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145 Cards in this Set
- Front
- Back
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What is Obstructive Sleep Apnea (OSA)? - 5 characteristics. |
Obstruction of the upper airway 1. Tongue & soft palate fall backwards 2. Partial or complete 3. During sleep 4. Apnea (no respirations > 10 seconds) 5. Hypopnea (shallow respirations) |
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OSA occurs in a? - can last? - explain. - can occur? |
Occurs in a cycle - can last from 10 to 90 seconds - startles them, wakes them up, and then they go back to sleep. * can occur 240-400 times a night. |
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OSA oxygen cycle? |
Apnea and/or hypopnea leads to hypoxemia, which leads to hypercapnia. |
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4 risk factors for OSA? |
1. Obesity 2. Increased neck circumference 3. Age > 65 4. Smoking |
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Increased neck circumference size? |
> 17 inches |
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5 clinical manifestations of OSA? |
1. Frequent awakening, insomnia 2. Loud snoring 3. Witnessed apnea episodes 4. Daytime sleppiness, irritability 5. Headache from hypercapnia * most symptoms related to not getting good sleep.* |
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What is hypercapnia? |
elevated CO2 levels. |
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OSA complications if untreated? (3) |
1. HTN 2. Pulmonary HTN - leads to right sided HF 3. Cardiac dysrhythmias - related to the HF |
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Since OSA oxygen levels are low, complications mainly? |
Related to the heart's compensation. |
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Diagnostic test for OSA? - what is the test looking for? |
Polysomnography (sleep study) > 5 apnea and/or hypopnea episodes in one hour with 3-4% drop in O2 saturation. |
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Collaborative care for OSA? (6) |
1. Lay on side to sleep 2. Elevate the HOB 3. Avoid sedatives or alcohol (ETOH) 3 to 4 hours before bedtime 4. Weight reduction 5. CPAP 6. BiPAP |
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What is a CPAP? |
Continuous positive airway pressure: gives a continuous amount of air (& pressure) at all times (both inhale & exhale) - keeps everything open. |
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What is a BiPAP? |
Bi-level positive airway pressure: inhalation pressures are higher, exhalation pressures are lower - goes with their breathing. |
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Difference between CPAP & BiPAP? |
CPAP: continuous & pressure stays the same throughout BiPAP: not continuous & pressure changes based on inhalation & exhalation |
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Why do patients prefer the BiPAP? |
Pressure changes, & they are not breathing against the pressure when they exhale. |
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Risk factors for pneumonia? (12) |
1. Age > 65 2. Air pollution 3. Smoking 4. Decreased consciousness (no deep breathing, coughing, or gag reflex = aspiration) 5. Immobility (lungs do not fully expand) 6. Immunosupression 7. Abdominal or thoracic surgery 8. Chronic diseases 9. DM 10. Tube feedings (aspiration) 11. Tracheostomy, ET tube (close to lungs, outside going in) 12. Upper respiratory infections |
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Pneumonia can be caused by? (4) - what is the most common? |
1. Bacterial 2. Viral 3. Fungal 4. Parasitic * Streptococcus Pneumoniae is the most common.* |
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Pneumonia can be acquired by? (6) |
1. Community Associated Pneumonia (CAP) 2. Hospital Associated Pneumonia (HAP) 3. Ventilator Associated Pneumonia (VAP) 4. Health Care Associated Pneumonia (HCAP) 5. Aspiration Pneumonia 6. Opportunistic Pneumonia |
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To be considered community associated pneumonia? (CAP) |
No hospitalization or long-term care in the last 14 days. |
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To be considered hospital associated pneumonia? (HAP) |
Greater than (or equal to) 48 hours after admission. |
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To be considered ventilator associated pneumonia? (VAP) |
Greater than (or equal to) 48 hours after intubation. |
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To be considered health care associated pneumonia? (HCAP) |
- Hospitalized within the last 90 days, long term care - IV antibiotics, chemo, wound care within the last 30 days - Hemodialysis |
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How do hospital associated (HAP) & health care associated pneumonia differ (HCAP)? |
In health care associated pneumonia (HCAP), the patients come into the hospital for OUTPATIENT procedures (chemo, IV antibiotics, dialysis, etc.) |
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To be considered aspiration pneumonia? |
Material goes through nose or mouth (oropharnygeal) - tube feeding aspiration, vomiting *goes into the lungs. |
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To be considered opportunistic pneumonia? |
Caused by PCP, fungal, or CMV (cytomegaly virus) * DEVELOPS IN AN IMUNOSUPPRESSED PATIENT - HIV, CANCER, TRANSPLANT, CYSTIC FIBROSIS. |
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Clinical manifestations of pneumonia?
