(located between the ribs) and the diaphragm


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The external intercoastal plus the diaphragm contract to bring

about inspiration:

Contraction of external intercostal muscles > elevation of ribs &

sternum > increased front- to-back dimension of thoracic cavity >

lowers air pressure in lungs > air moves into lungs

Contraction of internal intercoastal muscles > ribs moves

downward > decraese dimension of thoracic cavity > air moves

out of lungs:


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HYPOXIA

Hypoxia can occur from either severe pulmonary disease or from

extrapulmonary disease affecting gas exchange at the cellular

level.The four general types of hypoxia are;

1.HYPOXIC HYPOXIA- It is a decreased oxygen level in the

blood resulting in decreased oxygen diffusion into the tissues. It

may be caused by hypoventilation, high altitudes, ventilation-

perfusion mismatch and pulmonary diffusion defects. It iscorrected by increasing alveolar ventilation or provide adequate

oxygen


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2.CIRCULATORY HPOXIA-

It is resulting from inadequate capillary circulation. It may be

caused by decreased cardiac output. local vascular obstruction,

low flow states such as shock or cardiac arrest. It is corrected by

identifying and treating the underlying cause.

3. ANEMIC HYPOXIA-

It is a result of decreased effective haemoglobinconcentration,which causes deacrease in oxygen carryingcapacity of the blood


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4.HISTOTOXIC HYPOXIA-

It occurs when anoxic substance such as cyanide,interferes with

the ability of tissues to use available oxygen.


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PATHOPHYSIOLOGY OF HYPOXIA

Due to any factors such as anemia

Cell can switch to anaerobic Less oxygen supply to cells resulting in

availability of less

Metabolism energy for cellular functions

Result in accumulation of acids

Distruction of tissues and organs

Imbalance in chemical environment of cells

Release of lysosomal enyzymes

Tissue distruction


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FACTORS AFFECTING OXYGENATION

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Oxygen is influenced by three types of factors;

1 Physiological Factors

Any condition that affects cardiopulmonary functioning directly

affects the bodys ability to meet oxygen demands.

The general classification of cardiac disorders include

disturbances in conduction, impaired valvular

function,myocardial hypoxia,cardiac myopathic conditions and

peripheral tissue hypoxia.

Respiratory disorders include hyperventilation,hypoventilation

and hypoxia


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11

Some more physiologic processes are

1.Anaemia

2.Pregnancy

3. Fever 4.Infection

5. CNS alteration

6.Influences of chronic diseases


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2. DEVELOPMENTAL FACTORS-

The developmental stage of the client and the normal aging

process can affect tissue oxygenation

1.I nfants and toddlers-are at greater risk for upper respiratorytract infections

2.School age chi ldren and adolescents-are exposed to

respiratory infections and respiratory risk factors such as

smoking 3.Young and middle age adul ts-are exposed to multiple

cardiopulmonary risk factors like unhealthy diet,lack of

exercise ,stress and drug uses.


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4.Older adults-Thephysiologic changes occurs.Ventilation andtransfer of respiratory gases decline with age,leading to loweroxygenation levels

3. LIFE STYLE FACTORS

Life style factors which lead to oxygen imbalance- Cigarette smoking

Junk foods

Spicy and fatty foods

No exercise Stress

Substance abuse


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ENVIRONMENTAL FACTORS

Alttitude, heat,cold and air pollution affect oxygenation.

Air pollution cause stinging of eyes and chocking even in healthypeople.

MEDICATIONS-

Certain medications including sedatives, hypnotics can causerespiratory deprression and narcotics including morphine

SYMPTOMS OF OXYGEN INSUFFICIENCY

Body weakness


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Cont--15-

Loss of memory

Muscle ache

Depression

Dizziness Irritability

Infection

Fatigue

Acidity Lowered immunity

Bronchial problems


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Irrational behaviour

INTERVENTIONS

1.OXYGEN THERAPY

2.SUCTIONING

3.NEBULIZATION

1.OXYGEN THERAPY

Oxygen therapy is used for paitient who suffer from

hypoxaemia. The decision to administer oxygen,the amountto deliver and the method to be used depend on thepurpose for which it is being administered


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INTERVENTIONS

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The effectiveness of oxygen in the treatment of the patientdepends on the pathologic process present.The physicianindicates the method by which oxygen is to be given and thenumber of liters per minute.

The nurse responsible for carrying out the directive shouldact promptly and remember that although oxygen may bebeneficial,it may also be dangerous.

Therefore the nurse should carefully observe any patient

who is receiving oxygen.

INDICATIONS-


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INTERVENTIONS

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COPD

Hypoxaemia

Pulmonary embolism

Pneumonia Tension pneumothorax

Asthma

Pulmonary edema

2. GOALS OF OXYGEN THERAPY

To relieve hypoxaemia


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INTERVENTIONS

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To reduce work of breathing

To decrease the work of myocardium

To relieve tissue hypoxia

3. OXYGEN DEL IVERY METHODS

1 NASAL CANNULA-

A nasal cannula is used when the patient requires a low tomedium concentration of oxygen .

This method is relatively simple and allows the patient to moveabout bed in bed ,talk,cough and eat without interrupting oxygenflow .


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INTERVENTIONS

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Flow rate in excess of 6 to 8 L/min may lead to swallowing of air

or may cause irritation and drying of the nasal and pharyngeal

mucosa.

2. FACE MASK

Oxygen masks are comfortable and are used when higher

concentrations of oxygen is given.

A simple oxygen mask provides concentration of oxygen from

40% to 60% depending on the patients ventilator pattern.

Flow rate of 5 to 8Lmin are normally required.This system is

particularly useful in individuals with COPD.


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INTERVENTIONS

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3.PARTIAL REBREATHING MASK

Have a reservoir bag that must remain inflated during both

inspiration and expiration.

The nurse adjust the oxygen flow to ensure that the bag does not

collapse during inhalation.

A high concentration of oxygen can be delivered ,because both

the mask and the bag serve as reservoirs for oxygen.

Oxygen enter the mask through small-bore tubing that connects at

the junction of the mask and bag.

As the patient inhales ,gas is drawn from the mask,from the bag

and potentially from room air through the exhalation


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PARTIAL REBREATHER


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ports.As the patient exhales,the first third of the exhalation fills

the reservoir bag .This mainly dead space and does not

participate in gas exchange in the lungs.

3.NON BREATHER MASK

Non breather mask consist of a mask and reservoir that are

separated by a oe-way valve that prevents expired air from

mixing with supplement oxygen.Exhaled air is directed out of

the mask through exhalation ports.If the mask conforms tightly

to the face ,100% oxygen concentration can be delivered.


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NON-BREATHER MASK


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INTERVENTIONS

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4.VENTURI MASK

Venturi mask is the most reliable and accurate method for

delivering precise concentrations of oxygen through non invasive

means.The mask is constructed in a way that allows a

concentration constant flow of room air blended with a fixed flowof oxygen .It can accurately used for patients with COPD because

it can accurately provide appropriate levels of supplemental

oxygen,thus aviding the risk of suppressing the hypoxic drive


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VENTURI MASK


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INTERVENTIONS

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6.TRANS TRACHEAL OXYGEN CATHETER

It is inserted directly into trachea and is indicated forpatients with chronic oxygenation therapy needs.

These cathetars are more comfortable,lessdependent on breathing patterns.Because no oxygenis lost into the surrounding environment,the ptientachieves adequate oxygenation at lower rates,making

this method less expensive and more efficient.


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INTERVENTIONS

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7.FACE TENTS

Facial tents can be used in clients who cannottolerate masks.

O2 concentration at a flow rate of 4 to 8 L/min. METHODS USED IN CASE OF PAEDIATRICS

IN CASE OF INFANTS

OXYGEN HOOD

Rigid plastic dome that encloses on infanthead

It provides precise oxygen levels and high humidity


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OXYGEN HOOD


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INTERVENTIONS

IN CASE OF CHILDREN

OXYGEN TENT

Made up of rectangular, clear,plastic canopy with outlets that

connect to an oxygen source.

