Medical-surgical Nursing Demystified

(Sean Pound) #1

CHAPTER 2 Respiratory System^105


HALLMARK SIGNS AND SYMPTOMS



  • Cyanosis

  • Fatigue due to hypoxia and heart failure

  • Wheezing due to underlying lung condition such as COPD or emphysema

  • Difficulty breathing (dyspnea) on exertion and when lying down (orthopnea)
    due to increased oxygen needs with movement and increased respiratory
    effort of the diaphragm when lying down

  • Productive cough due to underlying respiratory condition

  • Edema due to right-sided failure; fluid build-up will be in dependent areas

  • Weight gain due to fluid retention

  • Respiration greater than 20 breaths per minute (tachypnea); rate increases to
    meet body’s oxygen needs

  • Increased heart rate above 100 beats per minute (tachycardia) as the body
    attempts to compensate for hypoxia and carry more oxygen


INTERPRETING TEST RESULTS



  • Enlarged pulmonary arteries and right ventricle shown on a chest x-ray.

  • Enlarged right ventricle shown on echocardiography as a result of pulmonary
    hypertension.

  • Increased right ventricular and pulmonary artery pressures in a pulmonary
    artery catheterization. The right ventricle is pumping against greater-than-
    normal resistance within the pulmonary artery when sending blood to the lungs.

  • Decreased oxygen and increased carbon dioxide in arterial blood gas due to
    underlying lung disease.

  • Pulse oximetry shows decreased oxygen saturation.

  • Increased hemoglobin to compensate for hypoxia.


TREATMENT



  • Bedrest or decreased activity.

  • Oxygen therapy at 2 liters/minute (low flow rate) to help meet body’s needs.
    The COPD patient cannot tolerate a high flow of oxygen.

  • Administer calcium channel blockers to vasodilate:

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