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1. Fever, chills (inflammatory response) 2. SOB, crackles (fluids in lungs) 3. Chest pain (pleuritic from fluids) 4. Cough - productive or nonproductive 5. Sore throat |
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Differences that may be seen in older adults with pneumonia? (2) |
1. Hypothermia 2. Confusion |
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If the cough is productive? |
Ask the patient what it looks like. - color, consistency? |
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Increased inflammatory response causes? - With this, you will see? -- Therefore, patient will need to? |
INCREASED METABOLISM/ HYPERMETABOLIC STATE - Increase in metabolism & pulse Patient needs to increase calories & food intake to make up for the hypermetabolic state. Patient will also need to increase fluids due to fever. |
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Pneumonia complications? (5) |
1. Pleural effusion (fluid in pleural space) 2. Empyema (pus in pleural space) 3. Bacteremia/Sepsis (bacteria in blood if not treated) 4. Pericarditis/endocarditis (infection spread to the heart) 5. Meningitis (infection in cerebral spinal fluid) |
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5 diagnostic tests for pneumonia? |
1. CXR 2. WBC 3. Sputum culture (determines the bacteria & the needed treatment) 4. Blood culture (determine if it has spread to the blood [sepsis] & needed treatment) 5. ABG's |
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Why is a CXR needed for pneumonia? |
To look for consolidation or pleural fluid - consolidation is a fluid build up, will appear a white area on CXR |
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Is there a vaccine for pneumonia? - How often? |
Yes, influenza vaccine. - Given once a year - fall/winter season |
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Pneumococcal vaccine give to? (2) - comes in either? |
Given to those greater than or equal to sixty-five years old. Given to those less than sixty-five years old if chronically ill, immunosuppressed, smokers, or live in long-term care. - comes in one or two doses |
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What is priority care for those with pneumonia? |
ANTIBIOTICS!!! |
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Antibiotics given for pneumonia? (3) - class & examples. |
1. Macrolides - azythromycin (Zithromax) 2. Fluoroquinolones - levofloxacin (Levaquin) 3. Beta lactams - cefepime (Maxipime), ceftriaxone (Rocephin) |
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Other collaborative care for pneumonia?
