3.  Identify normal parameters for common diagnostic tests.  Describe the purpose, significance of results, and nursing interventions related to diagnostic examinations of the respiratory system.  Identify how to interpret ABG lab findings

5.  roentgenogram, chest radiographs  done to diagnose a chest disorder.  -visualizes:  lungs  vertebrae  ribs  heart  clavicles  major thoracic vessels  humeri  scapulae

6.  Pre-exam preparation  Client needs to remove  Articles of clothing  Anything containing metal  Wears a patient gown  Tied (never pinned)

7.  Pictures of small layers of lung tissue  Scanner can rotate at different angles  Non-invasive  Minimal radiation exposure  Painless

8. CT Scan of the Lungs

10.  Also called  Spiral CT Scan  Volume-Averaging CT Scanning  Continuously obtains images  Produces faster and more accurate results  Images the chest and abdomen in just one breath-hold (about 30 seconds)  Contrast imaging can also be done

11.  Patient teaching re: the procedure  Patient prep similar to CXR  Monitor post-contrast injection  s/sx of allergic reaction to the contrast medium  Allay the anxiety of claustrophobia  Answer questions

12. Pulmonary Angiography

13.  Radiographic contrast material injected into the pulmonary arteries  Visualization of the pulmonary vasculature  Detects:  Pulmonary Embolism (clot)  Variety of lesions (tissue damage) in the pulmonary vessels

14.  Let’s say … Pulmonary Embolism is suspected  A lung CT scan will be done first  If lung CT scan is negative  pulmonary embolism is ruled out  However….  If the Lung CT Scan is uncertain  If there are 2 or more other possibilities Definitive diagnosis may involve a pulmonary angiography

15.  Studies  Air Flow (ventilation)  Blood Flow (perfusion)  Purpose is to look for blood clots (pulmonary emboli) in the lungs  V/Q used in mathematical equations that calculate airflow and blood flow

16.  Performed in the radiology department  2-step procedure  Multiple pictures of the chest are taken from different angles  Special camera that detects a radionuclide  For half of these pictures  Patient breathes from a tube that has a mixture of air, oxygen, and a slightly radioactive version of a gas called xenon  Measures airflow in different parts of the lung  For the other half of the pictures  Camera tracks an injected radionuclide  Determines blood flow in different parts of the lung  Embolus is suspected in areas of the lung that have good airflow but poor blood flow.  Except for the minor discomfort of having the IV placed, the test is painless. It usually takes less than one hour.

18.  Assesses the presence and severity of disease in large and small airways  Composed of various procedures  Lung Volume Tests  Ventilation Tests (Volumes at rest breathing)  Pulmonary Spirometry (measures how fast and how much air you breath out)

19.  http://www.youtube.com/watch?v=1rjN2_h DXEY http://www.youtube.com/watch?v=1rjN2_h DXEY

20. Lung Volumes  Vital Capacity  Volume of air  Maximum inhalation slowly exhaled  Inspiratory Capacity  Largest amount of air  Inhaled in one breath from the resting expiratory level (approx 3500ml)  Total Lung Capacity  Volume of air in the lung after maximum inhalation (approx 5800ml)  Video explanation with chart Video explanation with chart

21.  Ventilation  Measures the amount of air inhaled and exhaled in each respiratory cycle (at rest breathing = tidal volume).  Pulmonary Spirometry  Evaluates the amount of air that can be forcefully exhaled after maximum inhalation [big breath in and out (blow out for 6 seconds)]  AKA Vital Capacity (which can include peakflow FEV1).

22.  Bronchoscope  Flexible tube with a camera

23.  Bronchoscope is passed through the nose, larynx, trachea, and bronchi  Local or general anesthetic may be given  Observation of the respiratory structures  Tissue samples may be obtained  Secretions can be suctioned for sampling

24. http://www.youtube.com/watch?v=KqZc1JqArco

25. Pre-Procedure  Explain Procedure  Answer Questions  Allay AnxietyPre-Procedure  Explain Procedure  Answer Questions  Allay AnxietyPost-Procedure  NPO until gag reflex returns (about 2 hours)  Semi-Fowler’s position  Turn side to side  Eases removal of secretions  Monitor for laryngeal edema and laryngospasms  Monitor sputum  S/Sx hemorrhage  Blood streaked sputum is expected to last for a few days after biopsyPost-Procedure  NPO until gag reflex returns (about 2 hours)  Semi-Fowler’s position  Turn side to side  Eases removal of secretions  Monitor for laryngeal edema and laryngospasms  Monitor sputum  S/Sx hemorrhage  Blood streaked sputum is expected to last for a few days after biopsy