Flow rate is adjusted at 10 to 15 L/min after flooding the tent for

5 minutes


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INTERVENTIONS

HAZRARDS OF OXYGEN IHALATION Infection

Combustion

Drying of mucous membrane of the respiratory tract

Oxygen toxicity

Atelectasis

Oxygen induced apnoea

Retrolental Fibroplasia

Asphyxia


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OXYGEN INSUFFIEIENCY

NURSING RESPONSIBLITIES FOR ADMINISTRATION OF OXYGEN

Check the name ,bed number and other identification dateof patient.

Confirm diagnosis and the need of oxygen therapy

Assess the patient for any sign of anoxia e.g cyanosis andalso assess the breathing pattern

Monitor for results of ABG

Monitor the signs of oxygen toxicity

Check that the oxygen is properly humidified

Every precaution should be taken to prevent entry ofinfection to patient


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OXYGEN INSUFFIEIENCY

Place a calling bell near the patient in case if nurse is not near

him.

Pay attention to kinks in tubing ,loose connection and faulty

humidifying apparatus as it may interfere with flow of oxygen

For fear of retrolental fibroplasias, give oxygen to newborn

babies for a short period at very low concentration.

Since oxygen supports combustion, fire precautions are to be

taken when oxygen is on low.Give proper instructions to the

relatives of client regarding this.


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MECHANICAL VENTILATION

In case of oxygenation failure mechanical ventilationis used to restore and maintain lung volumes.Conditions such as thoracic or abdominal surgery,drug overdose, neuromuscular disorders,multipletrauma, shock, and coma may lead to respiratoryfailure and the need for mechanical ventilation

Normal respiration begins with the contraction of

the diaphragm and respiratory muscles to createnegative pressure in the chest. A vacuum is created


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and air flows in.When a ventilator is used ,positivepressure (rather than negative pressure)forces airinto the lungs .The positive pressureis necessary forgas exchange and to keep alveoli open.Unfortunatelypositive pressure forces can damage the alveoli andmay retard venous return and cardiac output.

INDICATIONS-

Continuous decrease in Pao2 Increase in arterial CO2 levels

Persistent acidosis


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GOALS OF MECHANICAL VENTILATION

To maintain adequate ventilation

To deliver precise concentrations of FiO2

To deliver adequate tidal volumes to maintain anadequate minute ventilation and oxygenation

To lessen the work of breathing in those clients whocannot sustain adequate ventilation on their own.

To prevent complications from the underlyingproblems


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POSITIVE PRESSURE VENTILATION

Positive pressure ventilation inflate the lungs by exerting positive

pressure on the airway ,forcing the alveoli to expand during

inspiration.Expiration occurs passively. Endotracheal intubation

or tracheostomy is necessary in most cases.There are three types

of positive pressure ventilatiors; pressure- cycled ,time-cycled,and volumecycled.

1.PRESSURE CYCLED VENTILATORS

Delivers a volume of gas to the airway using positive pressureduring inspiration.The positive pressure is delivered until the

preselected pressure has been reached .When the preset pressure


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has been reached , the ventilator will cycled into passive

exhalation.A disadvantage to this type of ventilator is

that the volume delivered may not be sufficient

depending on the compliance of the lung and the

integrity of the ventilator circuit (_e.g kinking tube)

2. VOLUME- CYCLED VENTILATORS(volume-

controlled or volume

limited)-

Delivers a preset tidal volume of inspired gas .The tidal

volume has been preselected based on the ideal weight


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and is delivered to the client regardless of the pressure required todeliver this volume.The ventilator will automatically adjust the

pressure needed to deliver the preset volume ..If the clients

breathing is shallow ,the ventilator will increase pressure to

continue delivering the preset volume . A pressure limit can beset to prevent the occurrence of dangerously high airway

pressures.

3.TIME

CYCLED VENTILATORS

Timecycled ventilators terminate or control inspirations after a

preset time .


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MODES OF VENTILATION

ASSIST CONTROLLED VENTLATION

Mode of mechanical ventilation in which the patients breathing

pattern may trigger the ventilator to deliver a preset tidal volume

;in the absence of spontaneous breathing , the machine delivers acontrolled breath at a preset minimum rate and tidal volume.

SYNCHRONIZED INTERMITTENT MANDATORY

VENTILATION(SIMV)-


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Mode of mechanical ventilation in which the ventilator allows thepatient to breathe spontaneously while providing a preset number

of breaths to ensure adequate ventilation ;ventilated breaths are

synchronized with spontaneous breathing.

INTERMITTENT MANDATORY VENTILATION-

Mode of mechanical ventilation that provides acombination of mechanically assisted breaths and

spontaneous breaths.

CONTINUOUS POSITIVE AIRWAY PRESSURE-(CPAP)


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Positive pressure applied through out the respiratory cycle to aspontaneously breathing patient to promote alveolar and airway

stability ;may be administered with endotracheal or tracheostomy

tube, or by mask.

POSITIVE END EXPIRATORY PRESSURE (PEEP)-

Positive pressure maintained by the ventilator at the end ofexhalation to increase functional residual capacity and open

collapsed alveoli ,improves oxygenation with lower FiO2.

PRESSURE SUPPORT VENTILATION-


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Mode of mechanical ventilation in which preset positive pressureis delivered with spontaneous breaths to decrease work of

breathing

PROPORTIONAL ASSIST VENTILATION-

Mode of mechanical ventilation that provides partialventilator support in which the ventilator generatespressure in proportion to the patients inspiratory efforts;

decrease the work of breathing.the more inspiratorypressure the patient generates ,the more pressure theventilator generates ,amplyfying the patient,s inspiratoryeffort.
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SUCTIONING

SUCTIONING

Definition

Removal of secretions from the oral cavity and pharynx

Purposes

To remove secretions that obstruct the airway.

To facilitate ventilation

To obtain secretions for diagnostic purposes

To prevent infection that may result from accumulated secretions.


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SUCTIONING

NURSING ACTIONS

1.Assess for sign and symptoms indicating presence of upper

airway secretions

2.Explain to the client that suctioning will stimulate the

cough,gag reflex

3.Explain importance of and encourage coughing during

procedure

4.Assemble articles

5.Adjust bed to comfortable working position.Lower side rails

closer to you ,place the patient in a semi-fowlers position if

conscious.An unconscious patient should be placed in lateral


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lateral position facing you

6.Place towel or waterproof pad across patients chest

7.Wear mask or face shield

8.Turn on suction and adjust to appropriate pressure

a)Wall unit

Adult-100-120 mm of Hg

Child -95-110mm of Hg

Infant-50-95mm of Hg b)Portable unit

Adult-10-15mm of Hg

SUCTIONING


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SUCTIONING

Child-5-10mm of Hg

Infant-2-5mm of Hg

9.Wash hands

10.Perform oropharngeal suctioning

11.Reassess clints respiratory status

12.Remove towel,place in laundary bag

13.Reposition client;Sims position encourages drainage and

should be used if client has decreased level of consciousness 14. Wash and rinse used articles

15. Place catheter in clean dry area


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16.Document the procedures in nurses record

3)NEBULISATION THERAPY-

It is the process of dispersing liquid medication into microscopic

particles(aerosol) and delivering into lungs as patient inhales

PURPOSES

1.To administer medication directly into the respiratory tract for

sputum expectoration.

2.To reduce difficulty in bringing out thick tenacious repiratory

secretions

3.To increase vital capacity

-


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NEBULISATION THERAPY

3.To increase vital capacity

4.To relieve dyspnoea

NURSES ACTIONS

1.Identify patient and check physicians instructions

2.Monitor heart rate before and after the treatment for patients

using bronchodilators drug

3.Explain the procedure to the patient

4.Place the patient in a comfortable sitting or a semifowlersposition.

5.Add the prescribed amount of medication and saline or sterile

water to the nebulizer.


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NEBULISATION THERAPY

6.Place mask on patients face to cover his mouth and nose andinstruct him to inhala deeply and slowly through the mouth,hold

breath and then exhale several times.

7.Oberve expansion of chest to ascertain that patient is taking

deep breaths. 8.Instruct the patient to brathe slowly and deeply until all the

medication is nebulized.

9.On completion of the treatment encourage the patient to cough

after several deep breaths 10.Record medication used and descriptions of secrtions

expectorated


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3)NEBULISATION THERAPY-

11.Disassemble and clear nebuliser after each use .Keep theequipment in patients roomThe tubing is changed every 24 hrs.

12.Wash hands.

