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61 Cards in this Set
- Front
- Back
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Pneumonia (Patho/causes) |
-acute infection of lungs, occurring when infectious agent enters and multiplies in lungs -bacterial, viral, fungal, aspiration, hypostatic, chemical -elderly= serious risk for complications (pleurisy, pleural effusion, atelectasis, sepsis, meningitis, pericarditis, endocarditis) |
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Pneumonia (s/s) |
-fever, chest pain, dyspnea, shaking chills, productive cough (sputum may be purulent or blood tinged) -assess: crackles/wheezes, CXR, sputum and blood cultures, accessory muscle use, skin color, mucous membranes -atypical: fatigue, sore throat, dry cough, N/V -elderly: new onset confusion, lethargy, fever, dyspnea |
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Pneumonia (Nursing Interventions) |
-Relieve symptoms -Airways free of secretions -Dyspnea and fever under control -Assist with ADLs -Fluid replacement -Room humidified -Expectorants, antibiotics, acetaminophen -Cough, deep breathe q1-2hr -Chest PT (loosen sputum) -Position: semi-fowlers |
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Bronchitis |
-acute (inflammation of bronchial tree with increased mucous and inflammation, congested airways, usually following upper resp. infection) -chronic (symptoms >3 months/year for at least 2 consecutive years) -tx with antibiotic if bacterial -expectorant during day, suppressant at night |
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TB (Patho/causes) |
-chronic infectious disease that usually affects lungs, can involve other organs -can survive in dark environments but killed by direct sunlight -acid-fast bacillus -transmitted by droplet nuclei -pt becomes infected, may or may not develop active disease ("latent" if no infection) -immune system surrounds infected area with neutrophils and macrophages to seal off area/prevent spread |
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TB (risk factors, s/s, precautions) |
-crowded, poor ventilation, elderly, reactive from prior exposure, alcohol, immunocompromised, AIDS -night sweats, fatigue, blood-tinged/purulent sputum, afternoon fever, wt loss, anorexia -diagnose: PPD test to check for exposure, then CXR, sputum for AFB, bronchoscopy -filtration masks, (-)pressure room, notify infection control |
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TB Treatment |
-Multiple steps, up to 2 years, usually use 2-3 antibiotics, directly observed therapy if needed -Isoniazid (periph. neuropathy) -Rifampin (body fluids red/orange) -Pyrazinamide (gout-like s/s) -Ethambutal (optic neuritis, hepatotoxic) -remain isolated until sputum no longer contains TB |
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Restrictive Disorders- Pleurisy |
-membrane around lungs become inflamed- friction- increase in formation of pleural fluid -underlying resp. disorder -pleural friction rub, sharp pain with inspiration, shallow breaths -NSAIDs, pain control, cough/deep breathe -complications: pleural effusion, empyema, difficulty breathing |
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Restrictive Disorders- Pleural Effusion |
-excess fluid in pleural space -transudative (watery)- HF, liver, kidney; exudative (WBC, proteins)- infections, lung cx -SOB, pain, cough, tachypnea, dyspnea, lung sounds diminished or absent over effusion, poss friction rub -BR, chest tube, poss thoracentesis |
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Restrictive Disorders- Atelectasis |
-collapse of alveoli -post-op or other sources of hypoventilation -asymmetrical lung sounds, decreased lung sounds -cough/deep breathe, ambulate, position changes (sometimes laying on affected side for short periods will help reduce chest wall movement/pain), pain control -complications: pneumonia, infection |
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Croup- Acute, spasmodic |
-3 mon-3yrs -abrupt onset, usually night -viral -afebrile, barky cough -usually mild -night air, steroids, shower |
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Croup- Laryngotracheitis |
-3 mon-8yrs -gradual onset -viral/RSV -stridor, retractions -very serious -albuterol, epi, steroids |
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Croup- Laryngotacheo bronchits |
-3mon-4yrs -onset over couple of days, winter, males>females -viral/RSV -Steeples sign on xray -serious esp <6mon -airway support, o2, steroids |
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Croup- bacterial tracheitis |
-1 mon-13yrs -may be gradual onset -bacterial -position of comfort- laying down -may need airway support, antibiotics, suction |
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Croup- epiglottitis |
-2yrs-8yrs -sudden onset -bacterial (Hbb vaccine usually protects) -tripod/sniffing position, drooling -needs airway support -airway in OR, do NOT try to visualize throat/place anything in mouth |
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Cystic Fibrosis (patho, cause, diagnose) |
-genetic defect in protein that disrupts functioning of exocrine glands that affects organs by causing ducts or tubes to become clogged (airways, small intestines, pancreas, sweat glands) -both parents must be carriers -diagnose: CXR, sweat chloride test (check for level of chloride, Na in sweat- not reabsorbed as pass thru sweat ducts)
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Cystic Fibrosis (s/s) |
-thick sputum, frequent resp infections, coughing and purulent drainage, clubbed fingers -late: hemoptysis (bld tinged sputum), more frequent infections, resp failure, antibiotic resist -lack of pancreatic enzymes from blocked ducts- malabsorption syndrome (frequent foul smelling stools) |
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Cystic Fibrosis Nursing Interventions |
-no cure, control infections -enzyme replacement, monitor blood glucose -remove thick sputum -high cal, nutrient rich diet |
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Asthma (Patho, s/s) |
-inflammation and edema of mucosal lining of airways and spasm of bronchial smooth muscles (bronchospasm) -children not diagnosed til after age 5 -recurrent episodes of wheezing, breathlessness, chest tightness, coughing, rapid resp to compensate (hyperventilate), may become cyanotic (need o2 therapy) |