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1. Oxygen, pulse oximeter 2. Bronchodilators (to open airway) 3. Antipyretics (to decrease fever) 4. Analgesics (to decrease pain) 5. Incentive spirometer (to help with lung expansion) 6. Ambulation (to help with lung expansion) 7. Adequate rest, nutrition, and fluid intake |
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Nutrition for pneumonia? - why? Avoid? |
Increase calories & intake due to hypermetabolic state!!! Avoid MILK &/OR DAIRY (causes thickening of secretions) |
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If there is a pleural effusion or empyema present, the patient will need? |
A chest tube. |
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What is a chest tube? |
A chest tube sits in the pleural space to drain fluids/pus/air/blood from the area. What is being drained depends on the illness or what is going on within the lungs. |
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Chest tubes need to be kept? |
Below chest level. |
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Should there be an air bubble in the water seal chamber? - When is this a cause for concern? -- what could this indicate? |
Yes, during exhalation, coughing, or sneezing. - If continuous bubbling, air leak in system or a pneumothorax. |
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Chest tubes should be set to? |
-20 cm suction or water seal |
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DO NOT _____ CHEST TUBES? |
Empty. |
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What is important to consider for chest tubes? |
Pain management. |
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If a chest tube is disconnected? - DO NOT? |
Reconnect ASAP!!! - DO NOT CLAMP |
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If a chest tube is removed? |
Air tight dressing. |
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Dressing change for chest tube depends on? - 3 types? |
Depends on policy. 1. Vaseline gauze 2. Dry gauze 3. Sterile dressing |
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What is the leading cause of death for patients with HIV? |
Tuberculosis (TB) |
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What causes TB? |
Mycobacterium tuberculosis (acid-fast bacillus - AFB) |
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What is the main site for TB? |
The lungs, pulmonary! |
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Other sites for TB? (aka) (6) |
Extrapulmonary - Kidneys, bones, lymph nodes, CNS (meninges), adrenal glands, urogenital tract |
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TB Risk factors? |
1. Low socioeconomic status, homeless 2. Inner-city neighborhood 3. Ethnic minorities 4. Living or working in institutions (NH, prison, shelters, hospitals) 5. Immunosuppressed (HIV, chemo, radiation treatment) |
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Which ethnic minorities are at the greatest risk for TB? What percent of cases are among foreign-born? |
Asians - 60% foreign born |
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Transmission of TB? - such as? -- usually? |
Airborne droplets - breathing, speaking, coughing, sneezing * usually prolonged exposure, but not always! |
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Clinical manifestations of latent TB? (4) - What % will develop TB? |
1. Asymptomatic 2. Positive PPD (TB test) 3. Normal CXR 4. 5-10% will develop TB at some point |
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Clinical manifestations of active TB? (6) |
1. Fatigue 2. Weight loss 3. Fever, chills 4. Night sweats 5. Cough > 3 weeks, chest pain 6. Positive PPD & sputum culture 7. Abnormal CXR |
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Difference between latent & active TB? |
Latent: exposed to it; however, not gone to an active state - CANNOT SPREAD IT (dormant) Active: exposed to it and has gone to an active state - CAN SPREAD IT |
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Diagnostic tests for TB? (3) |
1. TB skin test (PPD) 2. CXR 3. Sputum for AFB x 3 |
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TB PPD? - how to tell if it's positive? - when do you read it? |
Will be positive if there is some kind of immune response to it. - Read 48 - 72 hours after given |
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POSITIVE PPD IN: Immunosuppressed patients? High risk? Low risk? |
Immunosuppressed: > 5mm induration
High risk: >10 mm induration Low risk: >15 mm induration |
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TB CXR? |
To look for infiltrates - not a very good diagnostic tool |
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Sputum for AFB x 3 - meaning? - what is a quicker option? -- why? |
Acid-fast bacillus: three different days - Biopsies are quicker -- AFB's can take six to eight weeks to come back |
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If a patient has active TB, they will need? - How long is treatment? |