Diagnostic studies-

A] PFT

Pulmonary function tests are routinely used in patients with

chronic respiratory disorders.They are performed to assess

respiratory function and to determine the extent of

dysfunction.Such tests include measurenents of lung

volumes.ventilatory function and the mechanics of


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HISTORY

Health History- The health history focuses on the physical and functional

problems of the patient and effect of these problems on the

patient,including his or ability to carry out activities of daily

living 1.DYSPNOEA-Difficult or labored breathing or shortness of

breath is a symptom common to many pulmonary and cardiac

disorders,particularly when there is decrease lung compliance or

increased airway resistance

2.ORTOPNOEA-

Inability to breathe in an upright posit


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HISTORY

It is important to ask the patient the following questions-

1.How much exertion triggers shortness of breath?

2.Is there is an associated cough?

3.Is the shortness of breath related to other symptoms?

4.At what time of day or night does the shortness of breath occur?

5.Is the shortness of braeth worse when the patient is flat in bed?

6.Does the shortness of breath occur at rest?with

exercise?Running?climbing stairs? 3.Pain

4.Hemoptysis


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HISTORY

5.Edema of the ankles and feet,cough and general fatigue andweakness

6.Obtains information about precipitating factors,duration,s

everity and associated factors and symptoms and also assess for

risk factors and genetic factors that contribute to the patientslung condition

7.Assess the impact of sign and symptoms on the patient,s ability

to perform activities of daily living and to participate in usual

work and family activities 8.Cough

Cough results from irritation of mucus membranes anywhere in t


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HISTORY

The respiratory tract.The stimulus that produces cough may arisefrom an infectious process or from an airway irritant such as

smoke ,dust or a gas.Cough may indicate serious pulmonary

disease,but it may caused by a variety of other problems as well

including cardiac disease,smoking and GERD Clinical significance

A dry ,irritative cough is characterstic of an upper respiratory

tract infection of viral origin or it may be side effect of ACE

inhibitor therapy Laryngotracheitis causes an irritative ,high pitched cough.

A severe or changing cough indicate bronchogenic carcinoma


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HISTORY

The time of coughing is noted

Coughing at night indicate the onset of left sided heart failure or

bronchial asthma

A cough in the morning with sputum production may indicate

bronchitis

A cough that worsens when the patient in supine suggests

sinusitis

Coughing after food intaake aspiration of material into the

trcheobronchial tree

9.Sputum


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HISTORY

A patient who coughs long enough almos invariably producessputum

Sputum production is the reaction of the lungs to any constantly

recurring irritant.

CLINICAL SIGNIFICANCE

The nature of the sputum is indicative of the causal condition

A profuse amount of purulent sputum or a change in color of the

sputum is a common sign of bacterial infection

Thin mucoid sputum results from viral bronchitis

A gradual increase of sputum over time may indicate the presence

of chronic bronchitis or bronchiectasis


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HISTORY

Pinktinged mucoid sputum suggests a lung tumor

Foul smelling sputum and bad breath indicate the presence of

lung abcess ,bronchiectasis or an infection caused by anerobic

organisms

10. CHEST PAIN

Chest pain or discomfort may be associated with pulmonary

conditions may be sharp, stabbing and intermittent or it may be

dull, aching and persistent. The pain is usually felt on the sidewhere the pathologic process is located ,but it may be reffered

elsewheree.g,to the neck,back or abdomen


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HISTORY

The nurse assess the quality,intensity and radition of pain andidentifies and explores precipitating factors and their relationship

to the patient condition

11.WHEEZING-

It is a high- pitched musical sound heard only on expiration .It is

heard with or without stethoscope,depending on its location

Oral or inhalant bronchodilator medications reverse wheezing in

most instances.

12.CLUBBING OF THE FINGERS-


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CLUBBING OF FINGERS


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HISTORY

The nurse considers the following points

Bloody sputum from the nose or the nasopharynxx is usually

preceded by considerable sniffing,with blood possibly appear

from the nose

Blood from the sputum is usually bright red ,frothy and mixedwith sputum.

If the haemorrhage is in the stomach ,the blood is vomited rather

than coughed up.Blood that has been in contact with gastric juice

is sometimes so dark that it is refferded to as coffee grounds


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HISTORY

It is a sign of lung disease that is found in patients with chronichypoxic conditions,chronic lung infections or malignancies of the

lung.

This finding may be manifested intially as sponginess of the nail

bed and loss of the nail bed angle.

12.HEMOPTYSIS

Expectoration of blood from the respiratory tract is a symptom of

both pulmonary and cardiac disease.

It is important to determine the source of the bleedingthe

gums,nasopharnyx,lungs or stomach

S O


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HISTORY

13.CYANOSIS- A bluish coloring of the skin is a very late indication of hypoxia

The presence or absence of cyanosis is determined by the amount

of unoxygenated hemoglobin in the blood .

Cynosis appears when there is at least 5g/dl of unoxygenated

hemoglobin

Assessment of cynosis is affected by room lighting ,the patients

skin color

Central cyanosis is assessed by observing the color of the tongue

and lips.This indicates a decrease in oxygen tension in the blood.


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Peripheral cyanosis results from decreased blood flow to a certainarea of the body,as in vasoconstriction of the nail beds or earlobes

from exposure to cold, and does not indicate a central systemic

problem

PHYSICAL ASSESSMENT OF THE UPPER

RESPIRATORY TRACT STRUCTURES

1.NOSE AND SINUSES

The nurse inspects the external nose for lesions,asymetry orinflammation and then ask the patient to tilt the head backward

PHYSICAL ASSESSMENT


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PHYSICAL ASSESSMENT

Gently pushing the tip of the nose upward ,the nurse examinesthe internal structures of the nose,inspecting the mucosa for

color,swelling,exudate or bleeding

The nasal mucosa is normally redder than the oral mucosa.It may

appear swollen and hyperemic if the patient has a commoncold,but in allergic rhinitis the mucosa appears pale and swollen.

The nurse inspects the septum for deviation,perforation or

bleeding

The nurse may palpate the the frontal and maxillary sinuses fortendreness

The frontal or maxillary sinuses is inspected by translumination

PHYSICAL ASSESSMENT


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PHYSICAL ASSESSMENT

If the light fails to penetraate ,the cavity likely to contain fluid orpus

2.PHARYNX AND MOUTH

After nasal inspection ,the nurse assess the mouth and pharynx,

instructing the patient to open the mouth wide and take a deep

breath .

Allows a full view of the anterior and posterior pillars

,tonsils,uvula and posterior pharynx

The nurse inspects these structures for color,symmetry and

evidence of exudate ,ulceration or enlargement


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PHYSICAL ASSESSMENT


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PHYSICAL ASSESSMENT

3.Trachea The position and mobility of trachea are noted by direct palpation

This performed by placing the thumb and index finger of one

hand on either side of trachea just above the sternal notch

The trachea is highly sensitive and palpating too firmly may

trigger a coughing or gagging response

Pleural or pulmonary disorders, such as pneumothorax,may also

displace the trachea

PHYSICAL ASSESSMENT OF THE LOWER

RESPIRATORY STRUCTURES AND BREATHING

PHYSICAL ASSESSMENT


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PHYSICAL ASSESSMENT

1.THORAX Inspection of the thorax provides information about the

musculoskeletal structure ,the patients nutritional status and the

respiratory system

Observe the skin over the thorax for color and turgor and forevidemce of subcutaneous tissue

CHEST CONFIGURATION

Normally the ratio of the anteriorposterior diameter to the lateral

diameter is 1..2There are four main deformities of the chestassociated with respiratory disease that alter this relationship-

1.Barrel chest-

PHYSICAL ASSESSMENT


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PHYSICAL ASSESSMENT

Occuras as a result of overinflation of the lungs.There is anincrease in the anteriorposterior diameter of the thorax.

2.Funnel chest(Pectus excavatum)

Occurs when there is depression in the lower portion of thesternum.This may compress the heart and great vessels,resulting

in murmurs

It may also occurs as a result with rickets os Marfan syndrome

3.Pigeon chest(Pectus Carinatum)-

It occurs as a result of displacement of the sternum.

