–Bed rest without bathroom privileges. Decreases cardiac workload.

–Place patient in high Fowler’s position. Decreases cardiac workload.

–Coughing, deep breathing exercises. Expands lungs and decreases discomfort

–Monitor vital signs.

–Administer as ordered:

○Corticosteroids. Decreases inflammation.

○Nonsteroidal Anti-inflammatory Drugs (NSAIDs). Decreases inflammation.

–Frothy or pink sputum. Related to fluids in the lungs.

–Bilateral Crackles. Related to build-up of fluids in the lungs.

–Tachycardia. The body’s attempts to increase oxygen flow to the heart.

–Jugular vein distention. Related to fluid overload.

–Cyanosis. Related to poor perfusion.

–Clammy, pale skin. Related to decreased circulation.

–Restlessness. Related to decreased oxygen to the brain.

–Difficulty breathing (dyspnea) when sitting upright. Related to fluid in the lungs.

–Hypertension. Related to increased vascular pressure.

–Oxygen saturation. oxygen saturation is < 90%

–Measure fluid intake and output. Assess for renal output and renal perfusion. Normal is 1 ml per kg per hour. Critical is < 0.5 ml per kg per hour.

–Place patient in high Fowler’s position. Decreases cardiac workload.

–Monitor vital signs.

–Place on low sodium diet. Decreases fluid retention.

–Decrease fluid intake to avoid risk of fluid overload.

–Measure weight daily. Weight increase indicates fluid retention.

–Monitor capillary refill. Normal is < 3 seconds.

–Administer as ordered:

○2 to 4 liters 100% oxygen. Use a non-rebreather face mask to increase oxygen supply to the patient.

○Vasodilator. Dilates blood vessels and decreases cardiac workload.

○Inotropic medication. Strengthens cardiac contractions.

○Diuretics. Decreases fluid volume.

○Analgesic. Decreases cardiac workload and pain.

○Bronchodilator. Dilates bronchiole tubes and decreases bronchospasms.

–Asymptomatic

–Cramps in effective area. Related to decreased blood flow.

–Positive Homans’ sign. Calf pain when toes are pointed upwards (dorsiflexion).

–Warmth in affected area. Related to inflammation.

–Swelling in one leg (edema). Related to decreased blood flow.

–Clot moved to lungs:

○Difficulty breathing not improved with oxygen. Related to blocked vessels in lungs.

○Tachycardia. The body’s attempts to increase oxygen flow to the heart.

○Bilateral Crackles. Related to build-up of fluids in the lungs.

–Elevate affected area to encourage circulation.

–Bed rest without bathroom privileges. Decreases cardiac workload.

–Apply warm, moist compresses on affected area to increase blood flow.

–Monitor for signs of clot moving to lungs.

–After clot resolves, tell the patient:

○No crossing legs, this causes decreased circulation.

○No oral contraceptives due to increase in clotting.

○Wear support hose.

–Administer as ordered:

○Nonsteroidal Anti-inflammatory Drugs (NSAIDs). Decreases inflammation.

○Anticoagulant. Decreases blood coagulation.

–Is the patient showing signs of problem breathing?

○Agitation. Related to decreased oxygen levels.

○Sweating. Related to increased stress from decreased oxygen levels.

○Cyanotic nail beds, tip of the nose, and ear lobes. Related to decreased circulatory oxygenation.

○Pale. Related to decreased circulation.

○Elevated shoulders. Related to use of accessory muscles to supplement diaphragmatic breathing.

–Keep questions simple that can be answered with yes or no. The patient is in distress.

–Initial Questions:

○What makes you feeling that something is wrong?

○What happen before you noticed this problem?

○Have you recently undergone any medical procedure?

–Follow up questions:

○Do you have a cough?

○How long have you been coughing?

○Are there changes in your cough?

○What time of day do you cough?

○What aggravates or relieves the cough?

○Is the cough productive?

○Do you have shortness of breath (dyspnea)?

○Do you have shortness of breath when lying down (orthopnea)?

○How many pillows do you use when sleeping?

○What aggravates or relieves shortness of breath?

○Are you drowsy or irritable during the day (sign of sleep apnea)?

○Do you have allergies?

○Have you been recently exposure to an allergen?

○What happens when you are exposed to an allergen?

○Do you smoke?

○How many packs per day?

○How long have you been smoking?

○Are you exposed to second-hand smoke?

○Do you have a respiratory disease?

○What treatment are you receiving?

○Were you exposed to environmental conditions that may be associated with your respiratory complaint?

–Count respiration. Normal is 10 to 20 respirations per minute

–Breathing patterns. Normal is even and unlabored.

–Abnormal:

○Biot’s Respiration. Alternating shallow rapid breathing followed by sudden apnea. Related to central nervous system problems.

○Cheyne-Strokes. A cycle of shallow to deep breathing followed by up to 20 seconds of apnea. Normal during sleep. Abnormal if related to cardiac failure, kidney failure, or central nervous system problems.

