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104 Cards in this Set
- Front
- Back
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Emergency Nursing-Legal Implications
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Several Federal Legislations including OBRA, EMTALA, and HIPAA. Consent to treat, Restraints, Mandatory Reporting, Evidence collection and preservation, and violence.
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OBRA-Omnibus Budget Reconciliation Act
(ED legal implications) |
ED personnel must stabilize the condition of any client considered medically unstable before transfer to another health care facility. Stabilization must occur regardless of the client's financial ability to pay for services.
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EMTALA- Emergency Medical Treatment and Active labor Act
(ED legal implications) |
Requires that a medical screening examination be performed on all EE clients before solicitation of information about ability to pay. Screening must be inclusive enough to determine whether the client is experiencing an emergency medical condition requiring treatment or, in the case of a pregnant woman, is experiencing labor contractions. An emergency medical condition includes drug abuse, hemodynamic instability, psychiatric illness, intoxication, severe pain, and labor.
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Medical Stabilization
(ED legal implications) |
Interpreted to mean that deterioration of the client is unlikely during the possible transfer or discharge of the client.
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HIPAA- Health Insurance Portability and Accountability Act
(ED legal implications) |
Provides national standards for electronic health care transactions, and was extended to protect the privacy of protected health information. Information in medical records, conversations with health care personnel, insurance records, billing information, and other health information that is collected. It restricts who can look at and receive a person's health information and stipulates that personal information cannot be used or shared without authorization.
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Consent to Treat
(ED legal implications) |
Implied emergency doctrine- emergency care may be rendered to the client. Assumes that the client would consent to treatment to prevent death or disability if the client were so able. Children younger than the age of legal majority must have consent of their parent or legal guardian for medical care to be rendered. Exceptions include emancipated minors; minors seeking treatment for communicable diseases, including sexually transmitted diseases, injuries from abuse, and alcohol or drug rehabilitation; and minor age females requesting treatment for pregnancy or pregnancy related concerns.
Informed consent still applies. Adults must be informed about the necessity of required treatments, expected outcomes, and potential complications. They must be mentally competent and understand the information being explained. |
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Restraints
(ED legal implications) |
Restraints may be used with the client is in danger of injuring self or others and when nonphysical methods of controlling the client are not viable. They may not be used to control a client solely for the convenience or because of staffing issues.
When restraints are used: A physicians order is needed Clients behavior must be documented Client must be periodically reevaluated for continued need of restraint, and circulation, motor, and sensory of distal extremity. Findings must be documented Client must be offered water and opportunities to relieve body needs, must be documented. Behavioral modification should be tried, and documented Those clients with psychological conditions that render them a danger to self or others, or those that are unable to provide food or shelter for self, may be held for a maximum of 72 hours. Within the 72 hours must be evaluated by psychiatrist to determine extension or release. |
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Mandatory Reporting
(ED legal implications) |
Incidents requiring reporting to federal, state, or local authorities, coroners offices, or animal control agencies include:
Suspected child, sexual, domestic, and older adult abuse; assaults; motor vehicle crashes; communicable disease such as hepatitis, sexually transmitted diseases, chicken pox, measles, mumps, meningitis, tuberculosis, and good poisoning; first-time or recurrent seizure activity; death; and animal bites. Clients and families must be told how to report concerns about safety and encouraged to report such incidents. |
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Evidence Collection and Preservation
(ED legal implications) |
The ED nurse must recognize unusual circumstances surrounding a client's injury or death. Evidence must be collected and legal authorities must be notified. Evidence may include bullets, weapons, clothing, and body fluid specimens. All evidence must be identified by the client's name, hospital identification number, date and time of evidence collection, type of evidence and the source (venipuncture, hematoma aspiration, vomitus, swab), and the initials or signature of the person collecting the evidence.
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Evidence Collection in the Emergency Department (page 2192)
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Glass fragments, bullets, broken fingernails, paint chips, loose hair follicles, fibers or trace evidence such as soil---Place each item in a paper envelope or specimen container.
Head or pubic hair samples--Collected samples from combings and cuttings are each placed in a paper envelope. Blood (from both venipuncture and possible hematoma evacuation), urine, gastric washings, or vomitus--a 20-30 ml sample is placed in a sealed container. Swabs from wounds, membranes, or orifices--Air-dry before placing in a a collection container or paper envelope. |
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Tips for preserving Evidence in the Emergency department (page 2192)
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1. Do not contaminate specimens or person- use gloves.
2. Minimally handle the body of a deceased person. 3. Place paper bags on the hands and feet and possibly over the head of a deceased person to protect trace evidence or residue. 4. Collect and place evidence on clean, white sheet until it can be packaged and labeled. 5. Do not place wet clothing in plastic bas as wet clothes can "sweat", thereby destroying evidence. Allow item to air dry, and then place inside individual paper bags. If item is soaked and continues to leak fluid, place inside another bag and label to alert crime lab that it contains body fluids. 6. Photograph inflicted wounds or injury before cleansing or repair. 7. Do not insert invasive tubes through pre-existing wounds or holes (do not place chest tube through chest wounds or IV catheters through needle track marks.) 8. Do not cut clothing through evidence holes such as stab wounds or bullet wounds. 9. Collect the clients' personal items, such as written notes, drugs or medications, and items from clothing pockets. 10. Do not allow family members, significant others, or friends to be alone with the client. |
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Maintaining "Chain of Custody" of Evidence in the ED (page 2192)
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1. Seal evidence with tape and label with client information data, date and time of collection, signature of person collecting evidence.
2. Document all collected evidence on designated forms. 3. Document all transfers of evidence from one person to another, include the reason for transfer of evidence. 4. Obtain signatures of the person releasing evidence and of the person receiving evidence. 5. NEVER leave collected evidence unattended. Call police or forensic nurse examiner immediately to retrieve evidence. 6. Air-dry evidence before placing it in a collection container or paper envelope. |
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Violence
(ED legal implications) |
Is increasing in the emergency department. It is important to recognize potentially violent clients and situations, id verbally and physically abusive cues from clients and others, listen to instinct or gut reactions, use simple communication to diffuse situations, require clients to completely undress before examination, minimize the presence of potential weapons, restrain client when necessary, avoid becoming a hostage, safety committee track all reported assaults, Report verbal and physical attacks.