4 drug therapy!!! For six to nine months!!! |
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What four medications are included in TB four drug therapy? - ACTIVE |
1. isoniazid (INH) 2. rifampin (Rifadin) 3. pyrazinamide (PZA) 4. ethambutol (Myambutol) |
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While taking the TB four drug therapy, NEED TO MONITOR? - WHY? - can cause? - ACTIVE |
LIVER FUNCTION TESTS - drugs are liver toxic - CAN CAUSE HEPATITIS |
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TB drug therapy needs? - What happens if not? -- Why may compliance be difficult? - ACTIVE |
COMPLIANCE IS ESSENTIAL. - CAN BUILD A RESISTANCE TO MEDICATION IF NOT TAKEN CONSISTENTLY -- THESE DRUGS ARE VERY EXPENSIVE |
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Important side effect of rifampin (Rifadin)? |
WILL CAUSE ORANGE COLORED URINE, BLOOD, TEARS, & SWEAT. * ALL BODY FLUIDS WILL BECOME AN ORANGE COLOR * |
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Latent TB collaborative care? (4) - medication? - prevent? - monitor? - avoid? |
1. isoniazid (INH) for six to nine months 2. Prevent active infection 3. STILL NEED TO MONITOR LIVER FUNCTION TESTS 4. AVOID ALCOHOL - MEDICATION IS ALREADY LIVER TOXIC |
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Is there a vaccine for TB? (aka?) - who receives it? -- what will it cause? --- Is it offered in the USA? Why/why not? |
YES, BCG vaccine! - infants in other parts of the world - results in a positive PPD skin test - Not given in the USA because it is only needed/given in high risk/rate countries! |
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TB Collaborative Care in the hospital? (3) |
1. AFB isolation 2. Negative pressure rooms (air will not go to other rooms) 3. Particulate mask (N95 MASK) - GIVEN TO STAFF, NEEDS TO BE SIZED CORRECTLY (FITTED) |
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If a TB patient needs to lead their room? |
They are given a standard isolation mask. |
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Why is at risk for pulmonary fungal infections? (5) |
1. Seriously ill 2. HIV 3. Immunosuppressed 4. On corticosteriods 5. Cystic fibrosis |
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Ways that people get pulmonary fungal infections? (4) |
1. Aspergillosis (mold in mouth that goes to the lungs) 2. Histoplasmosis (found in soil of rivers & valleys) 3. Candidiasis 4. Cryptococcus |
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Are pulmonary fungal infections transmitted from person to person? |
No. |
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Drug of choice for pulmonary fungal infections? |
IV Amphotericin B |
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IV Amphotericin B is not compatible with? |
NS (normal saline) & many other meds!!!! |
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Premeds given to reduce hypersensitivity of Amphotericin B? (3) |
1. diphenhydramine 2. acetaminophen 3. prednisone |
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Pulmonary embolisms mainly originate from? |
DVTs. |
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Risk factors for pulmonary embolism? (9) - these are? |
1. Immobility 2. Obesity 3. Smoking 4. HTN 5. History of DVT 6. Malignancy 7. A. - Fib 8. Surgery 9. Pregnancy *same as DVT* |
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Clinical manifestations of PE can be? - depends on? |
Sudden or gradual onset - depends on the size of the clot |
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Clinical manifestations of PE? (5) - which is the most common? |
1. Dyspnea!! - most common (around 80-85%) 2. Chest pain 3. Hemoptysis, cough, crackles, wheezing 4. Tachycardia 5. Mental status changes |
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PE mental status changes caused by? |
Hypoxemia. |
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Diagnostic tests for PE? (3) |
1. Chest CT (lung pictures) 2. VQ Scan 3. D-dimer (protein found in blood after clots (+)) |
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What is a VQ scan? - aka? - how does it work? -- what does it look at? |
Ventilation-Perfusion Scan - injects dye into an IV & monitors the dye (similar to a cardiac catheter - not as invasive) -- looks at circulation |
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Collaborative care for a PE? (5) - same as? |
1. IV heparin drip or LMWH SubQ- enozaparin (Lovenox) 2. Warfarin (Coumadin) 3. Monitor PTT, INR 4. O2 therapy, telemetry 5. Pain control *same as DVT* |
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Collaborative care when warfarin (Coumadin) is contraindicated? - why would warfarin be contraindicated? |
IVC Filter - somewhat like a basket/filter that catches the clots -- Bleeding disorders (GI bleed, ulcers, hypocoagulation disorders), fall risks |
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In severe PE cases, patient would need? (2) |