PHYSICAL ASSESSMENT


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PHYSICAL ASSESSMENT

There is an increaes in the anterior posterior d iameter

BREATHING PATEERNS AND RESPITATORY RATES

The normal adult who is resyting comfortably takes 12 to 18

braeths per minute(Eupnea)

BRADYPNEA OR SLOW BREATHING

TACHYPNOEA OR RAPID BREATHING

HYPERPNEA OR INCREASE IN THE DEPTH OF

RESPIRATIONS

APNEA OR CESSATION OF BREATHING


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Cheyen Stokes:


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Cheyen-Stokes:

Bi t' B thi ("Cl t " b thi )


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Biot's Breathing ("Cluster" breathing)

Kussmaul's Breathing


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Kussmaul's Breathing

Ataxic Breathing:


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Ataxic Breathing:

PHYSICAL ASSESSMENT


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PHYSICAL ASSESSMENT

KUSSMAUL;S RESPIRATION OR INCREEASE IN RATE ORDEPTH OF RESPIRATIONS

CHEYNE STOKES RESPIRATION(Alternating episodes of

apnoea and periods of deep breathing

BIOTS RESPIRATION OR CLUSTER BREATHING are cyclesof breath that vary in depth and having periods of apnoea

THORACIC PALPATION

For tenderness,massess,lesions,respiratory excursion and vocalfermitus

RESPIRATORY EXCURSION

PHYSICAL ASSESSMENT


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PHYSICAL ASSESSMENT

It is an estimation of thoracic expansion and may dislodgesignificant information about thoracic movement during

breathing

The patient is instructed to inhale deeply while the movement of

the nurses thumbs during inspiration and expiration is observed This movement is normally symmetric

Decreased chestexcursion may be caused by chronic fibrotic

disease

Asymmetric excursion may be due to fracturedribs,trauma,unilateral bronchial obstruction



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PHYSICAL ASSESSMENT


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PHYSICAL ASSESSMENT

TACTILE FERMITUS-The detection of the resulting vibrationon the chest wall by touch

The vibrations are detected with the palmer surfaces of the

fingers and hands or the ulner aspect of the extented hands on the

thorax

Air does not conduct sound well,but a solid substance such as

tissue doe, provied that it has elasticity and is not compressed

A patient with consolidation of a lobe of lung from pneumonia

has increased tactile fermitus.

TACTILE FERMITUS


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TACTILE FERMITUS

PHYSICAL ASSESSMENT


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PHYSICAL ASSESSMENT

THORACIC PERCUSSION It is used to estimate the size and location of certain structures

within the thorax

Percussion sounds

Flaatness-Large pleural effusion

Dulness-Lobar pneumonuia

Resonance-Simple chronic bronchitis

Hyperesonance-Emphysema

BREATH SOUNDS

THORACIC PERCUSSION


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THORACIC PERCUSSION

PHYSICAL ASSESSMENT


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PHYSICAL ASSESSMENT

CRACKLES- 1Crackles in general-Soft,high-pitched ,discontinous

popping sounds that occur during inspiration

Coarse crackles-Discontinous popping sounds heardin early inspiration;harsh,moist sound orginated inthe large bronchi

Fine crackles-Discontinous popping sounds heard in

late inspiration,orginates in the alveoli

WHEEZING

PHYSICAL ASSESSMENT


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PHYSICAL ASSESSMENT

SONOROUS WHEEZES Deep low pitched rumbling sounds heard primarily

during expiration,caused by air moving throughnarrowed tracheobronchial passages

Sibilant wheezes

Continuous ,musical,high pitched ,whistle like

sounds heard during inspiration and expiration

PLEURAL FRICTION RUB

PHYSICAL ASSESSMENT


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PHYSICAL ASSESSMENT

Harsh ,crackling sound like two pieces of leatherrubbed together

TERM USED SYMBOL DESCRIPTION REMARKS

FORCED VITAL FVC Vital capacity FVC is often


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CAPACITYp y

performed with amaximum forcedexpiratory effort

reduced in COPDbecoz of airtrapping

FORCEDEXPIRATORYVOLUME

FEV1 Volume of airexhaled in thespecified timeduring theperformance ofFVC

A valuable cue toof the expiratoryairway obstructionthe severity

Ratio of timedforced expiratory

volume to forcedvital capacity

FEV/FVC It is expressedpercentage of

forced vitalcapacity

Presence of airwayobstruction

FORCEDEXPIRATORYFLOW

FEF200-1200 Mean forceexpiratory flowb/w 200-1200 ml

of FVC

Large airwayobstruction

Oxyhemoglobin dissociation curve


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It shows the relationship between the partial pressure of oxygenand the percentage of saturation of oxygen

The percentage of oxygen can be affected by the following

factors-carbondioxide,hydrogen ion concentration,temperature

and 2,3diphosphoglycerate An increase in these factors shifts the curve to the right ,so that

more oxygen is released to the the tissues at the same Pao2

A decrease in thes e factors cause the curve to shift to left,making

the bond between oxygen and hemoglobin stronger.The unusualshape of the curve is a distinct advantage to the patient for two

reasons



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If the Pao2 decraese from 100 to 80 mm Hg as aresult of lung or heart disaese,the hemoglobin of thearterial blood remains almost maximally saturated(94%), and the tissues do not suffer from hypoxia

When the arterial blood passess into tissuecapillaries and is exposed to the tissue tension ofoxygen of oxygen9about 40 mm Hg )hemoglobingives up large quantities of oxygen for use by thetissues.


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ALLEN TEST


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ALLEN TEST

The blood supply to hand normally comes from 2 arteries, theradial artery and the ulnar artery. Before drawing blood for an

arterial blood gas test, physician will make sure that both arteries

are open and working correctly. A procedure called the Allen test

may be used to find out if the blood flow to your hand is normal.

For the Allen test, the health professional drawing the blood will

apply pressure to the arteries in the wrist for several seconds. This

will stop the blood flow to your hand, and your hand will become

cool and pale. Blood is then allowed to flow through the


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artery that will not be used to collect the blood sample. This isusually the ulnar artery, which is found on the outer (little finger

side) of your wrist. Arterial blood gases are usually taken from

the radial artery, which is found on the inner (thumb side) of the

wrist.

Allen testNormal (positive) hand quickly becomes warm and

returns to its normal color. This means that one artery alone will

be enough to supply blood to the hand and finger.

Abnormal (negative)the hand remains pale and cold. This means

that one artery is not enough to supply blood to your hand and

fingers. Blood will not be collected from an artery in this hand.

DIAGNOSTIC TESTS


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DIAGNOSTIC TESTS

of breathing,diffusion and gas exchange PFTS are performed bytechnician using a spirometer that has a volume collectin device

attached to a recorder that demonstrates volume and time

simultaneously.

A number of tests are carried out , because no singlemeasurement provides a complete picture of pulmonary

function.The most frequently used PFTs are Forced vital capacity.

,FEV 1,FEVI/FVC%,MW

B] ABG(Arterial Blood Gas Analysis) -

Meaurement of blood pH and of arterial oxygen and

DIAGNOSTIC TESTS


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DIAGNOSTIC TESTS

carbondioxide tensions are obtained whenmanaging patients with respiratory problems andadjusting oxygen therapy as needed.

The arterial oxygen tension (PaO2) indicates thedegree of oxygenation of blood and the arterialcarbondioxide tension (PaCO2) indicates theadequacy of alveolar ventilation

.ABG studies aid in assessing the ability of thelungs to provide adequate oxygen and emovecarbondioxide and the ability of the kidneys to

DIAGNOSTIC TESTS


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DIAGNOSTIC TESTS

reabsorb or excrete bicarbonate ions to maintain normal body PH

C) PULSE OXIMETRY

It is a non invasive method of continuously monitoring

the oxygen saturation of haemoglobin(SaO2)When oxtgen

saturation is measured with pulse oximetry it is referred to

as SpO2A probe or sensor is attached to the finger tipforehead,earlobe, or bridge of the nose

.The sensor detects changes in oxygen saturation levels by

DIAGNOSTIC TESTS


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G OS C S S

monitoring light signals generated by the oximetre and reflectedby blood pulsing through the tissue at th probe

Normal Spo2 values are 95% to 1005 Values less than 85%

indicate that the tissues are not receiving enough oxygen and

further evaluation is needed. d) SPUTUM STUDIES-

Sputum is obtained for analysis to identify pathogenicorganisms and to determine malignancy or hypersensitivity

which in turn helpful ito determine causes of oxygeninsufficiency.

