Download 211 Assessing the Respiratory System notes

Assessing the Respiratory System
The Lower Respiratory System
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The lungs
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Elastic connective tissue called stroma
Left lung smaller with two lobes
Right lung larger with three lobes
The pleura
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Pleural fluid allows lungs to move over thoracic wall during breathing.
The Lower Respiratory System
The bronchi and alveoli
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Respiratory membrane where gas exchange occurs
The rib cage and intercostal muscles
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Protect lungs
Sternum
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Manubrium, body, xiphoid process
The lower respiratory system, showing the location of the lungs, the mediastinum, and
layers of visceral and parietal pleura.
Respiratory bronchi, bronchioles, alveolar ducts, and alveoli.
Anterior rib cage, showing intercostal spaces.
Posterior rib cage.
Respiratory inspiration: lateral and anterior views. Note the volume expansion of the thorax
as the diaphragm flattens.
Respiratory expiration: lateral and anterior views.
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Factors Affecting Respiration
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Respiratory volume and capacity
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Pulmonary function tests
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Total lung capacity (TLC)
Vital capacity
Air pressures
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Inspiration
Expiration
Intrapulmonary pressure
Intrapleural pressure
Oxygen, carbon dioxide, and hydrogen ion concentrations
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Controlled by:
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Respiratory centers of medulla oblongata, pons of brain
Chemoreceptors in medulla and carotid, aortic bodies
Airway resistance, lung compliance, elasticity
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Distensibility of lungs
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Essential in inspiration
Alveolar surface tension
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Surfactant
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Lipoprotein interferes with adhesiveness of water molecules
Helps expand lungs
Fluid Deficit From Dehydration
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Elevated BUN, Creatinine is not as elevated (bun/Cr ratio is higher than usual)
Elevated sodium, potassium
Elevated hematocrit, hemoglobin
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Elevated specific gravity
Respiratory problems: thick, tenacious sputum
Treatment: increase fluid intake, humidity
Fluid Volume Excess Due to Overhydration
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Decreased BUN
Decreased hematocrit, hemoglobin
Decreased specific gravity
Decreased sodium, potassium
Respiratory problems: fluid in lungs, hypoventilation, frothy liquid sputum
Treatment: diuretics, restrict IV intake
Assessing Respiratory Function
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Diagnostic tests
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Arterial blood gases (ABGs)
Biopsy of the lung
Bronchoscopy
Chest x-ray
CT scan of the thorax
MRI of the thorax
Diagnostic tests
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Pulmonary angiography
Pulmonary ventilation scan
Pulse oximetry
Positron emission tomography (PET)
Sputum studies
Thoracentesis
Pulse Oximetry
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Measurement: finger, earlobe, nose; get good waveform or signal before read
Normals (97-100% in healthy clients)
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92%+ in clients with respiratory problems, as low as 90%
Falsely normal if anemic, dehydrated
SpO2 Approximate Equivalency to PaO2 in ABGs
100%=90, 90%=60, 60%=30 (no shifts)
Pulmonary Functions (PFTs)
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Computer measures volumes during breathing through a mouthpiece, with nose
clamped (some volumes: TLC, VC, IC, FRC, FEV1)
No smoking prior
Hold bronchodilators prior as may be given after baseline readings to assess med
effect
May be asked to exercise
Pulmonary Function Test (PFT) - Springfield Clinic , https://youtu.be/1rjN2_hDXEY
Chest Xray
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CHF
Pneumonia
Pneumothorax or hemothorax
Tuberculosis: active disease or history of
Pleural effusion
ET tube placement
Sputum Culture, Induced
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Purpose: gram stain, culture and sensitivity
Equipment: sterile sputum or specimen trap, sterile suction catheter, wall suction,
connecting tubing
Collection
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Have RT induce a sputum sample with NS via mask, which stimulates a cough.
Alternatively if not able to cough, use nasotracheal suctioning.
Bronchoscopy
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Purpose: remove secretions, biopsy, look around.
NPO prior to test for 6 to 8 hours, consent
Anesthetic spray, remove dentures.
Arrhythmias may occur.
NPO and side lying until gag reflex returns in 2-4 hours, take vital signs.
Bronchoscopy Procedure - See inside the lungs!, https://youtu.be/KqZc1JqArco
Thoracentesis
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Purpose: remove fluid from pleural space to assess or to treat excessive fluid
buildup (pleural effusion, empyema)
Needle inserted after lidocaine injections into pleural space, may cause
pneumothorax
Sit upright, no deep breaths, lean forward over a bedside table.
CXR, breath sounds, V.S. after to assess for pneumothorax, simple or tension.