–Cyanotic nail beds, tip of the nose, and ear lobes. Related to decreased circulatory oxygenation.

–Clubbing of fingers related to chronic deoxygenation of blood.

–Flaring nostrils. Related to respiratory distress.

–Pursing of lips. Related to effort by the patient to opening the airway longer to improve breathing.

–Asymmetrical chest movement. Related to uncoordinated respiration and the use of accessory muscles to breath.

–Displaced trachea. Related to collapsed lung.

–Agitation. Related to decreased oxygen levels.

–Feel chest wall vibrations (tactile fremitus). Place hands lightly on patient’s back. Have patient fold arms across chest. Ask the patient to say aloud “99.”

○Little vibration. Bronchial obstruction or fluid in pleural cavity (pleural effusion).

○Less vibration. Pleural effusion, emphysema, or pneumothorax.

○Intense vibration. Tissue consolidation.

–Feel separation of the frontal intercostal space. Place hands on the patient’s chest with thumbs position in the second intercostal space. Ask patient to breath normally.

○Thumbs separate equally. Normal.

○Thumbs separating asymmetrically. Pleural effusion, pneumonia, pneumothorax, or atelectasis (collapsed lung).

○Thumbs decrease separation. Emphysema, ascites (fluid), respiratory depression, paralysis of the diaphragm, obesity, atelectasis.

–Place one finger on the patient’s chest. Tap the finger to vibrate the lung fields:

○Front: Begin at the upper right, then move left, down, and to the right to the end of the rib cage.

○Back: Move along the shoulder lines then move upper right, across to the right, down and across to the left until the end of the rib cage.

–Hyperresonance. Indicates air in the lungs (asthma, emphysema, and pneumothorax)

–Hyporesonance (dull). Indicates decreased air in the lungs (atelectasis (partial collapse lung), pleural effusion, or tumor)

–Listen to air moving through bronchi with a stethoscope.

○Normal breath sounds:

▪Trachea: Harsh sound on inspiration and expiration

▪Bronchial (next to the trachea). High-pitched, loud, and discontinuous. Loudest on expiration.

▪Bronchovesicular (between scapulae and upper sternum). Medium-pitched, continuous on inspiration and expiration.

▪Vesicular (remaining lung area). Low-pitched, soft, prolonged on inspiration and short on expiration.

○Abnormal breath sounds:

▪Crackles. Crackling sound on inspiration. Related to air moving through secretions.

•Fine Crackles. Sounds like hair rubbing together.

•Coarse Crackles. Gurgling.

▪Wheezing. High-pitched sound on inspiration or expiration. Related to blocked airflow.

▪Rhonchi. Low-pitched sound (snoring) on expiration. Changes when the patient coughs.

▪Stridor. High-pitched wheezing during inspiration. Related to obstructed airway.

▪Pleural Friction Rub. Low-pitched grating sound on inspiration and expiration, painful.

–Voice sounds are chest vibrations when the patient speaks.

○Egophony: Ask the patient to say “E.”

▪Normal: Muffled.

▪Abnormal: Sounds like “A.” Lung area is dense (consolidated).

○Bronchophony: Ask the patient to say “99.”

▪Normal: Muffled.

▪Abnormal: Loud, lung area is dense (consolidated).

○Whispered pectoriloquy: Ask the patient to whisper “1, 2, 3.”

▪Normal: Unable to distinguish the numbers.

▪Abnormal: Loud and distinct, lung area is dense (consolidated).

–Stridor (high-pitched wheezing) on inspiration:

○Upper Airway Obstruction

○Croup (children)

○Aspiration of foreign body

–Stridor (high-pitched wheezing) on expiration:

○Lower Airway Obstruction

○Asthma

○Bronchitis

–Rapid respiration rate and grunting:

○Pneumonia

○Pulmonary edema

–Disordered control over breathing:

○Increased intracranial pressure

○Medication overdose

○Poisoning

○Neuromuscular disorder

–Difficulty catching breath or working to breath:

○Respiratory distress

○Inadequate perfusion

○Sepsis shock

–Change in voice:

○Upper airway obstruction

–Inability to speak more than one word at a time:

○Lower airway obstruction

–Difficulty breathing (dyspnea). Related to decreased oxygen in the blood.

–Pulmonary edema. Related to fluid in the lungs.

–Tachypnea. The body’s attempts to increase gas exchange.

–Crackles. Related to air moving through secretions.

–Hypoxemia. Related to decreased oxygen levels.

–Elevated shoulders. Related to use of accessory muscles to supplement diaphragmatic breathing.

–Decreased breath sounds. Related to blocked vessels in lungs.

–Cyanotic nail beds, tip of the nose, and ear lobes. Related to decreased circulatory oxygenation.

–Rhonchi. Related to secretions or obstruction of large airways.

–Anxiety. Related to decreased oxygen levels

–Tachycardia. The body’s attempts to increase oxygen flow to the heart.

