1) O2 delivery의 효율성을 판단하는 기준 : mental state
(capillary refill time ⅹ, wheezing ⅹ)
2) inspection → palpation → percussion → auscultation
3) 폐는 청진기의 diaphragm을 이용하여 검진 (혈관은 청진기의 bell을 이용하여 검진)
1) risk factors for respiratory disorders
2) pulse oximetry
- A sensor is placed on the client’s finger, toe, nose, ear lobe, or forehead to measure oxygen saturation, which then is displayed on a monitor. Maintain the transducer at heart level. Do not select an extremity with an impediment to blood flow.
- ① Select site. ② Assess the blood circulation by capillary refill time. ③ Attach sensor. ④ Turn on. ⑤ Compare oximeter HR with patient’s radial HR. ⑥ Verify alarms on.
- Pulse oximetry reading lower than 91% necessitates HCP notification; if the reading is lower than 85%, oxygenation to body tissues is compromised, and a reading lower than 70% is life-threatening. Agency procedures and HCP prescriptions are followed regarding actions to take for specific readings.
3) sputum specimen
- Obtain an early morning sterile specimen by suctioning or expectoration after a respiratory treatment if treatment is prescribed. Instruct the client to rinse the mouth with water before collection. Obtain 15ml of sputum. Instruct the client to take several deep breaths and then cough deeply to obtain sputum. Always collect the specimen before the client begins antibiotic therapy.
- If a culture of sputum is prescribed, transport the specimen to the laboratory immediately. Assist the client with mouth care.
4) ABGs (Arterial Blood Gases)
- Avoid suctioning the client before drawing an ABG sample because the suctioning procedure will deplete the client’s oxygen, resulting in inaccurate ABG results.
- normal ABGs values
7.35 to 7.45
35 to 45 mmHg
22 to 27 mEq/L
80 to 100 mmHg
96% to 100%
Oxyhemoglobin dissociation curve
- how to read ABGs
- Allen test
① Explain. ② Pressure over the ulnar artery and radial artery. ③ Open and close. ④ Release pressure from the ulnar artery. ⑤ Assess color. ⑥ Return in 6 seconds.
5) pulmonary function test
- Tests used to evaluate lung mechanics, gas exchanged, and acid-base disturbance through spirometric measurements, lung volumes, and ABG levels.
- Consult with the HCP regarding withholding bronchodilators for 4 to 6 hours before testing. Instruct the client to refrain from smoking or eating a heavy meal for 4 to 6 hours before the test. Instruct the client to void before the procedure and to wear loose clothing. Remove dentures.
6) chest x-ray film (radiograph)
- Question women regarding pregnancy or the possibility of pregnancy before performing radiography studies.
7) ventilation-perfusion lung scan
- The perfusion can evaluate blood flow to the lungs. The ventilation scan determines the patency of the pulmonary airways and detects abnormalities in ventilation. A radionuclide may be injected for the procedure.
- Obtain informed consent. Maintain NPO status for 8 hours before the procedure. Assess the client for allergies to dye, iodine, or seafood. Establish intravenous access. Have emergency resuscitation equipment available.
- Monitor the client for reaction to the radionuclide. Instruct the client that the radionuclide clears from the body in about 8 hours.
8) laryngoscopy and bronchoscopy
- Obtain informed consent. Maintain NPO status from midnight before the procedure. Establish intravenous access. Obtain vital signs. Assess the results of coagulation studies. Prepare suction equipment. Have emergency resuscitation equipment available. Sedation, not general anesthesia.
- Monitor vital signs. Monitor for complications, such as laryngospasm, bronchospasm or neck crepitus, dysrhythmias, hemorrhage, hypoxemia, and pneumothorax. Assess for the return of the gag reflex. Maintain NPO status until the gag reflex returns.
9) EndoBronchial UltraSound (EBUS)
- Tissue samples are obtained from central lung masses and lymph nodes, using a bronchoscope with the help of ultrasound guidance.
10) pulmonary angiography
- Obtain informed consent. Maintain NPO status for 8 hours before the procedures. Assess the client for allergies to dye, iodine, or seafood. Instruct the client that he or she may feel an urge to cough, flushing, nausea, or a salty taste following the injection of the dye. Establish intravenous access. Obtain vital signs. Assess the results of coagulation studies. Have emergency resuscitation equipment available.
- Monitor vital signs. Assess the insertion site for bleeding. Monitor the client for a delayed reaction to the dye.
- tattoo 있을 때는 f/u이 필요하다. Nicotine patch는 제거한다.
- ear plug를 사용할 것. 촬영 중 lie still.
- Obtain informed consent. Obtain vital signs. Assess the results of coagulation studies. Note that the client is positioned sitting upright, with the arms and shoulders supported by a table at the bedside during the procedure. Instruct the client not to cough, breathe deeply, or move during the procedure.
- Monitor vital signs. Apply a pressure dressing and assess the puncture site for bleeding and crepitus. Monitor for signs of pneumothorax, air embolism, and pulmonary edema.
13) lung biopsy
- Obtain informed consent. Maintain NPO status.
- Monitor vital signs. Monitor for bleeding.
14) skin test
15) throat swab
- 위가 비었을 때, tongue blade로 혀를 누른 후, After squeezing the bottom, push the swab in liquid.