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Triage (page 2194)
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The purpose of the triage process is to expediently determine the severity of a client's problem or condition in order to deliver emergency care in the most appropriate time frame. It determines which clients need treatment immediately and which can wait.
Emergent level-must be treated immediately otherwise life/limb/vision is threatened. Urgent-requires treatment but life/limb/vision is not threatened and care can be provided within 1-2 hours. Non-urgent--requires evaluation and possible treatment but time is not a critical factor. ESI-Emergency Severity Index- is another rating system- 5 point, which involves the nurse identifying the critical clients and then predetermining the number of department resources most likely required to treat the non-urgent clients. |
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Emergency Nursing Assessment (page 2194-2196)
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Involves both primary and secondary assessment.
Primary assessment- to immediately identify any client problem that poses a threat, immediate or potential, to life, limb, or vision. Gathered through objective info like physical exam and vital signs. Includes A-airway, B-breathing, C-circulation (both peripheral and organ specific). Any client involved in major trauma assessment of airway includes eval of the C-spine immobilization, and includes D- disability which includes a brief eval of LOC and pupil response to light. Secondary assessment-performed to identify any other non-life-threatening problems that clients may be experiencing. Both subjective and objective info are obtained. The assessment includes Neuro, HIstory, Pain, General overview, and head-to-toe (focused assessment) |
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ED Assessment-Secondary- Neurologic assessment (pg 2195)
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Determine LOC, orientation to person, place, time and event; Glasgow coma scale score; pupillary size, equality, and reaction to light and accommodation; and motor movement and strength or hand grips and pedal pushes. USE AVPU mnemonic:
A-Alert (client is awake and alert and needs to stimulus to respond to the environment. V- Verbal (client requires a verbal stimulus to elicit a response) P-Pain (client requires a painful stimulus to evoke a response) U-Unresponsive (the client is unresponsive to any applied stimulus) |
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ED assessment- secondary- History
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Elicit the nature of the clients chief complaint, duration of the problem, mechanism of injury from blunt or penetrating forces, associated manifestations related to the primary problem, past pertinent medical history, current medications and compliance, use of over-the-counter medications or herbs, routine use of alcohol or illicit drugs, known medication allergies, and immunization history. Women of childbearing age question about LNMP (last normal menstrual period), and number of pregnancies and outcomes.
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ED assessment-secondary- Pain (2195)
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use PQRST mnemonic
P-provoking factors Q- quality of pain (dull, sharp, pressure..) R- region/radiation S- severity T- timing Clients who rate their pain at 7 or above or denote severe pain need to be considered high risk and should be evaluated by a ED Dr. ASAP. Clients have a right to have their pain treated appropriately, in a timely manner, and effectively, without exception. |
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ED assessment- secondary-General overview (pg 2196)
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note overall health condition, skin color, gait, posture, unusual skin markings or body odors, and mood and affect. Baseline BP, and vitals. Actual weight in pediatric client and reported weight in adult.
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ED assessment-secondary- Head to Toe Assessment (pg 2196)
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remove clothing and examine areas of chief complaint, and any other associated complaints are focused. Determine additional normal and abnormal findings.
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Priorities in the ED
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Securing and maintaining a patent airway constitute the first priority in any ED client.
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Flail Chest (pg 2201)
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Occurs when two or more ribs are fractured in 2 or more places on the same chest wall side or when the sternum is detached from the ribs. The fractured segment has no connection with the remaining rib cage, and this segment then moves in a direction opposite than the rest of the chest wall during inhalation and exhalation (paradoxical chest wall mvmt). S/Sx- tachypnea, pain, and dyspnea.
Treatment- endotracheal intubation and mechanical ventilation. |
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Critical Care population of patients
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There are an increasing number of adults 65 years of age and older admitted to critical care. In 2004, 36.3 million older adults or 12.4% of the U.S. population was admitted to critical care. Of all adult hospital bed, more than 50% are filled with clients 65 years or age and older. Expecting an increase in the need for critical care as baby boomers age. 80% of older adults have 1 chronic condition, and 50% have reported at least 2.
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Critical Care stressors (86)
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frequent interruptions, personnel and equipment noise, constant light,s lack of privacy, and separation from significant others. Lack of sleep and frequent interruptions futher compound client illness. (clients in CCU spend 50% of normal sleep time awake)
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Critical care purpose
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The practice of administering immediate and continuous care to clients experiencing actual or potentially life-threatening health disorders.
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Critical care nurses with families (88)
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Nursing can do much to alleviate many of the stressors that face our critical care clients and family members. Must listen and take time to meet their needs. The 9 top priorities for families in critical care:
1. To be assured that the best care was being given to their family member by caring personnel. 2. To feel that there was hope 3. To know the prognosis 4. To understand how the client was being treated medically 5. To be reassured that it is all right to leave for a while 6. To feel accepted by hospital staff 7. To feel someone is concerned for the family's health 8. T feel the hospital personnel care about the client 9. To have explanations given in terms that can be understood. |
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CCU Client Characteristics (88)
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1. Resiliency- the ability to return to a restorative level of functioning using a compensatory coping mechanism.
2. Vulnerability- the level of susceptibility to actual or potential stressors that may adversely affect client outcomes. 3. Stability-ability to maintain a steady state of equilibrium 4. Complexity- The intricate entablement of 2 or more systems (physiologic, emotional, family dynamics, environmental) 5. Resource availability- influenced by the extent of resources brought to the situation by the client, family , and community. 6. Participation in care- client and family in being engaged in the delivery of care. 7. Participation in decision making- the client and family comprehending Information provided by health care providers and acting upon this information to execute the informed decisions. 8. Predicability- allows one to expect a certain course of events or course of illness. |
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CCU Essential Nurse Competencies
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1. Clinical judgement-clinical reasoning used by a HCP in the delivery of care.