Expectoration is the usual method for collecting a sputum

DIAGNOSTIC TESTS


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specimen.The patient is instructed to clear the nose and throat andrinse the mouth to decrease contamination of the sputum.After

taking a few breaths,the patient coughs(rather than spits),using

the diaphragm and expectorates into a sterile container.

The specimen is delivered to laboratory within 2 hours by the

patient or nurse.Allowing the specimen to stand for several hours

in a warm room results in the overgrowth of contaminant

organisms and may make it difficult to identify the pathogenic

organisms.

D) CHEST X- RAY-

To assess fluids,tumors,foreign bodies and other pathologic

DIAGNOSTIC TESTS


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conditions.Chest rays are usually taken after fullinspiration,because the lungs are best visualized when they are

aerated.

E) Computed tomography

It is an imaging method in which the lungs are scannedinsucessive layers by a narrow beam x-ray.The images produced

provide a cross-sectional view of the chest .

CT may be used to define pulmonary nodules and small tumors

adjacent to peural surfaces that are not visible on routine chest xrays

DIAGNOSTIC TESTS


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It is an imaging method in which the lungs are scanned in

sucessive layers by a narrow beam x-ray.

The images produced provide a cross-sectional view of the chest

CT may be used to define pulmonary nodules and small tumors

adjacent to peural surfaces that are not visible on routine chest xrays

G) BRONCHOSCOPY-

It is the direct inspection and examination of the larynx,

trachea and bronchi through either a fixed fibroopticbronchoscope or a rigid bronchoscope.

The purpose of diagnostic bronchoscopy are;

DIAGNOSTIC TESTS


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To examine tissues or collect secretions To determine the location and extent of the pathologic process

and to obtain a tissue sample for diagnosis.

To determine whether a tumour can be resected surgically

To diagnose bleeding sites(source of hemoptysis)

Therapeutic bronchoscopy is used to

1.Remove foreign bodies from the tracheobronchial tree

2.Remove secretions obstructing the traceobronchial tree

3. Destroy and excise lesions

DIAGNOSTIC TESTS


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. Destroy and excise lesions NURSES ROLE-

Obtain informed written consent

Withheld foods and fluids 6 hr prior to bronchoscopes

Explanation of procedure to the patient and administration of

preoperative medications(e.a atropine) to inhibit vagal

stimulation,suppress cough reflex, sedate the patient and relieve

the anxiety

Dentures must be removed

Instruct the patient to take nothing by mouth till the cough

reflexes returns after the procedure.

DIAGNOSTIC TESTS


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Assess the confusion and lethargy in patient because of ananaesthesia

Instruct the family and caregivers to report any shortness of

breath or bleeding immediately.

I) THORACENTESIS-

A sample of pleural fluid is obtained by thoracentesis forboth diagnostic and therapeutic purposes.It may be used

for 1.Removal of fluid and air from the pleural caviy

2. Aspiration of pleural fluid for analysis

THORACENTESIS-


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DIAGNOSTIC TESTS


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3. Pleural biopsy 4. Instillation of medication into the pleural space.

NURSES ROLE

Assess the patient for allergy to local anesthetics

Position the patient comfortably with adequate supports

Support and ressure the patient during procedure

Encourage the patient to refrain from coughing.

Record the total amount of fluid obtained during thoracentesis

and sends it to laboratory for evaluation.Also record nature of

fluid,color and its viscosity.

DIAGNOSTIC TESTS


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Monitor respiratory status of patient afterwards. Hematocrit and hemoglobin are also measured in order to assess

effectiveness of bodys oxygen delivery to the tissues.

G) PULMONARY ANGIOGRAPHY- It is most common used to investigate thromboembolic

disease of the lungs, such as pulmonary emboli andabnormalities of vascular tree.It involves rapid injection of

a radioopaque agent into the vasculature of the lungs forradiographic study of the pulmonary vessels

NURSING MANAGEMENT OF CLIENTS WITH

OXYGEN INSUFFICIENCY


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OXYGEN INSUFFICIENCY

History, physical assessment and results of diagnosticexamination. Prioritize the problem on the basis of :

A-airway

B-breathing

C- circulation

FOLLOWING ARE THE POSSIBLE NURSING DIAGNOSIS

1 Ineffective airway clearance may be related to

Retained secretions

Airway spasm

NURSING MANAGEMENT OF CLIENTS WITHOXYGEN INSUFFICIENCY


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Presence of artificial airway

MANIFESTED BY-

Feeling of shortness of breath

Use of accessory muscles

Difficulty in speaking

Cyanosis

NURSING INTERVENTIONS

1 Assess the respiratory pattern of the patient

2.Elevate head of the bed /change position every 2 hours

NURSING MANAGEMENT OF CLIENTS WITH OXYGEN

INSUFFICIENCY


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3.Insert oral airway as appropriate to maintain anatomic position

of tongue and natural airway

3. Assist with procedures (e.g bronchoscopy) to maintain clear

airway.

4.Encourage deep breathing and coughing exercises

4.Monitor hydration status of client as it will help in thining of

pulmonary secretions

5. Administer medications e.gMucolytic/Expectorant(Mucomyst)

,Methylxanthine(Aminophylline),Beta-adrenergic

sympathomimetic(albuterol,Terbutaline),Mast cellinhibitor(Cromolin sodium),


INSUFFICIENCY


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Corticosteroid(Betamethasone,Prednisone).

6. Oberve for signs of respiratory distress

7. Evaluate changes in sleep pattern

8.N ote color and amount of sputum

9.Monitor serial chest x-rays /ABG/Pulse oximetry

2.Ineffective breathing patternrelated to-

Restrictive pulmonary disease

Neuromuscular disease that can weaken respiratory musclese.e.g

myasthenia gravis


INSUFFICIENCY


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GOAL- TO PROMOTE LUNG EXPANSION

Nursing Interventions-

1.Auscultate chest,noting presence/character of breath

sounds,presence of secretions

2. Monitor rate and depth of respirations 3.Administre oxygen indicated for underlying pulmonary

condition,respiratory distress

4.Suction airway as needed to clear secretions

5. Proper postioning like fowler position by supporting the clientwith elevation of the head of the bed.

6.Encourage deep breathing exercises to the patient


INSUFFICIENCY


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7. Assist client in the use of relaxation techniques

Impaired gas exchangerelated to

Ventilation perfusion mismatch,

overall decrease in the amount of alveolar capillary surface areaavailable for gas exchange in case of emphysema

Manifested by altered findings on ABG or pulse oximetry

GOAL-Maintain and promote tissue oxygenation

Nursing Interventions-

Note respiratory rate ,depth,use of accesory muscles for braething


INSUFFICIENCY


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Auscultate breath sounds Monitor vital signs

Evaluate pulse oximetry to determine oxygenation

Elevate head of bed Encourage frequent position changes

and deep braething and coughing exercises Provide supplement oxygen at lowest concentration

Encourage adequate rest and limit activities to within clienttolerance

Administer medications as indicated


INSUFFICIENCY


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4. Decreased Cardiac output related to

Congestive heart failure causing pulmonary edema,heart failure

or shock

Manifested by

Low BP,cool clammy skin, weah threay pulse,low urie output anda diminishing level of consciousness,crackles in case of of

pulmonary edema,pink frothy sputum

Nursing interventions 1 Monitor the vital signs of the patient

2.Maintain intake and outout of the patient


INSUFFICIENCY


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3.Monitor the weight of the patient 4.Limited sodium and reduced fluid intake in case of congestive

heart failure.

5. Restrict the activity of the patient and assist the patient with

activities of daily living in order to decrease oxygen demand onbody.

6.Proper positiong preferably sitting or semi-sitting in order to

decrease fluid load to heart and pulmonary edema.

7. Administer medications to improve cardiac output includingcardiac glycosides and other inotropic agents.


INSUFFICIENCY


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5.Activity intolerance related to dyspnoea and hypoxiamanifested by fatigue

GOAL- To improve the activity of the patient of the patient

Nursing Interventions 1.Assess the level of activity performed by patient

2.Assist the patient in daily activities

3.monitor the vital signs before and arter activity

4.Monitor the severity of dyspnoea and oxygen saturation

5.Maintain supplemental oxygen therapy as needed


INSUFFICIENCY


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6.Advise the client to avoid conditions that increase oxygendemand such as stress,smoking

7.Instruct the client energy conversation techniques e.g adequate

rest period.

