RESPIRATORY FUNCTION: ASSESSMENT OF L A NURSE TO THE FOLLOWING SECTIONS: VITAL SIGNS: State Respiratory breathing patterns (frequency, rate, ventilation, dyspnea, orthopnea), breathing sounds (stridor, wheezing, etc), chest movements: retractions ( intercostal, suprasternal, supraclavilcular), secretions and cough: type of discharge (sputum, hemoptysis, burning, density, ...), presence of cough: dry or productive irritant (cough more secretion). circulatory status: heart rate (tachycardia or bradycardia ), blood pressure, oxygenation (anoxia (lack of O2), hiposemia, hypoxia, cyanosis). THE FACTORS AFFECTING THE RESPIRATORY FUNCTION: Altitude (decreases O2 (a + height, lower pressure), Environment, Emotions (frequency increases ), Exercise (frequency increases), Health, Lifestyle: work .... circulatory function: Age, Sex, Exercise, Emotions, etc. what the physical assessment: The nurse can detect symmetry in the lung fields (both lungs expand) also listen (to know the presence of fluid or mucus, noise) Assessment of vital signs: Breathing: eupnea, tachypnea, bradipnea, apnea, Volume: Hyperventilation, hypoventilation. Ritmo: Cheyne-Stokes, Biot. Dyspnoea or orthopnea (needs to sit down to breathe). Sounds Abnormal stridor, rales, wheezing, gasping. Movements of the chest: If you are rhythmic and symmetrical. Retractions: substernal, suprasternal, supraclavicular, tracheal circulation. secretions and cough: productive or dry. Coughing: dense, brownish, blackish, bloody (hemoptysis), Pulse: tachycardia, bradycardia, arrhythmia, weak pulse. Blood pressure: hypertension, hypotension. Signs of skin color: pale skin, cyanosis, anoxia, hypoxemia. CLINICAL SIGNS OF HYPOXIA : Rapid rise of the pulse, shallow, rapid breathing, increased restlessness, flaring of the nostrils, substernal or intercostal retractions, cyanosis. DIAGNOSTIC TESTS TO KNOW: Analysis of sputum, pharyngeal Cultivoexudado, Blood gases, radiological and endoscopic tests, pulmonary function tests, Thoracentesis. PROBLEMS RELATED TO THE NEED TO BREATHE: By air permeable non-obstruction as the airway is known to be blocked by the presence of abnormal sounds (heard by auscultation). You have a cough, shortness of breath, runny , change in frequency, depth, cyanosis. ineffective breathing patterns: when breathing is insufficient to maintain the demand for O2 in tejidos.Síntomas cells: dyspnea, retractions, cough, flaring (widening of the nostrils), respiration through pursed lips, orthopnea. Gas exchange deteriorated: by physiological changes, age, illness. Decreased cardiac output: Factors Influencing: decreased heart rate, decreased blood volume, electrolyte imbalance, cardiac arrest (respiratory failure).C FACTORS CONTRIBUTING TO THE AIRWAY PERMEABLEPERMEABLE THIS NO: Discharge, trauma, pain, medication, lost consciousness, dehydration, immobility. FACTORS INFLUENCING BREATHING PATTERNS ineffective: inadequate chest expansion, neuromuscular disorders, musculoskeletal disorders, chronic pulmonary disease, hyperventilation , airway obstruction. DETERIRADO GAS EXCHANGE ISSUES: Acidosis, Alkalosis. factors that decrease cardiac output heart failure, blood volume depletion, electrolyte imbalance, heart stop. NURSING MEASURES TO PROBLEMS ARISING FROM THE NEED FOR BREATHING: Adequate position Deep breathing and coughing, adequate hydration, health promotion practices and a healthy environment. that causes limitations in chest expansion: immobility, bed rest, pain, Obesity. WHICH IS THE RESULT OF AN INADEQUATE THORACIC EXPANSION: Ineffective breathing pattern .- When breathing is efficient to supply sufficient O 2 to tissues appropriate to their demands. How to Get A FEW Breathe normally: proper position, deep breathing and coughing, adequate hydration, healthy environment, other techniques of nursing lung inflation techniques (breathing exercises, spirometry ), postural drainage (accompanied by percussion, vibration, claping) techniques to drain the airways (humidifiers, nebulizers), Techniques for avoiding the deterioration of the airways (aspirated secretions). THAT IS THE TOS: The cough is caused by sudden spasmodic contraction of the thoracic cavity, resulting in violent release of air from the lungs, producing a distinctive sound. PURPOSE OF THE DEEP BREATHING: mobilize secretions and facilitate expectoration. That got to hydration of the patient: Keep moisture from respiratory mucous secretions preventing thick. THAT IS THE Oxygen: Oxygen therapeutic use. Its purpose is to increase the supply of oxygen to the tissues to the maximum carrying capacity of arterial blood. Wherever there is a deficient supply of O 2 to tissues. Cellular hypoxia may be due to: Decrease the amount of oxygen or the partial pressure of oxygen in the inspired gas, alveolar ventilation decreased, altered ventilation / perfusion, impairment of gas transfer, decreased cardiac output, hypovolemia, shock, decreased hemoglobin or chemical alteration of the molecule. Signs that indicate the need for oxygen therapy: Rapid Growth of pulse, rapid and shallow breathing, increased restlessness, Flaring of the nostrils, substernal or intercostal retractions, Cyanosis. METHODS TO ADMINISTER OXYGEN: nasal cannula nasal oxygen or glasses, face mask with or without reservoir, Venturi Mask, oxygen tents, incubators, mechanical respirators, QEU EN Oxygen toxicity: T his is observed in individuals receiving oxygen at high concentrations (greater than 60% for more than 24 hours). MANIFESTATIONS OF TOXICITY: Depression of alveolar ventilation, resorption atelectasis, pulmonary edema, fibrosis lung, retrolental fibroplasia (in premature infants), decreased hemoglobin concentration. NURSING CARE TO A PATIENT SUBJECTED TO Oxygen: Maintaining the patency of the airway, remove oral secretions, nasal and tracheal, if necessary, restrict smoking , Prepare the equipment and administer oxygen through a humidified, monitor the flow of liters of oxygen and the humidifier, check the position of the oxygen supply device, change the device from oxygen mask nasal cannula during meals, as tolerated, Watch for signs of toxicity, oxygen-induced hypoventilation, checked regularly oxygen delivery device and the placement of the mask / cannula to ensure that given the concentration required to monitor the effectiveness of oxygen therapy (pulse oximeter, arterial blood gases), if necessary, verify the patient's ability to tolerate the suspension of the administration of oxygen while eating, Check oxygen equipment to ensure it does not interfere with attempts to breathe for the patient, observe patient anxiety related to the need for oxygen therapy. Observe skin erosions by the friction of oxygen device. PERFORMANCE OF NURSING .- -Suitable position, deep-breathing techniques and coughing, respiratory-education, deep breath, hold and drive, "drink more water, health-promotion practice and a healthy environment. NURSING CARE .--maintain airway patency .- remove oral secretions, nasal and traqueales.-Restrict smoking-Prepare and manage team of O2 through the humidification system and monitor the flow vigilarlo.-liter of O2 and humidificador.-Check the position of the device O2. input-Watch for signs of toxicity, hypoventilation induced O2.-checked regularly O2 supply device and the placement of the mask / cannula to ensure that the concentration is given prescrita.-Controlling the effectiveness of oxygen therapy .- Check the patient's ability to tolerate the suspension of the administration of O2 while comemos.-Observe the patient's anxiety related to the need for therapy O2.-Observe breaks in the skin by friction device O2.