27. Sputum Culture  Sputum specimen collected - obtained for microscopic studies - culture and sensitivity

28. Cytology  Cell studies - tests for the presence of abnormal or malignant cells - Any body secretions - pleural fluid - abdominal fluid - pericardial fluid, etc. Melanoma

29. Lung Biopsy  Open lung biopsy  Transbronchial  Done through a bronchoscope  Cells and/or secretions obtained for testing  Done when pulmonary disease cannot be diagnosed by other means  Nursing Interventions  Same as for bronchoscopy

30. Thoracentesis  Surgical Perforation  Into the pleural space  Excess pleural fluid removed  Sample obtained for diagnostic testing  Instillation of medication into the pleural space

31.  Diagnostic tests on pleural fluid - Specific gravity - RBCs - WBCs - protein - glucose - culture and sensitivity - abnormal or malignant cells - biopsy of the pleura.  Thoracentesis video Thoracentesis video

32. Nursing Interventions  During procedure:  Monitor vital signs  Monitor respiratory status  Monitor general appearance  After procedure:  Position patient comfortably on the unaffected side  Continue to monitor patient respiratory status and vital signs

33. Pulse Oximetry

34. Pulse Oximetry (SpO2)  Continuous peripheral monitoring of the pulse and saturation of oxygen in the blood  Assessment of gas exchange  Noninvasive method  Normal Range = 95-100%  Probe is applied to a finger, e arlobe, toe, or the bridge of the nose.

35. Pulse Oximetry (SpO2)  Monitor displays the hemoglobin- oxygen saturation and pulse rates  Allows the nurse to see continuous changes in the pt.’s oxygen saturations  Interventions can happen immediately.

36. Pulse Oximetry - Precautions  For Best Results  Do Not:  Place the probe on an extremity that has an injury, B/P cuff, IV, or arterial line in place  Do:  Place the probe over a pulsating vascular blood bed  Protect the probe from strong light  Remove nail polish  May affect the reading  Avoid excess patient movement Note: Hypothermia, hypotension, and vasoconstriction can affect readings

37. Pulse Oximetry - Considerations  SpO2 < 85% (normal 95-100%)  Weakened ability of hemoglobin to release oxygen to the plasma  SpO2 < 70%  Life threatening  If patient has circulatory problems:  Probe may not be able to transmit  If Pulse Oximeter unable to accurately transmit:  ABGs should be drawn

38. Understanding ABGs Acid/Base Balance

39. Arterial Blood Gases [ABG]  Done by Arterial Blood Draw  Measures lung’s ability to:  Oxygenate arterial blood  Remove Carbon Dioxide  Evaluates Acid-Base Balance

40.  Procedure:  5 mL (5cc) syringe with needle  Usually radial artery is used  Approximately 1mL (1cc) of blood is drawn  Apply direct pressure to the site for at least 5 minutes  If patient is taking aspirin, coumadin, or other blood thinner apply direct pressure for 20 minutes

41.  Measures:  pH  Hydrogen (H+) ions present  PaO2  Partial pressure of oxygen dissolved in arterial blood  HCO3  Calculated value of amount of bicarbonate (HCO3-) in the bloodstream  PaCO2  Amount of carbon dioxide dissolved in arterial blood  Base Excess (B.E.)  Amount of excess/insufficient level of bicarbonate in the system  SaO2  Arterial oxygen saturation

43. AcidsBases  Body uses Acids and Bases to maintain homeostasis  RespiratoryRenal  Respiratory and Renal systems both contribute to the balance  Respiratory System can effect change in 15-30 minutes  Renal System takes hours to days to have an effect  AcidsBases  Acids and Bases are counter balanced  ABG  ABG measures this acid/base status of the arterial blood

44.  Respiratory System  Intake of oxygen and release of CO2  CO2 is a volatile acid  Decreased respiratory rate = retain CO2  increased CO2 in blood  Acidosis  Increased respiratory rate = blow off CO2  decreased CO2 in blood  Alkalosis

45.  Renal System  Kidneys get rid of non-volatile acid  (Hydrogen – H+) Bicarbonate (HC03-)  Maintain constant Bicarbonate (HC03-) level  Bicarbonate is the body’s base

46.  Excess H+ (Hydrogen)  elevated pH  Decreased HCO3- (Bicarbonate)  Kidneys  Kidneys try to compensate by  Excreting H+  Retaining HCO3-  Respiratory System  Respiratory System tries to compensate by  Increasing ventilation  Blow off CO2 to decrease the acidosis

47.  Decrease of H+ and excess of HCO3-  Kidneys  Kidneys try to compensate by  Excreting HCO3-  Retaining H+  Respiratory System  Respiratory System tries to compensate by  Decreasing ventilations (hypoventilation)  Retain CO2 and decrease the alkalosis