FLUID AND ELECTROLYTE IMBALANCE


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INTRODUCTION Fluid and electrolyte balance within the body are necessary to

maintain health and function in all body systems.

These balances are maintain by the intake and output of water

and electrolytes and regulation by the renal and pulmonarysystems.

Body fluids are regulated by fluid intake ,hormonal control and

fluid output .This physiological balance is termed homeostasis.



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Amount and composition of body fluids Approximately 60% of weight of a typical adult consists of

fluid(water and electrolytes).Factors that influence the amount of

body fluid are age,gender and body fat,.

1.Age-younger peope have a higher percentage of bogy fluid thanolder people

2.Gender-Men have proportionate more body fluid than women.

3.Body fat-People who are obese have less fluid than those are

thin,because fat cells contain little water



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Body fluid is located in two fluid compartments;theintracellular(fluid in the cells) and the extracellular space(fluid

outside the cells).

Approximately two thirds of body fluid is in the intracellular

fluid(ICF)compartment The ECF compartment is further divided into the

intravascular,interstitial and transcellular fluid spaces.

The intravascular space(the fluid within the blood

vessels)contains plasma . Approximately 3L of the average 6L of blood volume is made up

Of plasma


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The remaining 3L is made up of erythrocytes,leukocytes andthrombocytes.

The interstial space contains the fluid that sorrounds the cell and

totals about 11 to 12 L in an adult.

Lymph is an interstitial fluid .The transcellular space is thesmallest division of the ECF compartment and contains

approximately 1L.Examples of transcellular fluids are

cerebrospinal,pericardial,synovial,intraocular and pleural

fluids;sweat and digestive secretions.

Loss of ECF into a space that does not contribute to equilibrium

between the ICF and the ECF is referred to as a thirdspace fluid

shift,or third-spacing for short.



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Early evidence of a third space fluid shift is a decrease in urineoutput despite adequate fluid intake

.Urine output decreases because fluid shifts out of the

intravascular space;the kidneys then receive less blood and

attempt to compensate by decreasing urine output .Other sign and symptoms of third spacing that indicate an

intravascular fluid volume deficit include increased heart

rate,decreased blood pressure,decreased central venous

pressure,edema,increased body weight and imbalances influid intake and output

Third space shifts occurs in ascites,burns,peritonitis ,bowelobstruction and massive bleeding into a joint or body



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cavity. ELECTROLYTES

Electrolytes in body fluids are active chemicals?(cations that

carry positive charges and anions that carry negative charges).The

major cations in body fluid aresodium,potassium,calcium,magnesium and hydrogen ions.The

major anions are chloride,bicarbonate,phosphate,sulphate .

REGULATION OF BODY FLUID COMPARTMENTS 1.OSMOSIS AND OSMOLALITY



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When two different solutions are separated by a membrane thatis impermeable to the dissolved substances,fluid shifts through

the membrane from the region of low solute concentration to the

region of high concentration until the solutions are of equal

importance.

This diffusion of water caused by a fluid concentration gradient is

known as osmosis

2.DIFFUSION Diffusion is the central tendancy of a substance to move

from an area of higher concentration to one of



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Lower concentration.It occurs through the random movement ofions and molecules.examples of diffusion are the exchange of

oxygen and carbon dioxide between the pulmonary capillaries

and alveoli.

3.FILTRATION

Hydrostatic pressure in the capillaries tends to filter fluidout of the intravascular compartment into the interstitial

fluid.Movementof water and solutes occurs from an area ofhigh hydrostatic pressure to an area of low hydrostaticpressure.Filtration allows the kidneys to filter 180L of



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plasma per day

4.Sodium-Potassium pump

The sodium concentration is greater in the ECF than in theICF and because ofthis,sodium tends to enter the cell bydiffusion.

This tendancy is offset by the sodium-potassium

pump,which is located in the cell membrane and activelymoves sodium from the cell into the ECF.

.Active transport implies tha t energy must be expended for



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the movement to occur against a concentration gradient.

ROUTES OF GAINS AND LOSSESS

Water and electrolytes are gained in various ways.Ahealty

person gains fluids by drinking and eating.Fluids may beprovided by the parenteral route(intravenously andsubcutaneously)or by means of an enteral feeding tube inthe stomach or intestine.

1.KIDNEYS The usual daily urine volume in the adult is 1 to 2L.A

general rule is that the output is approximately 1 ml of



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urine per kilogram of body weight pr hpur(1ml/kg/h) in allage groups.

2.SKIN

Sensible perception refers to water and electrolytes lossthrough skin(sweating).

The chief solutes in sweat are sodium,chloride andpotassium.

Actual sweat loss can vary from 0 to 1000ml or more everyhour,depending on the environmentaltemperature.Continous water loss by evaporation (



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approximately 600 ml/day). Occurs through the skin.Fevergreatly increases insensible water loss through the lungsand the skin ,as does loss of the natural skinbarrier(e.G,through major burns)

.LUNGS

The lungs normally eliminate waer vapour(insensible loss)ata arate of approximately 400 ml eyery day.The loss ismuch greater with increased respiratory rate or depth, or ina dry climate



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HOMEOSTATIC MECHANISMS The body is equipped with remarkable homeostatic

mechanisms to keep the composition and volume of bodywithin narrow limits of normal.Organs involved inhomeostasis include the kidneys,lungs,heart,adrenalglands,parathyroid glands and pituitary gland

1.KIDNEY FUNCTIONS

Vital to the regulation of fluid and electrolytebalance,the kidney normals filters 170L of plasmaevery day in the adult,while excreting only 1.5 L of



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urine. They act both autonomously and in response to bloodborne

messengers,such as aldosterone and antidiuretic hormone

Renal failure results in multiple fluid and electrolyte

abnormalities.

2.HEART AND BLOOD VESSEL FUNCTIONS

The pumping action of the heart circulates bloo through thekidneys under sufficient pressure to allow for urineformation.Failure of this pumping action interferes with



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renal perfusion and thus wuth water and electrolyteregulation

3.LUNG FUNCITONS

The lungs also vital in maintaining homeostasis.Throughexhalation, the lungs remove approximately 300 ml ofwater daily in the normal adultAbnormal conditions suchas hyperpnea(abnormally deep respirations) or continouscoughing,increase this loss;mechanical ventilation withexcessive moisture decrease sit.



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4.PITUITARY FUNCTIONS The hypothalamus manufactures ADH,which is stored in

the posterior pituitary gland and released as needed.

ADH is sometimes called the water conserving hormone

because it causes the body to retain water. Functions of ADH include maintaining the osmotic

pressure of the cells by controlling the retention orexcretion of water by the kidneys and by regulating bloodvolume

. ADRENAL FUNCTIONS



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Aldosterone, a mineralocorticoid secreted by the zonaglomerulosa(outer zone) of the adrenal cortex,has aprofound effect on fluid balance..

Increased secretion of aldostrerone causes sodiumretention and potassium loss.Decreased secretion ofaldosterone causes sodium and water loss and potassiumretention.

6.PARATHYROID FUNCTIONS

The parathyroid glands.embedded in the thyroid gland,regulate calcium and phosphate balance by means of



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parathyroid hormone(PTH).PTH influences boneresorption,calcium absorption from the intestines and calcium

resorption from the renal tubules.

OTHER MECHANISMS BARORECEPTORS

The baroreceptors are small nerve receptors that directchanges in pressure within blood vessels and transmit this

information to the central nervous system. They are responsible for monitoring circulatory volume,

and they regulate the sympathetic and parasympathetic



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neural activity .. They are categorized as either low-pressure or

high-pressure baroreceptors.

Low-pressure baroreceptors are in the cardiacatria,particularly the left atrium.

High-pressure baroreceptors are nerve endings inthe aortic arch and carotid sinus,as arterial

pressure decreases ,baroreceptors transmit fewerimpulses from the carotid sinus and the aortic archto the vasomotor center.



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A decrease in impulses stimulate the sympathetic nervous systemand inhibits the parasympathetic nervous .The outcome is an

increase in cardiac rate ,conduction and contractibility and an

increased circulatory volume.