–Restlessness. Related to decreased oxygen levels.

–Place patient in high Fowler’s position. Decreases cardiac workload.

–Bed rest. Decreases cardiac workload.

–Measure weight daily. Weight increase indicates fluid retention.

–Monitor vital signs.

–Measure fluid intake and output. Assess for renal output and renal perfusion. Normal is 1 ml per kg per hour. Critical is < 0.5 ml per kg per hour.

–Coughing and deep-breathing exercises. Improves pulmonary gas exchange.

–Administer as ordered:

○Analgesic. Decreases pain.

○Diuretics. Decreases fluid volume.

○Proton Pump Inhibitor. Decreases risk of aspiration and gastric stress ulcer.

○Steroids. Decreases inflammation.

○Exogenous surfactant. Decreases surface tension within alveoli that causes alveoli to collapse.

–Atopic asthma (extrinsic) caused by allergens.

–Non-atopic asthma (intrinsic) caused by cold air, humidity, or other non-allergens.

–Difficulty breathing (dyspnea). Related to decreased oxygen in the blood.

–Bronchoconstriction. Related to inflammation.

–Tachypnea. The body’s attempts to increase gas exchange.

–Wheezing on inspiration or expiration. Related to blocked airflow.

–Cough. Related to removal of mucus and secretions that block the airways.

–Elevated shoulders. Related to use of accessory muscles to supplement diaphragmatic breathing.

–Tachycardia. The body’s attempts to increase oxygen flow to the heart.

–Anxiety. Related to decreased oxygen levels

–Sweating (diaphoresis). Related to increased anxiety from decreased oxygen.

–Hyperresonance on percussion. Related to hyperinflation of lungs.

–Remove trigger.

–Place patient in high Fowler’s position. Decreases cardiac workload.

–Monitor pulse oximetry, arterial oxygen saturation. 95% to 100% is normal on room air.

–Monitor vital signs.

–Give patient three liters of fluid daily to liquefy secretions.

–Administer as ordered:

○Oxygen therapy 1 to 2 liters per minute.

○Bronchodilator. Dilates bronchiole tubes.

○Anticholinergic medication. Decreases bronchospasms.

○Leukotriene modulators. Decreases inflammation.

○Corticosteroids. Decreases inflammation.

○Mast cell stabilizer. Decreases inflammation.

○Proton pump inhibitor. Decreases acid reflux that leads to bronchoconstriction.

–Decreased breath. Related to collapsed lung.

–Sweating (diaphoresis). Related to increased anxiety from decreased oxygen to cardiac muscle.

–Difficulty breathing (dyspnea). Related to decreased oxygen.

–Hypoxemia. Related to decreased gas exchange.

–Tachypnea. The body’s attempts to increase gas exchange.

–Tachycardia. The body’s attempts to increase oxygen flow to the heart.

–Cyanotic nail beds, tip of the nose, and ear lobes. Related to decreased circulatory oxygenation.

–Anxiety. Related to decreased oxygen levels.

–Elevated shoulders. Use of accessory muscles indicating an increased attempt to increase air flow.

–Provide humidified air to loosen secretions.

–Coughing, deep-breathing exercises. Expands lungs and decreases discomfort

–Use the incentive spirometer. Slow, deep breaths help lungs expand.

–Perform abdominal diaphragmatic breathing exercises with pursed-lip breathing. Helps lungs expand.

–Administer as ordered:

○1 to 2 liters per minute 100% oxygen. Use a non-rebreather face mask to increase oxygen supply to the patient.

○Bronchodilator. Dilates bronchiole tubes.

○Mucolytics. Loosens secretions.

–Coughing up blood (hemoptysis). Related to inflammation.

–Difficulty breathing (dyspnea). Related to decreased oxygen associated with inflammation.

–Cyanotic nail beds, tip of the nose, and ear lobes. Related to decreased circulatory oxygenation.

–Cough when lying down. Related to infection.

–Foul smelling cough. Related to infection.

–Crackles on inspiration. Related to air moving through secretions.

–Rhonchi on inspiration. Related to secretions or obstruction of large airways.

–Chest percussions. Loosens secretions in lungs.

–Postural drainage. Drain mucus from lungs to throat using gravity.

–Administer as ordered:

○Oxygen therapy 1 to 2 liters per minute. Supplement oxygen to the patient.

○Bronchodilator. Dilates bronchiole tubes.

○Antibiotics to treat the infection.

–Acute bronchitis. Reversible within 10 days.

–Chronic bronchitis [Chronic Obstructive Pulmonary Disease (COPD)]. Not reversible.

–Productive cough. Related to increased mucus production.

–Difficulty breathing (dyspnea). Related to decrease oxygen from increased mucus production.

–Wheezing on inspiration or expiration. Related to blocked airflow.

–Elevated shoulders. Related to use of accessory muscles to supplement diaphragmatic breathing.

–Fever. Related to infection.