2. Advocacy- working on another's behalf when the other is not capable of advocating for self. 3. Caring practices- the constellation of nursing interventions that create a compassionate, supportive, and therapeutic environment for clients and staff, with the aim of promoting comfort and healing and preventing unnecessary suffering. Caring behaviors include vigilance, engagement, compassion, and responsiveness to client and family. 4. Collaboration- the nurse working with others to promote optimal outcomes. 5. Systems thinking- the tools and knowledge that the nurse uses to recognize the interconnected nature within and across the health care or non health care system. 6. Response to diversity-sensitivity to recognize, appreciate, and incorporate differences into the provision of care. 7. Clinical inquiry- the ongoing process of questioning and evaluating practice, providing informed practice, and innovating through research and experiential learning. 8. Facilitation of learning- the promotion of learning for clients, families, nursing staff, physicians, other health care disciplines, and community through both formal and informal methods. |
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CCU- Advocacy Statement (88)
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1. Respect and support the right of the patient or the patient's designated surrogate to autonomous informed decision making.
2. Intervene when the best interest of the patient is in question. 3. Help the patient obtain necessary care. 4. Respect the values, beliefs, and rights of the patient. 5. Provide education and support to help the patient or the patient's designated surrogate make decisions. 6. Represent the patient in accordance with the patient's choices. 7. Support the decisions of the patient or the patient's designated surrogate, or transfer care to an equally qualified critical care nurse. 8. Intercede for patients who cannot speak for themselves in situations that require immediate action. 9 Monitor and safeguard the quality of care the patient receives. 10. Act as liaison between the patient. the patient's family, and health care professionals. |
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Nail Clubbing Assessment (pg 1532)
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Clubbing occurs as a compensatory measure for chronic hypoxia. The Shamroth technique is used to assess for the condition. (A normal digit, with an angle of 160 degrees). Instruct eh client to place the nails of the fourth (ring) fingers together while extending the other fingers and to hold the hands up. A diamond-shaped space between the nails is a normal finding and indicates the absence of clubbing.
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Chest Percussion (1533-1534)
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Percussion over healthy lung tissue produces a resonant sound ( low-pitched, hollow).
1. Tympany: -high-pitched, hollow, drum like. (over stomach) 2. Flat: high-pitched, soft (over heavy muscles and bones like scapula, and spinous processes) 3. Dull: medium pitched, thud-like. (over organs, like the liver) 4. Resonant: low-pitched, hollow. (over lung tissue) |
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Adventitious sounds (1536) Crackles
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Abnormal or extra breath sounds.
Discontinuous, high-pitched, short crackling, popping sounds heard during inspiration that are not cleared by coughing; this sound can be simulated by rolling a strand of hair between fingers near the ear or by moistening thumb and index finger and separating them near the ear. Mechanism- Inhaled air collides with previously deflated airways; airways suddenly pop open, creating a crackling sounds as gas pressures between two compartments equalize. Ex: Late inspiratory crackles- occur with restrictive disease; pneumonia, heart failure, and interstitial fibrosis. Early inspiratory crackles occur with obstructive disease: chronic bronchitis, asthma, and emphysema. |
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Normal Breath Sounds (1535)
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Bronchial- High and loud. Harsh, hollow, and tubular. I < E. Heard over trachea and larynx.
Bronchovesicular- Moderate and mixed. I = E. Heard over major bronchi where fewer alveoli are located: posterior between scapulae especially on the right; anterior, around upper sternum in 1st and 2nd ICS. Vesicular- Low, and soft. Rustling like sound of wind in the trees. I > E. Heard over peripheral lunch fields where air flows through smaller bronchioles and alveoli. |
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Adventitious Breath Sounds (1536)- Coarse Crackes
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Loud, low-pitched, bubbling, and gurgling sounds that start in early inspiration and may be present in expiration; may decrease somewhat by suctioning or coughing but will reappear shortly; sound like opening a self-fastening velcro fastener.
Mechanism- Inhales air collides with secretions in trachea and large bronchi. Ex. Pulmonary edema, pneumonia, pulmonary fibrosis, and in terminally ill who have a depressed cough reflex. |
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Adventitious Breath Sounds (1536)- Atelectatic crackles
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Sound like fine crackles but do not last and are not pathologic; disappear after first few breaths; heard in axillae and bases (usually dependent) of lungs.
Mechanism- When sections of alveoli are not fully aerated, they deflate and accumulate secretions; crackles are heard when theses sections reexpand with a a few deep breaths. Ex. In aging adults, bedridden people or in people just aroused from sleep. |
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Adventitious Breath Sounds (1536)- Pleural friction rub
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Very superficial sounds that is coarse and low pitched; it has a grating quality as if two pieces of leather are being rubbed together; sounds just like crackles, but close to the ear; sounds louder if stethoscope is pushed harder onto chest wall; sound is inspiratory and expiratory.
Mechanism- Caused when pleurae become inflamed and lose their normal lubricating fluid; their opposing roughened pleural surfaces rub together during respiration; heard best in anterolateral wall where there is greatest lung mobility. Ex. Pleuritis, accompanied by pain with breathing (rub disappears after a few days if pleural fluid accumulates and separates pleurae) |
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Adventitious Breath Sounds- (1536)- Wheeze (High-pitched Rhonchi)
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HIgh pitched, musical squeaking sounds that predominate in expiration but may occur in both expiration and inspiration.
Mechanism- Air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors; passageway walls oscillate in apposition between closed and barely open positions; resulting sound is similar to a vibrating reed. Ex.- Obstructive lung disease such as asthma or emphysema. |
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Adventitious Breath Sounds (1536) Wheeze (low pitched rhonchi)
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Low-pitched, musical, snoring, moaning sounds; they are heard throughout cycle, although they are more prominent on expiration; may clear somewhat by coughing.
Mechanism- Air flow obstruction as described by vibrating reed mechanism above; pitch of wheeze cannot be correlated with size of passageway that generates it. Ex.- Bronchitis |
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Bronchoscopy (1537)
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A test used for diagnostic and therapeutic uses. Permits visualization of the larynx, trachea, and bronchi. Is useful for dx detection of tumors, inflammation or strictures as well as to obtain tissue biopsies. Therapeutic uses include removal of retained secretions or foreign bodies blocking air passages and to control bleeding within the bronchus.
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Asthma ABG assessment (1572)
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ABG results often show some degree of hypoxemia with elevated partial pressures of arterial carbon dioxide (PaCO2) in severe cases. If hypoxemia worsens acidosis can begin which can lead to respiratory or cardiac arrest.
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Asthma lung sounds
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Auscultation of breath sounds usually reveal wheezing, especially during expiration. The inability to auscultate wheezing in an asthmatic client with acute respiratory distress may be an ominous sign. It may indicate that the small airways are too constricted to allow any air flow. Bronchospasm's may lead to almost continuos coughing in an attempt to exhale and clear the airway.