RENIN-ANGIOTENSIN ALDOSTERONE SYSTEM

Renin is an enzyme that converts angiotensinogen,an inactivate

substance formed by the liver ,into angiotensin 1.Renin is

released by the juxtaglomerular cells of the kidney in response to

decreased renal perfusion .Angiotensin converting enzyme

converts angiotensin 1 to angiotensin 11.Angiotensin 11,with



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its vasoconstrictive properties, increases arterial perfusionpressure and stimulates thirst.

ANTIDIURETIC HORMONE AND THIRST

ADH and the thirst mechanism have important roles inmaintaining sodium concentration and oral intake of fluids.

Oral intake is controlled by the thirst center located in thehypothalamus.

As serumconcentration or osmolality increases or bloodvolume decreases ,neurons in the hypothalamus arestimulated by intracellular dehydration;thirst then occurs



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and the person increases his or her intake of fluids.Waterexcretion is controlled by ADH,aldosterone and baroceptors

RELEASE OF ATRIAL NATRIURETIC PEPTIDE-

ANP ,also called atrial natriuretic factor, is a 28 aminoacidpeptide that is synthesized, stored and released by musclecells of the atria of the heart in response to severalfactors.These factors include increased arterialpressure,angiotensin 11 stimulation and sympatheticstimulation



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LABORATORY VALUES USED IN EVALUATING FLUIDAND ELETROLYTE STATUS

1 Serum sodium 135-145mEq/L

2.Serum potassium 3.5-5.0mEq/L

3.Total serum calcium 8.6-10.2mg/dl 4.Ionized calcium 4.5-5.0mg/dl

5.Serum magnesium 1.3-2.5mEq/L

6.Serum phosphorous 2.5 -4.5mg/dl

7.Serum osmolality 275-300mOsm/kg

8.BUN 10 -20mg/dl



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9.Serum creatinine 0.7-1.4mg/dl 10.Hematocrit Males 42-52%, Females -35-47%

11.Serum glucose 60-110mg/dl

12.Serum albumin 3.5-5.0g/dl

13. Urine specific gravity 1.003-1.030

14.Urinary pH


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1 FLUID VOLUME DEFICIT(Hypovolemia) Decrease in intravascular and interstitial fluids.

CONTRIBUTING FACTORS

1.Loss of water and electrolytes, as in

vomiting,diarrhea,fistulas,fever,excess sweating,burns,blood loss,gastrointestinal suction, and third space fluid shifts

2. Decreased intake as in anorexia, nausea and inability to gain

acess to fluid.

3. Diabetes insipidus and uncontrolled diabetes mellitusalso contribute to a depletion of extracellular fluid volume



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SIGN AND SYMPTOMS 1.Acute weight loss

2.Decreased skin turgor

3.Oliguria,concentrated urine

4.Weak rapid pulse.prolonged capillary refill time 5.Low CVP,decreased BP,flattened neck veins,tacycardia

6.Dizziness,weakness,thirst and confusion

7. Muscle cramps

8. Sunken eyes



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LAB indications 1.Increased haemoglobin and hematocrit

2. Increased serum and urine osmolality and specific gravity

3.Increased BUN and creatine level

4. Increased urine specific gravity and osmolality

MEDICAL MANAGEMENT-

Pharmacologic Management

1.Isotonic electrolyte solutions(e.g lactated ringerssolution,o.9% sodium chloride) are frequently used to treathypotensive patient because they expand plasma volume.



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2. As soon as the patient becomes normotensive, ahypotonic electrolyte solution (e.g 0.45% sodiumchloride) is often used .

3. Accurate and frequent assessment of intake and

output, weight,vital signs,CVP,level ofconsciousness,breath sounds and skin color shouldbe performed

NURSING DIAGNOSIS


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Nursing diagnosis Fluid volume deficit related to insufficient fluid

intake,vomiting,diarrhea, haemorrhageNURSINGINTERVENTIONS

1.Check the weight of the patient 2.Monitor intake and output of the patient

3.Administer IV fluids to the patient

4.Administer medications e.g antiemetics to prevent the

patient from vomiting 5.Assist the patient to protect from any kind of injury



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2.EXTRA CELLULAR FLUID VOLUME EXCESS-(HYPERVOLEMIA)

Increased fluid retention in the intravascular & interstial spaces.

CONTRIBUTING FACTORS

1.Compromised regulatory mechanisms such as renalfailure,heart failure, and cirrhosis

2.Over-zealous administration of sodium containing fluids and

fluid shifts(burns)

3.Prolonged corticosteroid therapy,severe stress, andhyperaldosterism augment fluid volume excess



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SIGN AND YMPTOMS 1.Acute weight gain

2.Peripheral edema and ascites

3.Distented juglar veins

4..Crackles 5.ELevated CVP,Shortness of breath

6.Incresed BP,Bounding pulse and cough

7.Increased respiratory rate

LABORATORY FINDINGS

1.Decreased Hb and hematocrit



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2.adaecreased serum and urine osmolality 3.Decreased serum sodium and specific gravity

MEDICAL MANAGEMENT

Pharmacological management 1.Diuretics are prescribed when dietary restriction of

sodium alone is insufficient to reduce edema by inhibitingthe reabsorption of sodium and water by the kidneys.Loop

diuretics such as furosemide(Lasix),torsemide, cancausea greater loss of both sodium and water because theycan block sodium resorption in the ascending limb of the



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loop of henle.Thiazide diuretics such ashydrochlorthiazide or metalazone, are prescribedfor mild to moderate hypervolemia and loopdiuretics for severe hypervolemia

Electrolyte imbalances may result from the effectof the diuretic.Hypokalemia can occur with all thediuretics except potassium sparingdiuretics(sprinolactone) .Potassium supplementscan be prescribed to avoid thiscomplication.Decreased magnesium levels occur



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with administration of loop and thiazide diuretics due todecreased resorption and increased excretion ofmagnesium by the kidney

2.Hemodialysis Azotemia can occur with FVE when urea and creatinine are

not excreted due to decreased perfusion by the kidneys anddecreased excretion of wastes.High uric acidlevels(hyperuricemia) can also occur from increasedresorption and decreased excretion of uric acid by thekidneys.



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Hemodialysis or peritoneal dialysis may be used toremove nitrogenous waste and control potassiumand acid-base balance, and to remove sodium andfluid

NUTRITIONAL THERAPY

A low sodium diet is prescribed in order to reduce

fluid retention.

NURSING MANAGEMENT



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Clients vital signs should be assessed every 1 -8 hrs. IV fluid replacement should be monitored . If fluids

are administered too rapidly, hypervolaemia(fluidoverload ) may occur .

Frequent checks for chest crackles ,difficult inbreathing 7 neck vein engorgement are essential toprevent pulmonary edema with fluid volume excess.

The abdominal girth of client with ascites should bemeasured every 8 hrs.

If the extremities are involved , the circumference of



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the extremities and the peripheral pulses should bemeasured every hour.

Level of consciousness should be monitored

Prevent the breakdown of the skin.

Monitored the urine output of the patient

NURSING DIAGNOSIS

Fluid volume excess related to compromisedregulatory mechanisms of kidneys.