–Weight gain. Related to decreased perfusion leading to fluid retention.

–Fatigue. Related to increased respiratory and cardiac workload.

–Use incentive spirometer. Helps to expand lungs.

–High Fowler's position. Decreases respiratory and cardiac workload.

–Administer 3 liters of fluid daily. Helps to liquefy secretions.

–Weigh patient daily. A weight gain of 2 lbs. or more in a day indicates fluid retention.

–Measure fluid intake and output. Assess for renal output and renal perfusion. Normal is 1 ml per kg per hour. Critical is < 0.5 ml per kg per hour.

–Coughing, deep-breathing exercises. Expands lungs and decreases discomfort.

–Administer as ordered:

○Oxygen therapy 1 to 2 liters per minute via nasal cannula.

○Bronchodilator. Dilates bronchiole tubes.

○Steroids. Decreases inflammation.

○Diuretics. Decreases fluid volume.

○Proton pump inhibitor. Decreases acid reflux that leads to bronchoconstriction.

○Expectorant. Liquefies secretions.

○Anticholinergic. Reduces bronchospasm.

–Productive cough. Related to increased mucus production.

–Edema. Related to decreased perfusion leading to fluid retention.

–Weight gain. Related to decreased perfusion leading to fluid retention.

–Shortness of breath lying down (orthopnea). Related to fluids in the lungs.

–Difficulty breathing (dyspnea). Related to decreased oxygen from increased mucus production.

–Tachycardia. The body’s attempts to increase oxygen flow to the heart.

–Cyanotic nail beds, tip of the nose, and ear lobes. Related to decreased circulatory oxygenation.

–Fatigue. Related to increased respiratory and cardiac workload.

–Tachypnea. The body’s attempts to increase gas exchange.

–Wheezing on inspiration or expiration. Related to blocked airflow.

–Bed rest. Decreases cardiac workload.

–Monitor vital signs.

–Weigh patient daily. A weight gain of 2 lbs. or more in a day indicates fluid retention.

–No overexertion. Decreases respiratory and cardiac workload.

–Limit fluid to 2 liters daily. Patient is retaining fluids.

–Place patient on a low-sodium diet to decrease fluid retention.

–Monitor pulse oximetry, arterial oxygen saturation. 95% to 100% is normal on room air without chronic pulmonary disease. A lower value is normal for a patient with chronic pulmonary disease.

–Administer as ordered:

○Oxygen therapy 1 to 2 liters per minute via nasal cannula.

○Calcium Channel Blockers. Dilates blood vessels decreasing blood pressure.

○Potassium channel activator. Dilates blood vessels decreasing blood pressure.

○Angiotensin-converting enzyme (ACE) inhibitor. Dilates blood vessels decreasing blood pressure.

○Diuretics. Increases fluid excretion.

○Cardiac glycoside. Strengthens cardiac contractions.

–Difficulty breathing (dyspnea). Related to decreased oxygen from decreased cardiac output caused by inflammation.

–Elevated shoulders. Related to use of accessory muscles to supplement diaphragmatic breathing.

–Barrel chest. Results from the rib cage being partially expanded all the time caused by the chronic over-inflation of the lungs.

–Loss of weight. Related to increased caloric usage required by the increased respiratory workload. Chronically inflated lungs interfere with expansion of the stomach making it uncomfortable to eat.

–Diminished breath sounds. Related to the chronic hyperinflation of the lungs.

–Wheezing on expiration. Related to blocked airflow.

–Hyperresonance on percussion. Related to hyperinflation of lungs from trapped air in the alveoli.

–Place patient in high Fowler’s position. Decreases respiratory and cardiac workload.

–Measure fluid intake and output. Assess for renal output and renal perfusion. Normal is 1 ml per kg per hour. Critical is < 0.5 ml per kg per hour.

–Monitor vital signs.

–Monitor sputum changes for signs of infection.

–Use incentive spirometer. Helps to expand lungs.

–Administer 3 liters of fluid daily. Helps to liquefy secretions.

–Coughing, deep-breathing exercises. Expands lungs and decreases discomfort.

–Weigh patient daily. A weight gain of 2 lbs. or more in a day indicates fluid retention.

–Administer as ordered:

○Oxygen therapy 1 to 2 liters per minute via nasal cannula. Do not use more than 2 liters/minute for COPD patients if the patient is not intubated. Decreased carbon dioxide levels can decrease the respiratory drive in COPD patients.

○Bronchodilator. Dilates bronchiole tubes and decreases bronchospasms.

○Diuretics. Increases fluid excretion.

○Expectorant. Liquefies secretions

○Anticholinergic. Reduces bronchospasm

○Steroids. Decrease inflammation

○Proton pump inhibitor. Decrease acid reflux that leads to bronchoconstriction

–Difficulty breathing (dyspnea). Related to decreased oxygen caused by restricted lung expansion.

–Decreased breath sounds. Related to restricted lung expansion.