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Asthma Physical Assessment (1571-1572)
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Clinical manifestations of asthma attacks include nasal flaring, pursed-lip breathing, and use of accessory muscles. Cyanosis is a late sign. Auscultation will likely reveal expiratory wheezing. Pulse oximetry usually reveals low oxygen saturation, and ABG shows elevated CO2 levels. May see tachypnea, and increased respiratory rate.
Ask clients to rate dyspnea on scale of 0 to 10. Determine medication allergies. Ask about history of cardiac disease, history of asthma, look for patterns to identify triggers, ask about current medications. Ask about the ability to manage and general adaptation to asthma, assess attitude of the family. |
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Critical Monitoring of Asthma (1574)
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Notify physician if client still has these manifestations after treatment for asthma:
Increased anxiety Increased respiratory rate and effort Feelings of not being able to catch ones breath Continued low oxygen saturation Wheezing, both inspiratory and expiratory Almost continuous nonproductive cough Nasal flaring as respiratory distress increases Lips pursed while exhaling Use of accessory muscles of breathing Increasing tachycardia (normal response to B-adrenergic med) Paradoxical pulse as bronchospasm worsens Cyanosis and CNS depression as late findings |
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Reasons for Poor Asthma Control (1580)
ICE |
Inhaler technique- check clients technique
Compliance- Ask when/how much medication client is taking Environment- Ask client whether something in environment has changed Also consider Alternative Diagnosis- Assess client for the presence of concomitant upper respiratory disease or alternative diagnosis. |
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Nursing Interventions for Asthma (1574-1577)
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Thorough assessment and history, assess client frequently observing respiratory rate and depth. Assess breathing pattern. Place client in Fowler position and give oxygen. Monitor ABG and O2 sat. Suction secretions as needed. Monitor color and consistency of sputum. Encourage effective coughing, increase fluids, humidify room, postural drainage, lung percussion, and vibration. Oral care ever 2-4 hours, Change client position frequently. Administer medications, assess sin and mucous membranes for cyanosis
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Asthma Treatment (1576)
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See Stepwise approach for managing asthma in adults. Most clients will have a quick acting inhaler, and possibly a steroid (for reduction of edema and spasm), a mast cell stabilizer (like cromolyn, and nedocromil to suppress the release of Broncho-constrictive substances during antigen-antibody reactions) or a Leukotrine modifiers.
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Asthma Teaching (1577-1578)
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Review self care section page 1577, and the Client education guide on page 1578
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COPD causes (1577)
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COPD refers to several disorders that affect the movement of air in and out of the lungs. Most important of these are obstructive bronchitis, emphysema, and asthma. Can occur as a result of increase airway resistance secondary to bronchial mucosal edema or smooth muscle contraction. May be a result in decrease elastic recoil which results in a decreased driving for to empty the lung.
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Emphysema Assessment and progressive changes (1581, 1586)
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Have progressive dyspnea on exertion that eventually becomes dyspnea at rest. The anteroposterior diameter of the chest is enlarged and the chest has hyper-resonant sounds to percussion. Chest films show overinflation and flattened diaphragms. ABG values are normal until later stages when compensated respiratory acidosis is often evident. The client may have an enlarged heard and right ventricular lift. The ECG shows right heart strain pattern and right axis deviation. May see cyanosis around lip, neck vein distention, and pitting peripheral edema.
Changes- frequent respiratory infections, altered normal respiratory defense mechanisms and immune resistance. Acute respiratory failure may develop. spontaneous pneumothorax may develop. May worsen at night. hypoxia. |
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Bronchiectasis (1590)
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An extreme form of obstructive bronchitis which causes permanent, abnormal dilation and distortion of bronchi and bronchioles. It develops when bronchial walls are weakened by chronic inflammatory changes in the bronchial mucosa and occurs most often after recurrent inflammatory conditions. Any condition producing a narrowing of the lumen of the bronchioles may result in bronchiectasis (TB, adenoviral infections, and pneumonia) Some forms are congenital and are associated with cystic fibrosis, sinusitis, dextrocardia (heart located on the right side), and alterations in ciliary activity (Karageners syndrome)
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Bronchiectasis symptoms (1590)
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Main-cough and purulent sputum production in large quantities. Fever, hemoptysis, nasal stuffiness, and drainage from sinusitis are common. Fatigue, weakness, and clubbing may be noted.
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Pulmonary Embolism Clinical Manifestations (1592)
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Tachypnea, dyspnea, anxiety or fretfulness, and chest pain. Hypoxemia. Chest pain is usually sudden and exacerbated by breathing. Apprehension, cough, diaphoresis syncope, and hemoptysis may occur. Respirations increase. Crackles, accentuated second heart sound, and fever may also develop. Heart gallops, edema, heart murmur, and cyanosis may also be seen.
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Pulmonary Embolism Assessment Findings (NCLEX RN 752)
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Apprehension and restlessness; blood-tinged sputum; chest pain; cough; crackles and wheezes on auscultation; cyanosis; distended neck veins; dyspnea accompanied by anginal and pleuritic pain, exacerbated by inspiration; feeling of impending doom; hypotension; petechiae over the chest and axilla; shallow respirations; tachypnea and tachycardia.
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Priority Nursing Actions to take if PE is Suspected (NCLEX RN 752)
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1. Notify the Rapid Response Team
2. Reassure the client and elevate the head of the bed. 3. Prepare to administer oxygen. 4. Obtain vital signs and check lung sounds. 5. Prepare to obtain an arterial blood gas. 6. Prepare for the administration of heparin therapy or other therapies. 7. Document the even, interventions taken, and the clients response to treatment. |
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Pulmonary Embolism Diagnostic Findings (1592)
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Pulse ox-low and may be unresponsive to supplemental oxygen.
