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150 Cards in this Set
- Front
- Back
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Cough
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natrual defense mechanism; reflexive act to clear the airway
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nonproductive cough
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dry w/no sputum
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productive cough
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wet and congested
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What are the nursing implications for a cough
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contain secretions, dispose of properly, planned C&DB
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sputum
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normal secretions approximately 100cc/24hr.
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What should a nurse look for when assessing sputum
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color, amount, and character
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dyspnea, orthopnea
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distressing sensaition related to the feeling of inadequate ventilation
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What are the signs of dyspnea
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anxious, flared and dilated nostrils w/use of acessery muscle for breathing
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What are the nursing implications for dyspnea
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position, O2 (low flow)
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cyanosis
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bluish discoloration of the skin
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what are the S&S of cyanosis
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peripheral- nail beds clubbing and lack of color, central- bluish coloring of lips (more serious)
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What are the nursing implications for cyanosis
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postion, O2
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hypoxia
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deficiency of oxygen at the cellular level <90%
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What are the S&S of hypoxia
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air hunger, dyspnea, and restlessness, H/A disoriented/confusion, tachycardia, tachypnea, cyanosis
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What are the nursing implicaitions for hypoxia
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assess RR, ABG's, O2 sat, pulse oximetry, H&H, position & O2
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crackles (Rales) sounds
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smaller airways, increase of inspirations
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sonourous wheezing (Rhonchi)
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usually in large airways, continuous snoring sounds (thick, tenacious)
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Sibilant wheezes
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air rushes through narrowed airways
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Frictional Rubs
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crackling, grating sound, hard with inspiration and expiration
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What are the ways to prevent respiratory disease
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avoid irritants, vaccinations, avoid crowds, hygienic measures, hydration, healthy living
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What are the diagnositic tests for respiratory problems ... 8
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ABG, pulmonary function, imaging, bronchoscopy, mediastinoscopy, thoracentesis, sputum specimen, pulse oximetry
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What is ABG
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measures the pH and content of O2 and CO2 in arterial blood
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acidosis
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retained CO2, increase in H2CO3
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What are the S&S of acidosis
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Increase of P and RR, drowsiness, confusion, H/A
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What is the treatment of acidosis
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treat cause, medicated nebulizer
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Alkalosis
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too much Co2 blown off
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What are the S&S of alkalosis
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Dizziness, diaphoresis, numbness & tingling , muscle spasm
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What is the treatment of alkalosis
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rebreathe air i.e. with paper bag, slow RR, meds
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Pulmonary Function test
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use a spirometer to measure lung volumes
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Tidal volume
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volume of air inhaled and exhaled with a normal breath
(quiet breathing)500mL |
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Vital capacity
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maximum amount of air that can be expired after maximal inspiration 3-4L
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Imaging studies
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Chest X-ray- see consolidation or masses
Cat scan- see cross section of lung feild |
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Bronchoscopy
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direct visulization of the bronchial tubes with a lighted scope
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What is the purpose of a Bronchoscopy
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C&S, Biopsy tumor, bronchogram via dye to visualize bronchi
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What needs to be prepared for a bronchoscopy
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NPO, explain procedure, surgical permit, local or general anesthesia
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What is the nursing care for bronchoscopy
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Check return of gag reflex, humidify air/face mask, oral fluids slowly, maitain airway
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Mediastinoscopy
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scope inserted into the mediastinal space to view or biopsy and inspect lymph node
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Thoracentesis
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needle inserted into the pleural space to take sample of fluid (8th-9th intrercostal space)
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What is the purpose of a thoracentesis
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C&S
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What needs to be prepared for a thoracentesis
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permit, explination of procedure, collect equipment
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What is the nursing care of a pt. w/thoracentesis
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observe pt VS q15 minutes; watch for pneumothorax, care of specimen, position of unaffected side
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Sputum specimen
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analyze for C&S to identify microorganism and effective antibiotic
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When is the best time to gather a sputum specimen
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in the A.M
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Pulse oximetry
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noninvasive determination of O2 sat, or amount of oxygen carried in the blood stream
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What are the nursing implications for C/DB
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Position for maximum expansion/relaxation, breathe thru the nose, hold then out thru pursed lips, and dispose of secretions
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Incentive spirometry
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device to encouarge deep breathing
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What are the nursing implicaiton for incentive spirometry
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proper use, set goals, use q1-2h, and watch for signs of hyperventilaiton
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Oxygen therapy
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administer oxygen enriched environment to relieve hypoxia or dyspnea
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What are the devices use to admin O2
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Cannula (spectox)
Catheter Mask |
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How much low flow O2 at rest
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1-2L/min
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How much low flow O2 w/activity
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3-4L/min
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What are the nursing implications for oxygen therapy
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Check liter flow and tubing connections, avoid smoking, check electrical devices for shorts, check for effectiveness, O2 sign