–Tachypnea. The body’s attempts to increase gas exchange.

–Tachycardia. The body’s attempts to increase oxygen flow to the heart.

–Decreased blood pressure (in hemothorax). Related to decreased blood volume.

–Fever. Related to infection.

–Dullness on percussion over the affected area of the lung. Related to fluid in the pleural sac.

–Coughing. Related to attempts to open the airways.

–Pleural friction rub. Grating sounds related to the lining of the plural sac rubbing together as a result of fluid.

–Monitor vital signs.

–Coughing, deep-breathing exercises. Expands lungs and decreases discomfort.

–Make sure chest drainage tube (post-thoracentesis) is patent.

–Administer as ordered:

○2 to 4 liters per minute 100% oxygen. Use a non-rebreather face mask to increase oxygen supply to the patient.

○Antibiotics. Decreases infection.

–Difficulty breathing (dyspnea). Related to inflammation.

–Crackles. Related to air moving through secretions.

–Blood-tinged sputum. Related to infection.

–Coughing. Related to attempts to open the airways.

–Fever. Related to the inflammation response.

–Chills. Rapid muscle contraction and relaxation to increase the body temperature as part of the inflammation response in addressing the infection.

–Pain on respiration. Related to inflammation.

–Tachypnea. The body’s attempts to increase gas exchange.

–Tachycardia. The body’s attempts to increase oxygen flow to the heart related to decreased gas exchange.

–Hypoxemia. Related to decreased oxygen levels.

–Sweating (diaphoresis). Related to the body’s attempts to maintain an appropriate temperature. The body is cooling.

–Wheezing on inspiration or expiration. Related to blocked airflow.

–Monitor vital signs.

–Bed rest. Decreases respiratory and cardiac workload.

–Increase fluid. Helps to liquefy secretions.

–Place patient in high Fowler’s position. Decreases respiratory and cardiac workload.

–Use incentive spirometer every 2 hours. Helps to expand lungs.

–Measure fluid intake and output. Assess for renal output and renal perfusion. Normal is 1 ml per kg per hour. Critical is < 0.5 ml per kg per hour.

–Monitor sputum characteristics. Related to infection.

–Monitor pulse oximetry, arterial oxygen saturation. 95% to 100% is normal on room air without chronic pulmonary disease. A lower value is normal for a patient with chronic pulmonary disease.

–Administer as ordered:

○2 to 4 liters per minute 100% oxygen. Use a non-rebreather face mask to increase oxygen supply to the patient.

○Antibiotics. Decreases infection.

○Bronchodilator. Dilates bronchiole tubes and decreases bronchospasms.

○Antipyretic. Decreases fever.

–Open pneumothorax. Caused by penetrating chest wound.

–Closed pneumothorax. Caused by blunt trauma.

–Spontaneous pneumothorax. Caused by disease such as emphysema.

–Tension pneumothorax. Air in the pleural space is under pressure causing the lungs to compress.

–Tachypnea. Attempt to increase gas exchange.

–Tachycardia. Attempt to increase oxygen flow to the heart related to decreased gas exchange.

–Tracheal deviation toward the unaffected side (tension pneumothorax). Related to pressure in the pleural space.

–Absent breath sounds over the affected area. Related to collapsed lung.

–Sharp chest pain aggravated by coughing. Related to inflammation of pleura.

–Interventions

–Monitor pulse oximetry, arterial oxygen saturation. 95% to 100% is normal on room air without chronic pulmonary disease. A lower value is normal for a patient with chronic pulmonary disease.

–Monitor vital signs. Identify changes in the patient status.

–Place patient in high Fowler’s position. Decreases respiratory and cardiac workload.

–Bed rest. Decreases respiratory and cardiac workload.

–Make sure chest drainage tube is patent.

–Coughing, deep-breathing exercises. Expands lungs and decreases discomfort.

–Administer as ordered:

○2 to 4 liters per minute 100% oxygen. Use a non-rebreather face mask to increase oxygen supply to the patient.

○Analgesic. Decreases pain.

○Bronchodilator. Dilates bronchiole tubes and decreases bronchospasms.

○Antipyretic. Decreases fever.

–Difficulty breathing (dyspnea). Related to decreased oxygen.

–Hypoxemia. Related to decreased oxygen levels.

–Headache. Related to decreased oxygen to the brain.

–Irritability. Related to decreased oxygen to the brain.

–Confusion. Related to decreased oxygen to the brain.

–Cardiac arrhythmia. Related to decreased oxygen to the heart.

–Monitor pulse oximetry, arterial oxygen saturation. 95% to 100% is normal on room air without chronic pulmonary disease. A lower value is normal for a patient with chronic pulmonary disease.

–Coughing, deep-breathing exercises. Expands lungs.

–Monitor vitals.

–Administer as ordered:

○2 to 4 liters per minute 100% oxygen. Use a non-rebreather face mask to increase oxygen supply to the patient.