ABG- low PaO2 (hypoxemia), low PaCO2 (hypocapnia). Severe respiratory alkalosis. Increase in LDH3. V/Q lung scan- lungs are scanned and the amount of radioactivity counted gives an indication of obstruction to flow. Spiral CT scan- good for those who are unstable or have limited cardiopulmonary reserve. PULMONARY ANGIOGRAPHY- only definitive means of dx of PE. A radiopaque contrast is injected into the right atrium and pulmonary artery via a catheter threaded through a peripheral vein. Visualization of any filling defects of the heart and right pulmonary artery is achieved by taking sequential radiographs. IT is invasive and reserved for cases in which the index of clinical suspicion is high despite nondiagnostic findings on other tests. D-diner plasma test- excludes PE when the value is below 500 ng/L. |
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Pulmonary Embolism treatments/medications (1593-1594)
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Stabilize the cardiopulmonary System- low flow oxygen by nasal cannula, endotracheal intubation (if needed), Hypotension treated with fluids, inotropic medications if fluids don't raise BP. Bicarbonate for acidosis.
Anticoagulation therapy- begin with IV heparin to reduce the risk of further clots and to prevent extension of existing clots. Administer until INR of 2.5-3.0. Warfarin is begun 3-5 days before heparin is stopped to provide a transition to oral anticoagulation. Clients are maintained on warfarin for 3-6 months. Fibrinolytic Therapy- may be used if client is hemodynamically unstable. The agents lyse the clots and restore right-sided heart function. |
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Pulmonary Embolism Surgical Management (1594)
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Vena cava filters may be used to allow blood flow while trapping emboli. they are less effective than anticoagulation and may lead to DVT. Used when anticoagulants are contraindicated or ineffective.
Embolectomy- surgical removal of the emboli from the pulmonary arteries by either a thoracotomy or an embolectomy catheter. Catheters use high velocity jets of saline to draw the thrombus toward the catheter tip and pulverize it. |
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Atelectasis, Causes and nursing interventions (1597)
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The collapse of alveoli or lung tissue which develops when the alveoli become airless from absorption of their air without replacement of the air with breathing.
Causes-inhalation of irritating anesthetics, localized airway obstruction, insufficient pulmonary surfactant, or increased elastic recoil. Common after surgery. Nursing Intervention- The primary goal of nursing intervention is to prevent! Frequent position changes, early ambulation, coughing and deep breathing, IS, pain medication to help in taking deeper breaths. If it does develop administer oxygen 1-4 L/min. Postural drainage, chest physiotherapy, and tracheal suctioning may be ordered. If caused by obstruction bronchoscopy may be used to remove material. |
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Box 62-1 Causes of Atelectasis (1598)
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Reduction in Lung Distention Forces
Pleural space encroachment(pneumothorax, pleural effusion, tumor) Chest wall disorders (scoliosis, flail chest) Impaired diaphragmatic movement (ascites, obesity) CNS dysfunction (coma, over-sedation, Neuromuscular disorders) Localized Airway Obstruction Mucus plugging Foreign body aspiration Bronchiectasis Insufficient Pulmonary Surfactant Respiratory distress syndrome Inhalation anesthesia High concentrations of oxygen (oxygen toxicity) Lung contusion Aspiration of gastric contents Smoke inhalation Increase elastic Recoil Interstitial fibrosis (silicosis, radiation pneumonitis) |
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Pneumonia signs and symptoms (1599 and NCLEX RN 750)
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Infection of the pulmonary tissue. The edema associated with inflammation stiffens the lung, decreases lungs compliance and vital capacity, and causes hypoxemia. (An inflammatory process in the lung parenchyma associated with marked increase in interstitial and alveolar fluid.
Chills, elevated temperature, pleuritic pain, tachypnea, rhonchi and wheezes, use of accessory muscles when breathing, mental status changes, sputum production, sweats, fatigue, dyspnea. |
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Pneumonia age considerations (1599)
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Advanced age is a major risk factor for developing pneumonia. Chronic disease states (diabetes, heart disease, chronic lung disease, renal disease, and cancer) also increase the risk. Many older adults have one or more chronic conditions which increases their risk for developing pneumonia. Older clients may present not with a fever of respiratory manifestations but with altered mental status and dehydration.
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Lung Abscess nursing interventions (1603)
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A collection of pus within lung tissue.
Antibiotics will be prescribed on the basis of culture results. Promote hydration, teach effective cough technique, administer postural drainage. Note color, quantity, quality and smell of expectorated material including presence of blood. Provide frequent opportunities for oral care. Observe condition of oral mucosa for Candida overgrowth. Encourage long term dental care. Nystatin my be ordered. Antibiotic therapy is needed for 8 weeks or longer. Teach about medication- the reasons for taking them; specific direction like the time of day, frequency, and when to take in relation to food; potential side effects; what to do if side effects occur. Reassessment after medication course is completed (sputum culture/chest film) is essential to evaluate the effectiveness of treatment. |
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TB- incidence (1604)
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One of the two most prominent mycobacterial diseases known to humankind. The CDC reports and estimated 2 billion people (1/3) of the worlds population is infected with the bacterium that causes tuberculosis. Was the leading cause of death in before the 1940s. Has been a marked decline, but between 1985 and 1992 the number of reported TB cases increased by 20%.
2005- 14,093 reported cases of TB in the US. HIV infected are more susceptible to TB because mycobacterium tuberculosis is very opportunistic. In some HIV-seropositive populations the TB rate is 1000-fold higher than the annual rate in the UNited states. |
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TB assessment (NCLEX RN 754, 1605-1606)
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S/SX- may be asymptomatic in primary infection, fatigue, lethargy, anorexia, weight loss, low grade fever, chills, night sweats, chest tightness and dull aching chest pain may accompany cough; persistent cough and the production of mucoid and mucopurulent sputum, which is occasionally streaked with blood.
Symptoms of Active TB- Pulmonary- Dyspnea, nonproductive or productive cough; hemoptysis; chest pain that may be pleuritic or dull; chest tightness; crackles may be present on auscultation. General- fatigue, anorexia, weight loss, low grade fever with chills and sweats Chest Assessment- Chest X-ray is not definitive but show presence of chest infiltrates with calcifications in upper lobes. In advanced stages- dullness with percussion over involved parenchymal areas, bronchial breath sounds, rhonchi, and crackles. Partial obstruction of a bronchus caused by endobronchial disease or compression by lymph nodes producing localized wheezing. |
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TB Treatment (1606-1607)
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a long-term process that should be initiated immediately upon suspicion of infection. With dx of active TB client will be started on a minimum of 4 medications to ensure elimination of resistant organisms. Treatment continues long enough to eliminate or substantially reduce the number of dormant or semi-dormant bacilli.