48. Respiratory Acidosis pH ( below 7.35) PaCO2 (above 45 mmHg)

50. Respiratory Alkalosis pH ( Above 7.45) PaCO2 (below 35 mmHg)

52. Metabolic Acidosis Increased H+ (Hydrogen) Excess Loss (decrease) HCO3- (Bicarbonate) pH ( < 7.35 ) HCO3- (Bicarbonate) < 22 mEq/Liter

54. Metabolic Alkalosis Decreased H+ (Hydrogen) Increased HCO3- (Bicarbonate) pH ( > 7.45) HCO3- (Bicarbonate) > 26 mEq/Liter

56. The Land of ABG Activity

57.  Once upon a time there was a village known as ABG  Everyone there was related  Only a limited number of names  There were also very polite  Etiquette for learning each other’s names  All villagers have a first, middle, and last name  To learn their whole name, we must look at one name at a time

59. pH  We need to look at her pH first Hydrogen (H+)  The Hydrogen (H+) ions in her blood stream pH  If pH is  Between 7.35 – 7.45 (normal) COMPENSATED  Her first name is COMPENSATED  7.45 UNCOMPENSATED  Her first name is UNCOMPENSATED

60.  This Villager’s  pH = 7.60 What is her FIRST NAME???

61. Hello! My first name isUNCOMPENSATED pH (7.60)above  My pH (7.60) is above Normal Range! (7.35-7.45)  Normal is (7.35-7.45)

62. ***Warning!  Many villagers have the same first and last name! Middle Name  Knowing our villager’s Middle Name more information about her! will give us more information about her! Respiratory Metabolic  It will tell us if it is Respiratory or Metabolic

63. Middle Name  To find out our villager’s Middle Name we need to look at her:  PaCO2- Carbon Dioxide  (Amount of Carbon Dioxide in her arterial blood) Normal Range = 35 - 45  and  HCO3- Bicarbonate  (Amount of Bicarbonate in her bloodstream) Normal Range = 22 - 26

64. PaCO2- 45 If her PaCO2- is 45 Her Middle Name isRESPIRATORY HCO3- 26 If her HCO3- is 26 Her Middle Nname isMETABOLIC

65. Our Villager’s PaCO2- = 30 (Carbon dioxide in arterial blood) HCO3- = 22 (Value of Bicarbonate in the bloodstream) What is her Middle Name??

66. Middle Name My Middle Name is RESPIRATORY ! PaCO2- (30) BELOW My PaCO2- (30) is BELOW Normal Range = 35 – 45 My HCO3- (22) is NORMAL Normal Range = 22 - 26

67. Last Name pH  To find out our villager’s Last Name we need to look at her pH again:  Normal pH7.35 - 7.45  Normal pH is 7.35 - 7.45  If her pH is < 7.35  Her Last Name is ACIDOSIS  If her pH is > 7.45  Her Last Name is ALKALOSIS

68. PERFECT  To have a PERFECT Last Name pH7.40  our villager’s pH would have to be 7.40  This rarely happens!  If her pH is 7.35 - 7.39  She’s thinking of marrying into the ACIDOSIS family  If her pH is 7.41 - 7.45  She’s thinking of marrying into the ALKALOSIS family

69. pH 7.60  Our villager’s pH is 7.60  > 7.45  Last Name  Her Last Name is  ALKALOSIS

70.  First Name  UNCOMPENSATED pH7.60 pH = 7.60 * above normal range  7.35 – 7.45  Middle Name  RESPIRATORY PaCO230 below PaCO2 - = 30 * below normal range 35 – 45  35 – 45 HCO3- 22 within HCO3- = 22 * within normal range  22 – 26  Last Name  ALKALOSIS pH7.60 pH = 7.60 * above normal range 7.35 – 7.45  7.35 – 7.45

72.  Idenified normal parameters for common diagnostic tests.  Described the purpose, significance of results, and nursing interventions related to diagnostic examinations of the respiratory system.  Identified how to interpret ABG lab findings

73.  Read and review  AHN (pp. 378 – 384)  PowerPoint Lecture handouts (Day 1 and Day 2)  Land of ABG handout  Study for Quiz 1 (to be taken on Day 3)  Will cover Day 1 and Day 2 material  Select topic and begin research for Mid-Term Paper (due Day 5)

74.  Disorders of the Upper Airway  Read and review  AHN - pp. 384 – 395  Quiz 1  Respiratory A&P  Respiratory Assessment  Respiratory Labs and Diagnostics  ABG Lab Findings