○Bronchodilator. Dilates bronchiole tubes and decreases bronchospasms.

–Blood-tinged sputum (hemoptysis). Related to the infection.

–Productive cough persists for two weeks. The body’s attempts to clear the airways.

–Low grade fever. Related to the inflammation process.

–Chills. Rapid muscle contraction and relaxation to increase the body temperature as part of the inflammation response in addressing the infection.

–Difficulty breathing (dyspnea). Related to decreased oxygen in the blood.

–Night sweats. Related to the inflammation response in addressing the infection.

–Fatigue. Related to increased metabolism associated with the increased inflammation process.

–Weight loss. Related to increased metabolism associated with the increased inflammation process.

–Isolate the patient. Related to airborne infection.

–Monitor vitals. Identify changes in patient status.

–Monitor fluid intake and output. Identify fluid retention.

–Increase fluid. Helps to liquefy secretions.

–Bed rest. Decreases respiratory and cardiac workload.

–Increase carbohydrate, protein, Vitamin C in diet. Related to weight loss.

–Administer as ordered:

○Anti-tubercular antibiotic. Decreases infection.

–Difficulty breathing (dyspnea). Related to decreased oxygen in the blood.

–Shortness of breath lying down (orthopnea). Related to fluids in the lungs.

–Tachypnea. Attempts to increase gas exchange.

–Crackles. Related to air moving through secretions.

–Cyanotic nail beds, tip of the nose, and ear lobes. Related to decreased circulatory oxygenation.

–Rhonchi. Related to secretions or obstruction of large airways.

–Sweating (diaphoresis). Related to increased anxiety from decrease oxygen.

–Coughing up blood (hemoptysis). Related to inflammation.

–Diminished breath sounds. Related to decreased ventilation.

–Fatigue. Related to increased respiratory and cardiac workload.

–Place patient in high Fowler’s position. Decreases respiratory and cardiac workload.

–Coughing, deep-breathing exercises. Expands lungs.

–Monitor vitals. Identify changes in patient status.

–Monitor fluid intake and output. Identify fluid retention.

–Change patient position every two hours. Prevent pressure ulcers.

–Monitor pulse oximetry, arterial oxygen saturation. 95% to 100% is normal on room air without chronic pulmonary disease. A lower value is normal for a patient with chronic pulmonary disease.

–Administer as ordered:

○2 to 4 liters per minute 100% oxygen. Use a non-rebreather face mask to increase oxygen supply to the patient.

○Bronchodilator. Dilates bronchiole tubes.

○Anticholinergic. Decreases bronchospasms.

○Steroid. Decreases inflammation.

○Proton pump inhibitor. Decreases acid reflux that leads to bronchoconstriction.

○Analgesic. Decreases pain and decreases cardiac oxygen demand.

–Sudden difficulty breathing (dyspnea). Related to obstruction.

–Chest pain. Related to decreased oxygen to the heart.

–Tachypnea. Attempts to increase gas exchange.

–Tachycardia. Attempts to increase oxygen flow to the heart related to decreased gas exchange.

–Crackles at site of emboli. Related to air moving through secretions.

–Coughing up blood (hemoptysis). Related to inflammation.

–Anxiety. Related to decreased oxygen levels.

–Decreased level of consciousness. Related to decreased oxygen levels.

–Hypotension. Related to decreased oxygen levels.

–Leg swelling. Related to thrombus.

–Leg pain. Related to thrombus.

–Place patient in high Fowler’s position. Decreases respiratory and cardiac workload.

–Bed rest. Decreases respiratory and cardiac workload.

–Coughing, deep-breathing exercises. Expands lungs.

–Monitor fluid intake and output. Identify fluid retention.

–Monitor pulse oximetry, arterial oxygen saturation. 95% to 100% is normal on room air without chronic pulmonary disease. A lower value is normal for a patient with chronic pulmonary disease.

–Administer as ordered:

○2 to 4 liters per minute 100% oxygen. Use a non-rebreather face mask to increase oxygen supply to the patient.

○Anticoagulant. Decreases clot formation.

○Analgesic. Decreases pain and decreases cardiac oxygen demand.

○Thrombolytics. Removes clot within 3 to 12 hours of blockages.

–AEIOU

○Alcohol, arrhythmia

○Endocrine/exocrine, electrolytes, encephalopathy

○Insulin

○Oxygen, opiates

○Uremia

–TIPS

○Trauma, temperature disorders

○Infection

○Psychiatric, porphyria, poisons

○Shock, seizures, stroke, subarachnoid hemorrhage, space occupying lesion

–Assess the patient’s altered mental status:

○Alert. Responds to stimuli with little or no delay.

○Oriented. Oriented to time, person, and place.

○Sleepy. Arousable to a normal level of awareness.

○Lethargic. A global depression of awareness of the environment and of the patient himself.

○Stupor. Is sleepy and can be aroused to a semi-normal level of awareness using noxious stimuli.

○Coma. Cannot be aroused.