CDC recommends 2 phase approach. Induction phase using four drugs aimed at destroying large numbers of rapidly multiplying organisms. Continuation phase- usually using 2 drugs directed at eliminating remaining bacilli. The recommended treatment regiment is 2 months of isoniazid (INH), rifampin (RIF), pyrazinamide, and ethambutol. It is followed for 4 or 7 months of a combination of INH with either rifampin or rifapentine. If medication regimen does not seem effective then at lease 2 medications will be added to the failing TB treatment program Baseline studies are needed. |
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TB nursing interventions
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provide education about spreading of disease, teach about the side effects of medications, educate importance of medication compliance, adequate nutrition, increase intake o foods rich in iron, protein, and vitamin C, cover mouth and nose when coughing or sneezing, frequent hand washing, sputum cultures
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HIstoplasmosis (1610 and NCLEX RN 753)
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Mild forms do not require treatment. Progressive, disseminated or chronic forms are usually treated with intravenous itraconazole or amphotericin B until the client is asymptomatic for 7-10 days.
Nursing Interventions- Administer oxygen, monitor breath sounds, administer anti-emetics, antihistamines, antipyretics, and corticosteroids as prescribed, administer fungicidal medications as prescribed, encourage coughing and deep breathing, place client in a semi fowlers position, monitor vital signs, monitor for nephrotoxicity from fungicidal medications, instruct client to spray the floor with water before sweeping barn and chicken coops. |
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Chest Tube Drainage (1617)
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Measure and document the amount of drainage coming from the pleural space in the collection chamber. Helps determine the amount of blood loss and the flow rate of drainage from the pleural space. Drainage rates and amounts are used in planning blood replacement and assessing the clients status.
500-1000 ml of drainage may occur in the first 24 hours after chest surgery. Between 100 and 300 ml of drainage during the first 2hours, but then it should lessen. Chest drainage is grossly bloody immeidatly following surgery but it should not continue for more than several hours. Suspect hemorrhage if pulse becomes rapid and BP drops. If fluid levels do not rise, chick tubes for patency. |
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Reasons to notify the physician regarding Chest Drainage (1617)
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1. The drainage remains frankly bloody for longer than the first few post operative hours
2. Bleeding recurs after it has slowed 3. There are any other manifestations of hemorrhage |
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Chest Tube- Observe the water seal (1622)
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Fluid in the water-seal compartment should rise with inspiration and fall with expiration. When tidaling occurs, the drainage tubes are patent and the apparatus is functioning properly. If it does not occur:
1. Check to make sure the tubing is not kinked or compressed 2. Change the clients position 3. Have the client deep breathe and cough 4. If tidaling does not return, notify the surgeon. |
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Chest Tube bubbling (1622)
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Intermittent bubbling- is normal on expiration and indicates that the system is removing air from the pleural space.
Continuous bubbling- during both inspiration and expiration indicates that air is leaking into the drainage system or pleural cavity. Try to correct by: 1. locate the sources of the leak and repair it if you can. Begin inspection at the chest wall where the catheters are inserted. 2. if a catheter is loose, or partially removed, gently squeeze the skin up around the catheter or apply sterile petroleum gauze around insertion site. See if this stops the continuous bubbling. 3. If leak continues, check the tubing, inch by inch and all connections. If found it may be sealed with tape. 4. If leak is still not located, the entire drainage system may need to be replaced. Rapid bubbling- in the absence of air leak indicates a considerable loss of air as from an incision or tear in the pulmonary pleura. Notify the physician ASAP. May need to apply suction, increase the amount of suction, or thoracotomy to prevent collapse of the lung or mediastinal shift. |
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Chest Tube suctioning (1622)
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May be needed for 24 to 72 hours following surgery.
Wet suction control- suction typically 10-20 cm H2O. If an atmospheric air vent is occluded it can be very dangerous because it causes the suction to be applied directly to the pleural cavity. Dry suction control- up to 40 cm H2O of suction may be applied. Suction greater than 50 cm H20 may cause parenchymal damage and should not be applied by any type of system. |
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Chest tube suction apparatus function (1623)
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WAtch for bubbling. Absence of bubbling in a a suction-control chamber means that the system is not functioning properly and the correct level of suction has not been maintained. May be caused by large amount of air leaking into the pleural space or into the drainage apparatus and mechanical problems in the regulator. The most serious probelm is air leaking into the pleural space. Check for leaks by briefly clamping the chest drainage tube close to the clients body and observing the chamber. If bubbling in the control chamber-problem is air leaking into the pleural space and should attempt to correct with petrolatum gauze. If no bubbling in control chamber- problem is the connections or the regulator. Try to correct.
When the chest tube is clamped during examination watch client closely for signs of tension pneumothorax (dyspnea, tachycardia, hypotension, and tracheal shift) |
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Chest Tube-promote drainage (1623)
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Drainage systems must be placed lower than the clients chest (1-2 feet). THey must be placed upright on the floor or hug from the foot of the bed. If moving a client with a closed drainage system always keep the system below the chest. Even momentary elevation can cause fluid from drainage system to be siphoned back into the pleural cavity. Tubes may be clamped only if absolutely necessary. Make sure the client does not lie on the tubing causing compression or kinking. Coil drainage tubing on the clients mattress so it falls straight into the drainage apparatus.
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Chest tube removal (1624)
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Dr determines when to remove chest tubes. The lung must be reexpanded (seen as cessation of tidaling in the water seal chamber). Chest auscultation, percussion, and radiographs confirm lung reexpansion. Usually occurs 2-3 days postoperatively, but are generally left in place for 24 after all air and significant fluid drainage have stopped. May clamp temporarily to see if client will tolerate removal.
May not be removed if chest is draining more than 50-70 ml of fluid/day. Removal is moderately to severely painful, and premedication 30 min before removal is recommended. will need sterile scissors, suture removal kit, sterile petrolatum gauze, 4x4 gauze to cover wound, and occlusive waterproof tape. |
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Chest Tube accidental removal (1624)
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cover the insertion site with sterile petrolatum gauze and notify the surgeon. DO NOT apply an occlusive dressing because it increases the clients risk of developing a tension pneumothorax. Observe the client closely and remove the petrolatum gauze to allow air to escape if respiratory distress develops.