1. Thrombolytic therapy 2. Embolectomy |
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What is the drug used for thrombolytic therapy during PE? |
activase (Alteplase)- drug that will eat at the clot |
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What is a embolectomy? |
Surgical removal of the clot. |
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What is an IVC? |
Inferior vena cava filter - sits and collects the clots |
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Care for IVC filters? |
Need to be changed out if a lot of clots are gathered in the area. |
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What is asthma? |
Chronic inflammatory disorder - consists of air flow obstruction |
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Risk factors for asthma? (2) |
1. Genetic predisposition 2. Allergic response to common allergens |
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Triggers for asthma? (5) |
1. Allergens (pet dandruff, pollen, mold) 2. Air pollutants (perfumes, smoke, aerosol sprays) 3. Respiratory or sinus infection 4. Medications (NSAIDS, beta blockers) 5. Exercise, cold air, stress, hormones, GERD |
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Steps of asthma? (6) |
1. Trigger is presented 2. Inflammation occurs in the lungs 3. Mucous increases 4. Bronchiole hyperresponsiness increases 5. More inflammation occurs 6. So much inflammation that there is an obstruction. |
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Asthma exacerbation consists of? (5) |
1. Dyspnea 2. Hypoxemia 3. Wheezing 4. Diminished breath sounds 5. Cough, chest tightness |
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Diagnostic tests for asthma? |
1. Pulmonary Function Tests (PFT) 2. CXR, ABG's 3. Peak flow |
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What do PFT's look at? |
Volume of air when inhaling & exhaling. |
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Why are ABG's used in asthma? |
To look for hypoxia or high CO2 levels. |
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What does a peak flow test do? |
Peak expiratory flow meter. |
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Collaborative care for asthma? (4) |
1. Avoid triggers 2. O2 therapy, bronchodilators 3. Corticosteriods (IV, PO, or inhaled) 4. Leukotriene modifiers |
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Bronchodilators used for asthma? (2) |
1. albuterol 2. ipratropium |
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Leukotriene modifier for asthma? (1) |
montelukast (Singulair) |
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What is given FIRST during an asthma attack? - WHY? |
BRONCHODILATORS GIVEN FIRST TO OPEN THE AIR WAY BEFORE GIVING OTHER MEDICATIONS, SUCH AS STERIODS |
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If an asthma attack is severe? (2) |
1. Intubation 2. Mechanical ventilation - may be required |
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What is the third leading cause of death in the US? |
COPD |
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COPD is a combination of? - what are they? |
Two obstructive airway diseases - Chronic bronchitis - Emphysema |
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What is chronic bronchitis? |
- Inflammation of the bronchioles -- COUGH FOR THREE MONTHS IN ONE YEAR = CHRONIC |
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What is emphysema? |
Hyperinflation of the lungs |
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1/2 OF THE PEOPLE DIAGNOSED WITH COPD... |
WILL DIE WITHIN TEN YEARS |
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COPD incidence higher in? - but? |
Higher in males - Rising in women |
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MAJOR RISK FACTOR FOR COPD? |
CIGARETTE SMOKING!!! |
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Other risk factors of COPD? |
1. Occupational exposure 2. Air pollution 3. Severe recurring respiratory infections 4. Increasing age (w/ other risk factors) 5. Alpha-I antitrypsin (AAT deficiency) |
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What is AAT? |
Alpha-I antitrypsin (AAT) - protein important for lung function, have a deficiency |
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COPD is? Excess? Changes? Impaired - Results in? |
Chronic inflammation of the lungs & progressive - excessive mucus production - structural changes (remodeling) - impaired ventilation/perfusion - air trapping/hyperinflation |
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What is air trapping/hyperinflation? |
BARREL CHEST - air goes in, but CANNOT FULLY COME OUT!!! HYPOXEMIA, HYPERCAPNIA (low oxygen, high CO2) |
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Differences between COPD & asthma? |
COPD is progressive & inflammation is always present. In asthma, inflammation is triggered by something. |
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Clinical manifestations of COPD? |