○Delirium. Acutely confused showing psychomotor excitement and impaired memory and perception. The patient may experience hallucination.

○Dementia. A gradual deterioration of mental function.

–Assess for mental impairment using the Abbreviated Mental Test Score (AMTS). Each correct answer is valued at 1 point. A score of 6 or less suggest mental impairment that requires further testing.

○What is your age?

○What is the time to the nearest hour?

○What year is this?

○What is the name of this hospital?

○Do you know who I am? Do you know who this person is? The patient is expected to recognize two people who are in the room by name or title.

○What is your date of birth?

○When was Pearl Harbor attacked? (Any important history event can be asked.)

○Who is the President of the United States?

○Count backwards from 20 to 1.

○Mention an address to the patient then ask the patient to repeat the address.

–Changes in pupils:

○PERRLA. Pupils equal, round, and reactive to light and accommodation (normal)

○Pinpoint bilateral nonreactive to light indicates:

▪Lesion in the pons resulting from a hemorrhage

▪Drug intoxication (heroin, opiates)

○Dilated bilateral fixed nonreactive to light indicates:

▪Cerebral ischemia

▪Anticholinergic toxicity

▪Severe brain damage

▪Hypoxia

▪Drug (sympathomimetic) intoxication (cocaine, methamphetamine, amphetamines, ecstasy, bath salts, stimulants)

○Small unilateral nonreactive to light indicates:

▪Spinal cord lesion

○Dilated, unilateral fixed nonreactive to light indicates:

▪Normal if patient has a history of severe eye injury

▪Increased intracranial pressure

○Subdural hematoma or epidural hematoma

▪Brain stem compression

▪Brain herniation leading to oculomotor nerve damage

○Midsize, bilateral, fixed, nonreactive indicates:

▪Contusion

▪Brain edema

▪Brain hemorrhage

▪Laceration of the brain

▪Infarction in the brain

–Motor function. Inability to perform this exercise quickly may indicate alcohol toxicity, cerebellar disorder, or stroke:

○Push against your hands. There should be equal pressure from both arms.

○Close eyes, then extend both arms, palms up, for 20 seconds. Both arms should remain in position without any drift.

○Sit at the edge of the bed and raise both legs against your hands. There should be equal pressure from both legs.

○Push feet against your hands. There should be equal pressure from both legs.

○Stand. The patient should stand without assistance or support.

○Sit. The patient should sit without assistance or support.

○Walk. The patient’s gait should be steady.

▪Bias towards one side may indicate a cerebellar lesion on that side.

▪Unsteady gait may indicate abnormal cerebellar functioning.

○Touch nose with an extended finger one hand at a time. The patient should be able to perform this action without hesitation.

○Touch your extended finger as you move your finger. The patient should be able to perform this action without hesitation.

○Touch each finger with the thumb on his same hand. Perform the test on the other hand. The patient should be able to perform this action without hesitation.

–Reflexes

○Tactile stimulation. Stroke the patient’s skin. The more you stroke, the less of a reflex response should be noticed.

○Plantar Reflex. Use a tongue blade and slowly stroke from the patient’s heel to the great toe. Toes should flex. The Babinski’s reflex (fanning of the smaller toes and upward movement of the great toe) is abnormal unless the patient is 2 years of age or younger.

○Abdominal reflex. Stroke one side of the abdomen with the handle of the reflex hammer. Abdominal muscles contract and the umbilicus should deviate toward the same side. Repeat this on the opposite side.

–Cranial nerve assessment (Table 8.4):

–Cerebral Contusion. Blunt force trauma thrusts the brain against the inside of the skull resulting in cerebral edema, cerebral hemorrhage, and loss of consciousness longer than that in a concussion.

–Cerebral Edema. Fluid within the skull moves to the third space resulting in increased cranial pressure.

–Concussion. Blunt force trauma thrusts the brain against the inside of the skull but does not result in bruising.

–Contrecoup Injury. Blunt force trauma causes the head to recoil thrusting the brain against the inside of the skull at a point opposite of the blunt force trauma.

–Coup Injury. Blunt force trauma thrusts the brain against the inside of the skull at the point of the blunt force trauma.

–Epidural hematoma. Bleeding from an artery with blood accumulating between the dura and skull.

–Intracerebral Hemorrhage. Bleeding within brain tissue caused by shearing or tearing of small vessels within the brain and between the cerebrum and brain stem.

–Subarachnoid Hemorrhage. Bleeding between the arachnoid mater and the pia mater, the location of cerebrospinal fluid.

–Subdural Hematoma. Bleeding from a vein in the area between the dura mater and the arachnoid mater resulting in slow, chronic bleeding.

–Symptoms are related to the location of the bleed and the amount of tissue affected by the bleed:

○Unequal pupil size. Related to increased intracranial pressure.

○Diminished or absent pupil reaction. Related to optic nerve impairment.

○Cognitive changes. Related to ineffective functioning of the frontal lobe and temporal lobe.