Thoracentesis to remove 1200cc of Pleural Fluid at Harborview,
https://youtu.be/noDxydboLrA
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Assessing Respiratory Function
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Health assessment interview
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Family history
Risk factors
Lifestyle questions
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Smoking history
Exposure to environmental or occupation toxins
Exercise
Use of recreational drugs
Age-Related Changes in the Respiratory System
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Decrease in elastic recoil of the lung
Loss of skeletal muscle strength in thorax and diaphragm
Fibrosis in the alveoli
Fewer functional capillaries
Less effective cough
Decrease in PO2
Respiratory Assessments
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Thoracic assessment
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Respiratory rate
Anteroposterior diameter/transverse diameter ratio
Intercostal retraction or bulging
Chest expansion
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Trachea position
Lung sounds
Diaphragmatic excursion
Breath sound assessment
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Auscultation
Sounds
Crackles
Wheezes
Friction rubs
Abnormal Breath Sounds
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Bronchial or bronchovesicular sounds heard in an abnormal area.
Adventitious sounds
o Crackles, rales
o Gurgles, rhonchi
o Wheezes
Bronchial or bronchovesicular
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Heard over the alveoli
Indicate consolidation, such as in pneumonia
Cause: no air entering those alveoli involved
Besides auscultation, voice sounds can help identify.
Voice sounds
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Bronchophony
Egophony
Have client say E, but you hear A with a stethoscope over the affected alveoli
Treatment: remove secretions
Whispered pectoriloquy
Crackles (rales)
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End of inspiration
May clear with coughing
Delayed opening of alveoli
Due to fluid, mucous, hypoventilation, atelectasis
Found in pneumonia, CHF, COPD, hypoventilation problems
Treatment: avoid fluid overload, cough more or suction, increase ventilation by deep
breathing or incentive spirometer, increase activity and ambulation
Gurgles (rhonchi)
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Inspiratory or expiratory
Indicates mucous in larger airways
Due to ineffective cough or suctioning, accumulation of secretions in large airway
Found in CHF, COPD, hypoventilation problems
Treatment: cough more or suction, expectorants, adequate analgesia
Wheezes
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Inspiratory or expiratory
Narrowing of large airways due to bronchospasm and mucous, results in
hypoventilation
Found in COPD, asthma, anaphylaxis, tetany
Treatment: bronchodilator medications, steroids, treat cause, oxygen, ET, ventilator
Sequence for lung auscultation.
Breath Sounds Reference Guide
http://www.practicalclinicalskills.com/breath-sounds-reference-guide.aspx
Basics of Lung Sounds,
http://www.easyauscultation.com/course-contents?courseid=201
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Assessing Acid–Base Balance
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Arterial blood gases measured
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pH
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PaCO2
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PaO2
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Serum bicarbonate
Base excess
Arterial Blood Sampling Purpose and Equipment
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Purpose: to assess ventilation, perfusion, diffusion in lungs
Equipment for ABG sample via radial artery: TB size heparinized venting syringe,
small short needle, anesthetic, ice
ABG Collection from Radial Artery
RNs can only draw ABGs only from radial artery or an arterial line. MDs can draw
from femoral artery.
Allen’s test to assess for ulnar artery patency
Direct syringe between forefinger and index finger on top of radial artery, at a 45
degree angle. Flash in hub of needle will be seen. If syringe does not fill, aspirate
slowly.
Remove air bubbles from syringe. Put sample on ice to slow down the metabolism of
the sample.
Send sample with temperature of pt., O2 amount and delivery type (cannula or mask
type)
Pressure on site for 5 minutes or more.
Wait 20 minutes after oxygen changes to draw sample.
Normal Arterial Blood Gas Values
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Abnormal pO2
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Normal 80-100
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Acceptable for chronic lung disease clients: 60+
Hypoxia, hypoxemia
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Cause: hypoventilation, low diffusion, low perfusion
High pO2
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Cause: excess oxygen administration
Abnormal HCO3 (bicarb)
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Normal: 22-26 (28 in some sources)
Low HCO3 (metabolic acidosis)
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Cause: renal disease
High HCO3 (metabolic alkalosis)
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Cause: excess bicarbonate intake
Secondary causes: too much bicarb IV, excessive antacid intake
Oxygen–hemoglobin dissociation curve. The percent O2 saturation of hemoglobin and
total blood oxygen volume are shown for different oxygen partial pressures (PO 2).
Arterial blood in the lungs is almost completely saturated. During one pass through the
body, about 25% of hemoglobin-bound oxygen is unloaded to the tissues. Thus, venous
blood is still about 75% saturated with oxygen. The steep portion of the curve shows
that hemoglobin readily off-loads or on-loads oxygen at PO2 levels below about 50
mmHg.
Acid–Base Imbalance
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Acidosis
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Hydrogen ion concentration above normal (pH below 7.35)
Alkalosis
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Hydrogen ion concentration below normal (pH above 7.45)
Metabolic disorders
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Concentration change of bicarbonate
Acid–Base Imbalance
Respiratory disorders
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Concentration change of carbonic acid
Primary
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Due to one cause
Mixed
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Occur from combinations of respiratory and metabolic disturbances
Common Causes of and Compensation for Primary Acid–Base Imbalances
The Patient with Respiratory Acidosis
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pH < 7.35 and PaCO2 > 45 mmHg
Risk factors
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Conditions that depress ventilation
Chest trauma
Aspiration of a foreign body
Acute pneumonia
Overdoses over narcotic or sedative
Hypoventilation = Respiratory Acidosis
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Low respiratory rate and/or volume
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Causes: pain with breathing, asthma, brain or spinal cord disease or trauma,
excessive sedation, more than 3 liter of oxygen in a COPD client
Treat: remove cause, increase rate and volume, oxygen
The Patient with Respiratory Acidosis
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Risk factors
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Cardiac arrest
COPD
Asthma
Cystic fibrosis
Multiple sclerosis
Respiratory acidosis. Hypoventilation and retained CO2 (increased PaCO2) increase H+ levels
in body fluids, causing the pH to fall.