NURSING DIAGNOSIS


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Nursing Interventions 1.Check the weight of the patient

2.Monitor intake output of the patient

3.Restrict the fluid intake of the patient

4.Administer diuretics to the patient

5.Instruct the patient to take low sodium



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3. HYPONATREMIA

Is a serum sodium level below 135mqL

ETIOLOGY

Renal disease resulting in salt wasting

Adrenal insufficiency

GI loss(Diarrhea)

Incresed sweating

Diuretics

Burns Liver cirrhosis

SIADH



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Vomiting

SYMPTOMS

1.Anorexia

2.Nausea

3. Vomiting

4.Convulsions

5.Fatigue

6. Headache



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7.Irritability 8.Muscle Cramps

9.Muscle weakness

10.Restlessness

11.Dry skin

12.Incraesed pulse

13.Decraesed BP

14.Weight gain

15.Edema



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LABORATORY FINDINGS 1.Decreased serum and urine sodium

2.Decreased urine specific gravity and osmolality

MEDICAL MANAGEMENT 1.SODIUM REPLACEMENT-The obvious traeatment for

hyponatremia is careful administration of sodium bymouth,nasogastric tube or a parenteral route.For patients

who cannot consume sodium,lactated Ringers solutionor isotonic saline(0.9%



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sodium chloride)solution may be prescribed 2.WATER RSTRICTION-Hyponatremia is treated by

restricting fluid to a otal of 800 ml

4. HYPERNATREMIA Serum sodium level over 145meq/L

ETIOLOGY

1.Diabetes inspidus

2.Heat stroke 3.Hyperventilation



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4.Watery diarrhea

5. Burns 6.Diaphoresis

7.Excess sodium bicarbonate and sodium chlorideadministration

8.Salt water near drowning

SYMPTOMS

1.Thirst 2.Elevated body temperature

3. Swollen dry tongue and sticky mucous membranes



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4.Hallucinations,lethargy,restlessness,irritability,seizures

5.Pulmonay edema

6.Nausea and vomiting,anorexia,Increased pulse

and deacreased BP



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LABORATORY FINDINGS

1.Increased serum sodium and decreased urine sodium

2.Increased urine specific gravity and osmolality

MEDICAL MANAGEMENT Treatment of hypernatremia consisits of a gradual lowering

of the serum sodium level by the infusion of a hypotonicelectrolyte solution(e.g 0.3% sodium chloride) or an

isotonic solution(Dextrose 5% in water{D5W} Desmopressin acetate(DDAVP),a synthetic antidiuretic

hormone may be prescribed to treat diabetes insipidus if it



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is the cause of hypernatremia

5.HYPOKALEMIA

Serum potassium level less than 3.5meq/L

ETIOLOGY 1.Diarrhoea,vomiting,nasogastric suctioning

2.Corticosteroid administration

3.Hyperaldosteronism

4.OSMOTIC diuretics

5.Alkalosis

6.Starvation,Diuretics and digitalis toxicity



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CLINICAL MANIFESTATIONS

1.Anorexia,vomiting,diarrhea

2. Muscle weakness,paraesthesia,leg cramps

3.Dysrhythmia,vertigo,postural hypotension,flattened T wave.

4.Shallow respiration,shortness of breath 5.Fatigue,lethargy,decreased tendon reflexes,confusion

INVESTIGATIONS

ECG-Flattened T waves, ,Prominent U waves.ST depression



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MEDICAL MANAGEMENT

Determining & correcting the cause of imbalance.

Extreme hypokalemia requires cardiac monitoring

PHARMACOLOGIC MANAGEMENT Oral potassium replacement therapy is usually prescribed for

mild hypokalemia

Potassium is extremely irritating to gastric mucosa,therefore the

drug must be taken with glass of water or during meals. Potassium chloride can be administered intravenously for

moderate to severe hypokalemia & must be diluted in IV



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fluids.

Administration of potassium by IV push may result in cardiac

arrest .Potassium can be given in doses of 10 to 20 meq/hour

diluted in IV fluid if the client is on heart monitor.

High concentration of potassium is irritating to heart muscle.Thus

correcting a potassium deficit may take several days.

DIETARY MANAGEMENT

The administration of foods that are high in potassium help to



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correct the problem as well as prevent further potassium

loss. The adult recommended allowance of potassium is

1875 to 5625mg

.Common food source containing potassium-

Cabbage,Carrot,Cucumber,Spinach,Tomato,Fruits,Bana

na,Guava,Orange



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6)HYPERKALEMIA

Elevated potassium level over 5.0meq/L

ETIOLOGY

1.Retention of Potassium Renal insufficiency, renal

failure, decreased urine output, potassium sparig diuretics. 3 Infection , metabolic acidosis

4.Excessive IV infusions or oral administration ofpotassium


First tachycardia then bradycardia,electro cardiographic



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changes.Peak narrow T waves, wide QRS complex,depressed ST SEGMENT,Widened PR interval

Nausea,diarrhea,hyperactive bowel sounds.

Muscle weakness, muscle cramps, tinglingsensation(Paresthesia)

Oliguria & later anuria

.MEDICAL MANAGEMENT

When serum potassium level is 5.0 to 5.5 meq/l restrictionof dietary potassium intake.

If potassium excess is due to metabolic acidosis , correcting



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the acidosis with sodium bicarbonate promotes potassiumuptake into the cells.

Improve urine output decreases elevated serum potassiumlevel.

When hyperkalemia is severe , immediate actions areneeded to be taken to avoid severe cardiac disturbances.

Intravenous calcium gluconate infusions to decrease theantagonistic effect of potassium excess on the myocardium.

Infusion of insulin and glucose or sodium bicarbonate topromote potassium uptake



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.)HYPOCALCEMIA

Serum calcium below 8.5mg/dl

ETIOLOGY

1.Inadequate dietary calcium intake ,vitamin D defiency 2.Malabsorption of fat in intestine.

3.Metabolic alkalosis( less ionized calcium)

4.Renal failure with hyperphsophatemia, acute

pancreatitis,burns,cushing disease, hypoparathyrodism.

5.ALKALOSIS`



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SIGN AND SYMPTOMS

1.Numbness tingling of fingers,toes

2.Positive Trousseausign and chovesteksigns

3.Hyperactive deep tendon reflexes

4.irritabiliy 5.Impaired clotting time

INVESTIGATIONS

1.ECG- prolonged QT INTERVAL AND LENTHENED ST



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MEDICAL MANAGEMENT

Determining & correcting the cause of hypocalcaemia.

Asymptomatic hypocalcaemia is usually corrected with oral

calcium gluconate, calcium lactate or calcium chloride.

Administer calcium supplements 30 minutes before meals forbetter absorption and with glass of milk because vitamin D is

necessary for absorption of calcium from the intestine.

Intravenous calcium chloride or calcium gluconate (10%)nis

given slowly to avoid hypertension,bradycardia & other

arrhythmias.



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DIETARY MANAGEMENT Chronic or mild hypocalcaemia can be treated in part by

having the client consume a diet high in calcium e.g.

cheese, milk ,spinach

If hypocalcaemia is secondary to parathyroid deficiencythe client must avoid high phosphate foods e.g. milk

products , carbonated beverages



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.)HYPER CALCEMIA

Serum calcium leve l over 1O.5meq mg/dl

ETOLOGY

Metastatic malignancy- lung,breast,ovarian,prosatic,bladder,leumekia.

Hyperparathyroidism

Thiazide diuretic therapy

Prolonged immobilization

Excessive intake of calcium supplements and vitamin D.



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- Anorexia,vomiting,constipation,decreased peristalsis.

- Mild to moderate- Weakness,fatigue,difficulty to conc

Severe hypercalcemic state-extreme lethargy, confusion ,coma

-Dysrhythmias,heart block. Polyuria,kidney stones , renal failure.

Bone pain, fracture

MEDICAL MANAGEMENT

Treatment consists of correcting the underlying cause.

Intravenous normal saline(0.9%Nacl) given rapidly with



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furosemide to prevent fluid overload,promote urinary calcium

excretion.

Calcitonin decreases serum calcium level by inhibiting the effects

of PTH(Parathyroid hormone) on the osteoclasts and increasing

urinary calcium excretion.

Corticosteroid drugs decrease calcium levels by competing with

vitamin D thus resulting in decreased intestinal absorption of

calcium.

If the cause is excessive use of calcium or vitamin D supplements

or calcium containing antacids these agents should be either

avoided or used in reduction dosage.



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A newer form of drug therapy is etidronate disodium.This drug

reduces calcium by reducing normal and abnormal bone

resorption of calcium and secondarily by reducing bone

formation.

.)MAGNESIUM DEFICIT(HYPOMAGNESMIA)

Serum magnesium


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3.Insomnia,mood changes

4.Anrexia,vomiting and increased BP

TREATMENT

Mild magnesium deficiency is treated by diet alone .Principal dietary sources of magnesium, which is a

component of chlorophyll, are gren leafyvegetables,nuts,seeds,legumes,whole grains and sea food.If

necessary magnesium salts can be administered orally in anoxide or gluconate form to replace continous excessivelosses.



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Diabetic ketoacidosis

Chronic laxative use

Diarrhea

Acute MI,heart failure

Certain pharmacologic such as gentamicin,cisplatin andcyclosporine

SIGN AND SYMPTOMS

1.Neuromuscular irritability 2.Positive Trousseau and chovessteks signs


5/24/201

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