○Speech changes. Related to ineffective functioning of the left frontal lobe (Broca’s Area) of the brain.

○Motor movement changes. Related to ineffective functioning of the cerebellum.

○Decreased level of consciousness. Related to decreased oxygen supply to the brain.

○Amnesia. Related to ineffective frontal and temporal lobes of the brain and the limbic system.

○Unilateral paralysis (hemiplegia). Related to insufficient oxygen supply to a portion of the brain that controls movement of the paralyzed area.

○Facial weakness or droop. Related to inflammation of the facial nerve.

○Widening pulse pressure. Related to increased intracranial pressure.

○Increased blood pressure. Related to increased intracranial pressure.

○Slow pulse. Related to increased intracranial pressure.

–Place patient in semi-Fowler’s position. Decreases pressure on the brain by allowing drainage by gravity.

–Monitor vitals. Identify changes in patient status.

–Seizure precautions. Prevents injury if patient exhibits seizure.

–High protein, high calorie, high vitamin diet. Related to increased metabolism.

–Monitor for Diabetes Insipidus (drinking large amounts of water). Related to injury to the pituitary gland.

–Monitor neurologic status.

–Administer as ordered:

○Osmotic diuretics. Decreases cerebral edema.

○Loop diuretics. Decreases edema and circulating blood volume.

○Antihypertensive medication. Decreases blood pressure.

○Opioid. Decreases agitation and pain.

–Unilateral facial paralysis. Related to inflamed nerve.

–Change in taste. Related to inflamed nerve.

–Ear and jaw pain. Related to inflamed nerve.

–Monitor for eye irritation.

–Provide meals in private. Patient my feel self-conscious when eating.

–Administer as ordered:

○Artificial tears. Moistens eyes.

○Corticosteroid medication. Decreases inflammation.

–Seizures. Related to infection.

–Severe headache not relieved by medication. Increased blood flow related to the inflammation process.

–Drowsiness. Related to increased cranial pressure.

–Confusion. Related to effect on the cerebellum.

–Ataxia (loss of coordination). Related to effects on the cerebral cortex, basal ganglia, and cerebellum.

–Widened pulse pressure. Related to increased cranial pressure.

–Nystagmus (involuntary eye movement). Related to effects on the temporal lobes.

–Aphasia (inability to use or understand language). Related to effect on the cerebellum.

–Monitor vital signs. Identify changes in patient status.

–Monitor mental status. Identify changes in the frontal lobe.

–Monitor fluid intake and output. Identify fluid retention.

–Monitor movement. Identify changes in the cerebral cortex, basal ganglia, and cerebellum

–Monitor senses. Identify changes in the parietal lobe.

–Administer as ordered:

○Antibiotics. Decreases bacterial infection.

○Corticosteroids. Reduces inflammation.

○Anticonvulsants. Decreases the risk of seizures.

○Osmotic diuretics. Decreases cerebral edema.

–Meningiomas: Benign tumors generated from the meninges.

–Gliomas: Malignant, rapidly-growing tumor generated from glial cells.

–Astrocytoma: Type of glioma.

–Oligodendroglioma: Slower growing glioma.

–Glioblastoma: Differentiated gliomas (a type of astrocytoma).

–Parietal Lobe:

○Visual field defect

○Sensory loss

○Seizures

–Frontal Lobe:

○Anosmia (loss of sense of smell)

○Personality changes

○Expressive aphasia

○Slowing of mental activity

–Occipital Lobe:

○Prosopagnosia (face blindness)

○Impaired vision

–Cerebellum or brain stem:

○Ataxia

○Lack of coordination

○Hypotonia of limbs

–Temporal Lobe:

○Receptive aphasia

○Auditory hallucinations

○Depersonalization

○Seizures

○Smell hallucinations

○Emotional changes

○Visual field defects

–Monitor neurologic function. Identify changes in patient status.

–Seizure precautions. Prevents injury if patient exhibits seizure.

–Administer as ordered:

○Glucocorticoid. Decreases inflammation.

○Anticonvulsant. Decreases risk of seizures.

○Osmotic diuretic. Reduces cerebral edema.

○Proton Pump Inhibitors. Decreases gastric irritation.

–Asymptomatic unless rupture occurs.

–Decreased level of consciousness. Related to decreased oxygen to the brain.

–Headache. Related to hemorrhage and increased intracranial pressure.

–Elevate head of bed 30 degrees. Decreases intracranial pressure.

–Bed rest. Decreases demand for oxygen.

–Monitor level of consciousness. Identify changes in patient status.

–Monitor vital signs for indication of increased intracranial pressure (widened pulse pressure and bradycardia).

–Report headache immediately to the healthcare provider. Related to increased intracranial pressure.

–Administer as ordered:

○Glucocorticoid. Decreases inflammation.

○Anticonvulsant. Decreases risk of seizures.

○Stool softener. Decreases pressure related to straining during bowel movement.