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Humidification
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moistureize air pt. breathes to liquefy secretions/soothing/decrese swelling
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What are the types of humidification
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Heated nebulizer, room humidifier
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What are the nursing implications for humidification
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use sterile distilled water
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Postural drainage and percussion
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help facilitate drainage of sputum from lungs
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Postural drainage
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pt. placed in various positions to help facilitate drainage of sputum from lungs via gravity
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Percussion
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tapping on the chest to loosen up mucus
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What are the nursing implications for postural drainage and percussion
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perform a.c. not on full stomach, disposal, watch kidney/spinal cord areas, use other respiratory treatments, oral hygiene
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Suctioning
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used when a pt. is unable to cough or handle own secretions, clear airway
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Where are the nursing implications for suctioning
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Suction only when withdrawing suction catheter, no longer than 10-15 seconds per pass, use O2 between suctioning
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tracheotomy and tracheostomy
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creation of new opening in trachea to facilitate breathing
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What are the types of tracheotomy
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plastic/disposable tube with cuff
larygectomy tube has short, larger lumen |
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What are the nursing implications for tracheotomy and tracheostomy
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dressing changes/inspection, humidification, trach tapes to hold in place, cuff care, communication
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What are the different types of thoracic surgery
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Thoracotomy, Wedge Resection, Lobectomy, Pneumonectomy
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Thoracotomy
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open chest cavity between 4,5,6,or 7th rib
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Wedge resection
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removal of well circumscribed area of the lung
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Lobectomy
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resection of one lobe
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pneumonectomy
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resection of the entire lung
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What is the purpose of chest tubes
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placed in pleural space to remove air/fluid and re-expand lung
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What are the nursing implications for chest tubes
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do not raise above chest level, C&DB, medicate, if gets disconnected- clean and reconnect
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What are the nursing implications for the removal of a chest tube
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x-ray before and after, watch for pneumothorax, inclusive dressing
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What is the activity for a pt. w/thoracic surgery
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up as soon as fully awake, pre-medicate
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What is the discharge teaching for a pt. w/throacic surgery
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Activity level at own speed but as much as possable, care for stitch pain, numbness around incision, C/DB
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What are the S&S of fractured ribs
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sharp pain over fracture site, dyspnea, limited respiratory excursion
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What is the treatment and nursing care for a pt. w/fractured ribs
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rib belt or ace wrap, semi-fowlers to fowlers position, mild sedation, C/DB
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Flail chest
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loss of stability of chest was with subsequent respiratory impairment due to multiple rib fractures
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What are some S&S of flail chest
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paradoxal breathing, respiratory distress, cyanosis, hypoxia
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Pneumothorax
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air in the pleural space form injury or ruptured bleb
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What are the S&S of pneumothroax
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sudden sharp chest pain, dyspnea and anxiety, hypoxia, cyanosis
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What is the treatment and nursing care for pneumothroax
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chest tube and drainage, siting position w/progressive ambulaiton, surgery to stop bleeding
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Acute coryza
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the common cold
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Acute pharyngitis
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(sore throat)inflamation of the mucous membranes of the pharynx, usually w/acute rhinitis or sinusitis
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Acute laryngitis
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inflamaition of the mucus membranes lining the larynx inflam of vocal cords. w/upper resp infection. 3weeks becomes chronic
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Influenza (Flu)
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epidermic viral infectionof the respiratory tract- fever joint pain, chills
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Pleurisy
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inflammation of visceral and parietal plura
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What are the causes of pleurisy
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pneumonia, TB, Chest trama, lung cancer
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What are the risk factors for cancer of the larynx
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smoking, chronic laryngitis, chronic voice strain, heavy air pollution
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What are the S&S of Cancer of the larynx
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hoarseness, lump when swallowing, pain is late, respiratory S&S
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What are the treatments of larynx cancer
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partial or total laryngectomy, radiation
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What is the preop nursing care for a pt. getting/laryngectomy r/t cancer of larynx
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explain procedure, prepare for voice loss, emotional support
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What is the postop nursing care for a pt. w/laryngectomy r/t cancer of the larynx
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ventilation, nutrition, incision, stoma care, communication
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What is ventilation care r/t laryngectomy
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trach care and position HOB at 45 degrees
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What is nutrition care r/t laryngectomy
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N/G tube, tube feeding
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What is stoma care r/t a laryngectomy
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learn suctioning/care of stoma, humidification, safty, medi-alert tag
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What is communication r/t a laryngectomy
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laryngeal speech, artificial larynx, laryngeal prosthesis
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What are the risk factors for lung cancer
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smoking, air pollution, chemical dust, second hand smoke
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What are the S&S of lung cancer
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nagging cough, hemoptysis, dyspnea
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What are the methods of dx lung cancer
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chest x-ray, bronchoscopy, sputum specimen, open lung biopsy
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What are the types of surgerys for lung cancer
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lobectomy and pneumonectomy
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What is the nursing care for a pt. w/lung cancer
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chest tubes, position/activity, ventilation, emotional support
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Atelectasis