The Patient with Respiratory Acidosis
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Pathophysiology and manifestations
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Acute respiratory acidosis
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Headache, irritability, and decreased level of consciousness, blurred vision
Cardiac arrest, dysrhythmias, ventricular fibrillation
Chronic respiratory acidosis
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Weakness, dull headache, impaired memory, personality changes, sleep
disturbances
The Patient with Respiratory Acidosis
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Diagnosis
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ABGs
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pH and PaCO2
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Serum electrolytes
Chest x-ray
Sputum studies
Medications
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Bronchodilators
Antibiotics
The Patient with Respiratory Acidosis
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Respiratory support
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Pulmonary hygiene
High-acuity care
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Intubation, mechanical ventilation
The Patient with Respiratory Acidosis
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Health promotion
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Identify, monitor, and teach patients at risk
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Receiving anesthesia, narcotic analgesics, sedatives
Chronic lung disease
Priorities of care
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Restoring effective alveolar ventilation and gas exchange
The Patient with Respiratory Acidosis
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Diagnoses, outcomes, and interventions
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Impaired Gas Exchange
Ineffective Airway Clearance
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Continuity of care
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Focus on underlying cause
Compensation
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Rate and depth of respirations
Hydrogen ion and bicarbonate conservation and elimination
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Time Required for Compensation to Occur
Lungs can compensate immediately, if possible
Kidneys take a few days to compensate, if possible
Abnormal, Uncompensated ABGs
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pH Low: acidosis
Cause: high pCO2 or low HCO3 (bicarbonate)
pH High: alkalosis
Cause: low pCO2 or high HCO3
Need a normal pH to live more than a few hours or days
Abnormal, Partially Compensated ABGs
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pH Low: acidosis
Cause: high pCO2 or low HCO3 (bicarbonate)
pH High: alkalosis
Cause: low pCO2 or high HCO3
Both pCO2 and HCO3 are high for respiratory problems.
Both pCO2 and HCO3 are low for metabolic problems.
Abnormal, Compensated ABGs
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pH is normal.
Both pCO2 and HCO3 are abnormal, both are low or both are high.
e.g. pH 7.35, pCO2 50, HCO3 30.
pH low normal, closer to acidosis than alkalosis.
pCO2 is elevated =respiratory acidosis.
However, HCO3 elevation counteracts the elevated pCO2 effect resulting in a normal
pH.
The Patient with Respiratory Alkalosis
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pH > 7.45; PaCO2 < 35 mmHg
Risk factors
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Anxiety
Hyperventilation
Hyperventilation = Respiratory Alkalosis
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High respiratory rate and/or volume
Causes: anxiety, confusion, brain disease or trauma
Treatment: treat cause, decrease rate and volume, intubate ET, ventilator, sedate,
paralyze temporarily
The Patient with Respiratory Alkalosis
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Pathophysiology
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High fever
Hypoxia
Gram-negative bacteremia
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Thryrotoxicosis
Aspirin overdose
Encephalitis
High progesterone levels
Mechanical ventilation
The Patient with Respiratory Alkalosis
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Manifestations
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Lightheadedness, dizziness, numbness and tingling
Palpitations, sensation of chest tightness
Seizures and loss of consciousness
The Patient with Respiratory Alkalosis
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Diagnosis
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ABGs: pH and PaCO2
Medications
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Sedative or antianxiety agent
Drugs for underlying conditions
The Patient with Respiratory Alkalosis
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Respiratory therapy
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Paper bag
Ventilator settings
Oxygen
Health promotion
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Identify patients at risk in hospital
Monitor assessment data, ABGs to identify early manifestations
The Patient with Respiratory Alkalosis
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Diagnoses, outcomes, and interventions
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Ineffective Breathing Pattern
Continuity of care
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Control underlying cause
Refer anxiety cases to counselor
Teach how to identify hyperventilation
pH Playgound (understanding pH)
http://www.acid-base.com/ph.php
https://docs.google.com/presentation/d/1h0DXftFSTsv32IM9vC8WKoY7DP0grmuMRwvvRPDYf0/edit#slide=id.i0
http://www.nursingcenter.com/static?pageid=1030183
http://www.rnceus.com/abgs/abgmethod.html
http://respiratorytherapycave.blogspot.com/2008/11/abg-interpretation-made-easy.html
http://www.tacomacc.edu/home/jmiller/211/unit1/ABG%20Analysis%20Tutorial_files/frame
.htm
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