1. Productive cough 2. Dyspnea on exertion (SOB w/ activity) 3. Dyspnea at rest (late stage) 4. Barrel chest 5. Diminished breath sounds 6. Expiratory wheezing (obstruction) 7. Weight loss (hypermetabolic, too SOB) 8. Hypoxemia/hypercapnia (resp. acidosis) 9. Polycythemia |
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What is polycythemia? |
Compensation when the body makes more hemoglobin to carry more oxygen |
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Most respiratory issues cause a? |
hypermetabolic state. |
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COPD IS WHAT ABG? |
RESPIRATORY ACIDOSIS |
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ABG NORMAL PH? |
7.35-7.45 - IF BELOW 7.35, ACIDIC - IF ABOVE 7.45, BASIC |
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ABG NORMAL CO2? |
35-45 - IF BELOW 34, BASIC - IF ABOVE 45, ACIDIC |
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ABG NORMAL HC03? |
22-26 - IF BELOW 22, ACIDIC - IF ABOVE 26, BASIC |
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Therefore, to be RESPIRATORY ACIDOSIS? - PH - HCO3 - C02 |
PH WILL BE BELOW 7.35. HC03 WILL BE RANDOM CO2 WILL BE ABOVE 45 |
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Complication of COPD? (4 steps) |
1. Chronic hypoxia & acidosis 2. Pulmonary HTN 3. Cor pulmonale (RV hypertrophy) 4. Right-sided HF |
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COPD exacerbations? - what does this mean? |
Gets worse, symptoms increase. - Treatment plan needs to be changed |
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Depression/Anxiety in COPD? |
Depression due to effects on ADL. Anxiety due to inability to breathe. |
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Diagnostic tests for COPD? (6) |
1. PFT 2. AAT levels 3. ABG 4. O2 assessment 5. 6 minute walk test 6. Echocardiogram (to look for HF) |
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What is a six minute walk test? |
To see if oxygen drops w/ activity - if the patient drops below 88%, they will be put on oxygen. |
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COPD Collaborative Care? |
1. Avoid pollutants & risks for infection 2. Influenza & pneumoccocal vaccine 3. Smoking cessation; slow progession 4. Drug therapy 5. Oxygen therapy |
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Can COPD be cured? |
No; however, it can be slowed - Also, medications are being created & tested to cure COPD in the future. |
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Drug therapy for COPD? (3) |
1. Bronchodilators (albuterol & ipratroprium) 2. Inhaled corticosteriod (fluticasone/salmeterol [Advair]) 3. Oral corticosteriods (exacerations) |
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Albuterol is a? - therefore, it will increase? -- monitor? |
Beta agonist - Will increase HR -- Monitor BP & HR |
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Oxygen therapy for COPD? (3) - which is the most common? |
1. Keep O2 sat > 90% 2. O2 @ 2L/nc (MOST COMMON!!) 3. Ventimask (24-48%) |
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What is a Ventimask? |
Can provide low, constant O2 concentrations for COPD pts. |
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O2 therapy complications? (2) |
1. Combustrion/Fire - NO SMOKING NEAR O2 2. CO2 narcosis |
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What do you do if a patient has CO2 narcosis? (3) - Patient will be? (2) |
1. Titrate O2 to lowest effective dose 2. Keep O2 @ < 4L/nc!!! 3. Monitor ABG's: to look at CO2 levels - Patient will be confused & lethargic. |
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Patient will go home with O2 per NC if? (2) |
1. PaO2 is less than or equal to 55 2. O2 saturation is less than or equal to 88% |
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Ventimasks can be set? Non-rebreathing masks? |
Ventimasks can set the amount of O2 desired. Non-rebreathing give 100% O2. |
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COPD Surgical Therapy - Collaborative Care? (2) |
1. LVRS (lung colume reduction surgery) - take out damaged part of the lung, then other parts of the lungs can expand more. 2. Lung transplantation - Unilateral is the most common - COPD pt.'s are most common on list for lung transplants |
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Further COPD Collaborative Care? |
1. Pursed-lip breathing: prolonged exhalation 2. HOB elevated: useful for all respiratory issues 3. Pace activities with rest periods 4. Monitor O2 with activity 5. Chest physiotherapy 6. Nutrition |
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What is chest physiotherapy? |
Respiratory can do percussion & vibration of the lungs to loosen secretions. |
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Nutrition for COPD patients? |
1. Increased fluid intake: to break up secretions 2. 5-6 small, high calorie/high protein meals: hypermetabolic state, & smaller meals due to SOB when breathing |