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Cystic Fibrosis (1627)
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A multi-system disorder (autosomal recessive trait disorder) characterized by exocrine glad dysfunction. The mucus produced by the glands is abnormally thick, tenacious, and copious, causing obstruction of the small passageways of the affected organs (respiratory, GI, and reproductive system) Is a progressive and incurable disorder, and respiratory failure is a common cause of death; organ transplantations may be an option to increase survival rates. (NCLEX RN 446)
A congenital restrictive lung disorder in which the secretions of the exocrine glands are abnormal. Affects the sweat glands, respiratory system, digestive tract (pancreas), and reproductive tract. The most common inherited genetic disease in the Caucasian population. |
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Cystic Fibrosis Nursing Diagnosis
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Psychosocial concerns are a nursing priority
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Lung Transplantation (1628-1629)
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The definitive therapy for many end-stage lung diseases that are unresponsive to treatment.
Preop- med and psych evaluation, tests to rule out active infection and evaluate cardiac, hepatic, hematopoietic, and renal functions; (smoking, poor nutritional status, active non-pulmonary infection, disease in other organ systems will be ruled out as a transplant candidate) Postop- observe for bleeding. Pulmonary edema may develop in the denervated transplanted lung, so the cline will be placed on mechanical ventilation with Positive end-expiratory pressure (PEEP) for 24-48 hour. Fluids are restricted. Client is at risk for infection, organ rejection, pneumothorax, pleural effusions, pulmonary embolism, venous thrombosis, lung hyper inflation, and phrenic nerve injury. Isolation is used. Watch for signs of infection. Cyclosporin A is the most important immunosuppressive agent for lung transplants to avoid rejection. |
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Lung Transplant Self Care (1629)
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Teach about medication regiment, need for daily medications. Report fever, dyspnea, cough, new or increased productive sputum, chest pain, reduced exercise intolerance, excessive weight gain, and fatigue to the physician.
At follow up monitor for signs of rejection, compliance with immunosuppressive therapy, and progress in functional status. |
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Modes or Mechanical Ventilation (1642)
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Continuous mandatory ventilation (CMV), aka assist control A/C- delivers gas at preset tidal volumes.
Pressure controlled ventilation- delivers gas at preset pressures over a set inspiratory time Pressure support ventilation Intermittent ventilation |
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CMV or A/C
Continuous mandatory ventilation (1642) |
Delivers gas at preset tidal volumes.
Application- primary ventilatory mode in clients who are apneic or have weak respiratory efforts. Nursing implication- May hyperventilate, sedation may be needed to control spontaneous breaths. |
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Pressure Controlled Ventilation (1642)
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Delivers gas at preset pressures over a set inspiratory time.
Application- Primary ventilatory mode for clients with changing pulmonary mechanics, such as airway resistance or lung compliance (ARDS) NI- Increase thoracic pressure may lead to decreased cardiac output for impaired venous return. Requires sedation and/or paralysis |
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Pressure Support Ventilation (1642)
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Application- primary ventilatory mode for clients with stable respiratory drive to overcome airway resistance form ET tube. Primary weaning mode.
NI- Client should have less work to breathe, monitor for hypercapnia |
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Intermittent mandatory ventilation (1642)
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Application- Primary ventilatory mode for clients with decreased lung compliance or increased airway resistance. Occasionally used for weaning.
NI- Monitor for hypercapnia |
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Pressure cycled ventilation (1642)
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Delivers a volume of gas to the airway using positive pressure during inspiration. The positive pressure is delivered until the preselected pressure has been reach, then the ventilator will cycle into passive exhalation.
Disadvantage- the volume delivered may not be sufficient depending on the compliance of the lung and the integrity of the ventilatory circuit. |
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Volume-Cycled ventilation (1642)
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Delivers a preset tidal volume of inspired gas. The TD has been preselected based on ideal body weight, and is delivered to the client regardless of the pressure required to deliver this volume. The ventilator automatically adjusts to the pressure needed to deliver the preset volume. a pressure limits can be set to prevent dangerously high airway pressures.
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Time Triggered Inhalation (1642)
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used to manage clients who cannot breathe on their won. The ventilator will trigger a breath after a preset time, serving as back up in case a clients own breathing rate falls below a preset value.
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Negative Pressure inhalation (1642)
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triggered by the initial negative pressure that begins inspiration. AS soon as the client initiates a breath the ventilator is triggered to produce inhalation. Set to reduce the workload of breathing. Pressure fluctuations like hiccoughs, or leaks can cause premature triggering.
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Flow-triggered inhalation (1642)
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Occurs when the client can initiate a breath. The ventilator completes the breath by sensing the flow of air into the chest. Works well in combination with PEEP.
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Volume-Triggered ventilation (1642)
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occurs when the ventilator completes the breath to maximize inhaled gas volumes.
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Positive End-Expiratory Pressure (1643)
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applied during expiration to prevent intrathoracic pressures from returning to ambient atmospheric pressure. PEEP is applied during mechanical ventilation and is used to apply positive airway pressure that keeps the alveoli open and reduces the amount of shunting with the goal that the FiO2 may be reduced to the lowest level to maintain gas exchange and to prevent O2 toxicity. The pressure increased functional residual capacity (FRC) and enhances oxygenation as a result of enlarged surface area that is available for diffusion. Pressure of 10-25 cm H2O are used in adults.
Risks- over-distention of the alveoli, V/Q mismatch, subcutaneous emphysema, and decreased cardiac output from increased intrathoracic pressure. |
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Mechanical Ventilation- (1641-1652)
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Review pages in the book, too much information to write out!
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Adult (Acute) Respiratory Distress Syndrome (1652)
ARDS |
A sudden, progressive form of respiratory failure characterized by severe dyspnea, refractory hypoxemia, and diffuse bilateral infiltrates.
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ARDS assessment/clinical manifestations (1653)
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Early manifestations- 12-24 hours after injury- increased respiratory rate and profound dyspnea. Breathing becomes increasingly labored; client may show air hunger and retractions. Chest auscultation may or may not reveal adventitious sounds (from fine inspiratory crackles to widespread coarse crackles). ABG increase hypoxemia <60 that does not respond to increased inspired oxygen levels (FiO2 <40%). initially respiratory alkalosis leading to metabolic acidosis.