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collapse of alveoli
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What are the causes for atelectasis
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mucous plug in bronchioles post anesthesia, pneumonia, ventilators, debilitated pt., tumors
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What are the S&S of atelectasis
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increase T, P, RR, dyspnea, orthopnea, crackles, decreased breath sounds
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What is the treatment for atelectasis
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C&DB, medicated and heated neb, suction as last resort
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Pneumonia
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inflammation of the alveoli because of bacteria or virus and exudate secreted as responce, problem w/o2 and co2 exchange
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What are the types of pneumonia
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bacterial, viral, fungal, nosocomial, legionnaires
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Bacterial pneumonia
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pneumococcal, nosocomial
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viral pneumonia
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patchy, diffuse throughout lung field- negitive sputum
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legionnaires disease
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acute bacterial bronchopneumonia from stagnant H2O
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What are the S&S of pneumonia
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sudden onset of:
chills and fever, cyanosis, tachycardia, dyspnea/tachypnea Cough, pain, weak and malaise |
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How is pneumonia dx
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lab- increse of WBC, blood cultures
Chest x-ray |
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What is the treatment of pneumonia
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supportive- clear airway, O2, diet, FF, rest, mild analgesic
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Histoplasmosis
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fungal infection from eastern/central US, lives in dark moist areas, increse w/chicken bat excrete
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Coccidioidomycosis (Valley fever)
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found in dry arid soil, Arizona, New Mexico, Texas, w/rodents
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What are the S&S of fungal infections
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masks as TB, increase temperature, malaise, cough
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What is the treatment for fungal infections
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antifungal agents (Amphotericin B; Nizoral/Diflucan)
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Tuberculosis
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infection of the lung from acid fast bacilli
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What are the risk factors for TB
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Homeless, malnurtrition, immuno-compromised
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What are the S&S of TB
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Productive cough, blood in sputum, low grade fever, fatigue, anorexia, chest pain, dyspnea
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How is TB dx
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Skin test, x-ray, sputum C&S
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What is the treatment for TB
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Multiple drug therapy
STRIPE: STreptomycin, Rifampicin, Isoniazid, Pyrizinamide Ethambutol |
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COPD
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broad clasification, indicates obstructive air flow entering &/or leaving lungs
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What disorders are included in COPD
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Chronic bronchitis, emphysema, asthma, bronchiectasis
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Chronic bronchitis
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repeated inflammation/infection of bronchial tree
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What are the S&S of chronic bronchitis
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excessive mucus production, crackles and wheezes, cyanotic, dyspnea with bronchospasms, polycythemia, Resp acidosis
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Emphysemia
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complex and destructive lung disease of alveoli
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What are the causes for emphysemia
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Smoking, Air pollution, heredity
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What are the S&S of Emphysemia
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dyspnea, weakness, barrel chest, chronic nonproductive cough, Increse of CO2, distended neck veins, thin
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What are the treatments for emphysemia
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avoid irritants, stop smoking, avoid cold air,
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What are some treatments for emphysemia
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Liquefy secretions, Low flow O2, decrease bronchospasms
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What are the medications for emphysemia
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Glucocorticoids- anti-inflam action and bronchodilators
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What are teaching/discharge points for emphysemia
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Breathing retraining, graded exercise, adequate rest, home equipment, diet- small meals
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Asthma
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Intermittent airway obstruction, reaction that narrows airways
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What are the different types of asthma
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Allergy (extrinsic) antigen/antibody reaction
Non-allergic (intrinsic) reaction to infections/cold weather/stress- ideopathic |
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What are the S&S of Asthma
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Paroxysmal wheezing, tightness of chest, hypoxia, cyanosis, mild resp. alkalosis from tachypnea, cough,
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What are the treatments for asthma
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Medications, O2, cool environment, liquefy secretions, decrease anxiety, allergy shots
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What are the medications for asthma
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bronchodilators, Glucocorticoids, antibiotics
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What are the important pt. teaching points for asthma
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air conditioning/swamp coolers, no smoking, position, relieving stress, FF
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Pulmonary embolism
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Moving clot that obstructs one or more of pulmonary arteries/arterioles; results as hypoxemia and atelectasis
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What are the sources of Pulmonary embolisms
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DVTs, and mural thrombi (left ventrical thrombus)
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What are the risk factors for Pulmonary Embolis
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venous stasis, hypercoagulability, post op pt.
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What are the S&S of pulmonary embolism
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Chest pain, tachypnea/dyspnea, apprehensive, tachycardia, crackles, hemoptysis
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What is the treatment/care for pulmonary embolism
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stabilize pt.
bedrest- HOB up, HOB up, VS, IV, ABGs, reduce anxiety, anticoagulant therapy |
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What are the important teaching points for a pulmonary emolism
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prevention, early ambulation, turning, ROM, anticoagulants
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Adult respiratory distress syndrome (ARDS)
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combination of symptoms that results from injury to lung
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What are the causes for (ARDS)
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Mssive injuries- trama, head injuries, major surgery, near drowning, infection
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What is the pathohysiology of (ARDS)
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increase in capillary permeability and lungs become edematous (hypoxemia) alveoli collapse
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What are the S&S of (ARDS)
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Rapid shallow breathing, dyspnea, hypoxia, cyanosis, crackles, tachycardia
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What is the treatment and nursing care for (ARDS)
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ICU, Mechanical ventilation, ET tube, observations- VS, electrolyte, ABGs, I/O, quiet relaxed environment
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