Chest x-ray- diffuse, bilateral, rapidly progressing interstitial or alveiolar infiltrates. (in absence of fluid overload). ratio of PaO2 to FiO2 is < or = to 200 mm Hg (regardless of PEEP) PAWP < or = to 18 mm Hg. |
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ARDS Treatments (1654) (from the concept maps)
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AFter initial injury give prophylactic antibiotics and anti-inflammatory agents.
Give oxygen antioxidants to reverse o2 toxicity- scavenge oxygen free radicals- N-Acetylcysteine and procysteine are effective in reducing the degradative effect of the proteases. mechanical ventilation with modest tidal volumes hemodynamic agents to improve cardiac output- Inotropic agents like dobutamine or dopamine m improve CO and increase systemic BP. Fluids are monitored to prevent fluid overload. Place client in prone position- used to improve oxygenation by changing the distribution of perfusion. A change in the dependent part of the lung results in increased perfusion to the less damaged portions of the lungs and decreased pulmonary shunting. Reduce compression of the lung by the heart, improve chest wall compliance, and results in better draining of bronchial secretions. Administer surfactants-successful in neonates but not had same results in adults. Mechanical ventilation with PEEP- to maintain oxygen saturation at or above 90% (maintain adequate blood oxygen levels). PEEP is used to decrease intrapulmonary shunting and to recruit collapsed alveoli. Nitric Oxide (NO)-selective vasodilation in pulmonary vascular system and a powerful bronchodilator. Inhaled NO dilates capillary bed of the lungs which reduces the pressure in the pulmonary arteries without lowering systemic BP. Kinetic therapy via a continuously rotating bed may improve ventilation. Movement of at lease 45 degrees from side to side is needed. Beware of sacrum shearing. Assess body twice daily. |
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ARDS complications (1656-1657)
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Monitor for cardiac dysrhythmias (caused by hypoxemia), O2 toxicity, renal failure, thrombocytopenia, GI bleeding, sepsis from invasive lines, DIC.
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ARDS Nursing Management (1657)
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Place client in prone position, evaluate client's response to treatment as well as carefully monitor for complication. Emotional support for the client's family and significant others. Clear communication and frequent condition updates are essential to keeping the family adequately informed.
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Universal Blood Donor/Recipient (1658)
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If blood is needed before results of typing and crossmatching are available the client is given O-NEGATIVE BLOOD!
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Flail Chest(1659)
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has paradoxical movement of a segment of the chest wall caused by fractures of 4 or more ribs anteriorly and posteriorly within each ribs. The end of the fractured rib may tear the pleura and lung causing hemopneumothorax. The flail section floats moving independently of the chest wall during ventilation causing the underlying lung tissue to be sucked in with inspiration (instead of expanding outward) and blown out with expiration (instead of collapsing inward).
S/Sx- hypoventilation and hypoxia may result. Client may experience emotional and physical distress while trying to breathe despite excruciating pain. Respirations are rapid, shallow, and labored. Paradoxical movement can be seen. Breath sounds may be absent or decreased on the affected side and crepitus may be heard or felt. Treatment- usually intubation and mechanical ventilation to accomplish: restore adequate ventilation, thus reducing hypoxia and hypercapnia Decrease paradoxical motion by using positive pressure to stabilize the chest wall internally. Reduce pain by decreasing movement of the fractured ribs. Provide an avenue for removal of secretions Internal stabilization with continuous ventilation may require 21 days or more. Muscle relaxants or paralyzing agents may be administered to reduce the risk of separation of the healing costochondral junctions. |
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Sucking Chest Wound (1662)
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a traumatic open pneumothorax. A traumatic opening in the chest wall that is large enough for air to move freely in and out of the chest cavity during ventilation. This abnormal mvmt of air through the chest wound produces a sucking noise that is audible in a quiet environment.
If this occurs immediately cover the wound securely with anything available. Fix the temporary dressing in place with several strips of wide tape. If the client is awake and cooperative, have them take a deep breath and try to push it out while keeping the mouth and nose closed. This pushing effort against the closed glottis helps to push air out through the wound and reexpand the lungs. When client does this place dressing before the client inhales again. Stay with client. Carefully assess for indications of tension pneumothorax and mediastinal shift (heart, great vessels, trachea, esophagus) are pushed to the unaffected side. If this appears to be developing after the wound is sealed, unplug the seal and allow the air to escape. Closed chest drainage is necessary to remove the air from the pleural space and allow the lung to reexpand if it is collapsed. |
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Mediastinal Flutter (1662)
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A complication which results from air rushing in and out of ht ethoracic cavity on the affected side. With inspiration the mediastinal structures (heart, trachea, esophagus) and collapsed lung are pushed toward the unaffected side. With expiration these structures then move back toward the affected side. Fluttering back and forth movements of these vital mediastinal structures produce severe cardiopulmonary compromise, which is fatal if not treated promptly. Chest tubes must be inserted on affected side away from the open wound.
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Near Drowning Assessment (1664)
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May see pink frothy sputum (indicates pulmonary edema). Auscultation may reveal crackles, rhonchi, and wheezes. WBC may be elevated.
Begin assessment with ABC. If possible spinal injury, immobilize the spine. CPR should be initiated if necessary and continued especially in hypothermic clients (may be successful long after typical CPR guidelines would indicate discontinuation). Obtain history of submersion including length, temp of water, injuries, and type of water. Assess LOC. Note respiratory efforts and adventitious sounds. Open airway while maintaining spinal immobility. Look for signs of hypoxia (confusion, irritability, lethargy, unconsciousness) Obtain vitals. For respiratory insufficiency, intubate and ventilate with 100% oxygen and 5-10 cm of PEEP to prevent alveoli from collapsing. If client is breathing provide support with non-rebreather mast. Monitor neurologic status carefully. Deteriorating LOC may indicate cerebral edema, severe acidosis, or increased hypoxia. |
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Carbon Monoxide Poisoning- Treatments (1665)
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Removal of CO fro the body is imperative. administering 100% oxygen will shorten the half-life of CO to 80 minutes. Hyperbaric oxygen may be needed to reduce the half life of CO to minutes by forcing it off the hemoglobin molecule for clients with severe CO poisoning. Hyperbaric oxygen will decrease the half-life of CO to 23 minutes.
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