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Asthma (triggers, meds) |
-allergens, pollutants, smoke, foods, medications, pet dander, molds, dust mites, emotional stress, exercise, resp infection -adrenergic bronchodilators or beta agonists (albuterol), corticosteroids (fluticasone), combo agents (advair, symbicort) |
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COPD (chronic obstructive pulmonary disease) |
-4th leading cause of death in US -pulmonary disorders, difficulty exhaling (Obstructive=difficult to get air Out) -chronic bronchitis (inflamed airway with thick mucous and productive cough) -emphysema (alveolar walls lead to large, abnormal air spaces in lunges because of loss of elastic recoil, unable to expel inhaled air which gets trapped) -asthma (unremitting to tx) |
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COPD (s/s) |
-cough, chronic sputum production, dyspnea every day (worse with exercise), activity intolerance, crackles, wheezes, diminished breath sounds, barrel chest, use of accessory muscles |
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COPD Stages |
I. Mild- mild airflow limitation, sometimes cough and sputum II. Moderate- airflow limitation worsens, SOB on exertion, may seek medical help at this stage III. Severe- increasing airflow limitation and SOB, decreased quality of life IV. Very Severe- severe airflow limitation, significant reduction in quality of life, exacerbations may be life threatening, O2 administered
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COPD Meds |
-adrenergic bronchodilators (albuterol)- dilate bronchioles, SE: increased HR, tremor -anticholinergic agent (atrovent, Spiriva)- bronchodilation, SE: dry mouth -nebulizer -corticosteroids (prednisone, flovent)- IV faster, with acute exacerbations -combo (advair)- daily, not rescue inhaler |
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COPD Nursing Interventions |
-smoking cessation -avoid aerosols -vaccines -fluids -cool mist humidification -chest physiotherapy -pulmonary rehab -high protein diet -diaphragmatic or pursed lip breathing -surgery, mechanical ventilation, hospice |
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Trauma- Pneumothorax |
-air enters pleural space and lung collapses d/t neg pressure -spontaneous (no injury) or traumatic -open (air can enter and escape), closed (air collects in space and can't escape), tension (closed, air and tension build up, pressure on heart/great vessels) -hemothorax (blood in pleural space) -sudden onset dyspnea, chest pain, tachypnea, asymmetrical chest expansion, diminished/absent breath sounds on affected side -may absorb with rest/O2, small needle in pleural space, chest tube, pleurodesis (talc/antibiotics, painful) |
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Pneumothorax S/s (P-Thorax) |
P- pleural pain T- trachea deviation H- hyperresonance O- onset sudden R- reduced breath sounds (+dyspnea) A- absent fremitus X- x-ray shows collapse |
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Trauma- Rib fracture |
-most common chest wall injury -pain on inspiration, coughing, crepitus, decreased breath sounds -complications: pneumonia, atelectasis, resp failure -don't use binders/belts bc restrict resp depth, ribs heal in about 6 wks, pain control |
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Trauma- Flail Chest |
-2 or more adjacent ribs broken and part of chest wall is free-floating -"paradoxical respiration"- affected part of chest collapses with inspiration, bulges with expiration -chest movement opposite to normal resp, dyspnea, tachypneic, tachycardic -O2 and pain meds, may need intubation, mechanical ventilation and/or chest tube |
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Pulmonary Embolism (patho/cause) |
-foreign object in pulmonary artery (usually blood clot) -ventilation-perfusion mismatch (area of lung is well ventilated with air but has no blood flow [perfusion], becomes dead space- impaired gas exchange) -most originate in deep veins of LE (DVT) |
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Pulmonary Embolism (Risk Factors of DVT/PE) |
-surgery under gen anesthesia -HF -fractures of LE -immobility -obesity -oral contraceptives -smoking -amniotic fluid embolism during l/d -air embolism from entry of air into bloodstream |
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Pulmonary Embolism (s/s, complications, diagnostics) |
-sudden onset dyspnea, gasping for air/anxious, tachycardia, tachypnea, cough, crackles, or friction rub, may have hemoptysis and pleuritic chest pain -complications: pulmonary hypertension- decreased cardiac output- pt becomes hypotensive -diagnose: spiral CT scan (uses contrast dye), ventilation-perfusion scan, pulmonary angiogram (uses radiopaque dye), D-dimer (rule out, D-dimer is fibrin fragment found in blood after thrombus formation) |
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Pulmonary Embolism Nursing Interventions |
-At risk: heparin/Coumadin, teds, SCDs -O2 (help dilate pulmonary vessels) -Blood thinners and clotting studies -Watch for bleeding/protect against it (slippers, soft toothbrush) |
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Acute Respiratory Failure (Patho/causes) |
-pt is unable to maintain adequate blood gas values -hypoxia may result from inadequate ventilation -hyercapnia and resp acidosis occur when lungs are unable to eliminate CO2 -chronic airway obstruction, CNS disorders (stroke, spinal cord injury, myasthenia gravis), inhalation of toxic substances, opioid overdose, aspiration -carefully monitor resp status when giving sedatives/narcotics (avoid/use carefully in pts with chronic resp disease) |
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Acute Respiratory Failure (s/s, diagnostic) |
-restless, confused, agitated, sleepy, cyanotic, dyspneic, resp rate rapid/deep -arterial blood gases show decreasing PaO2 and ph, increasing PaCo2 (resp acidosis) -diagnose: Pa02 below 60mmHg, PaCo2 above 50mmHg (in pts with chronic resp disease who have adapted to impaired gas exchange, drop in Pa02 10-15mmHg) |
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Acute Respiratory Failure Nursing Interventions |
-high flow O2 (if CO2 retainer- may need mechanical ventilation if requiring >1-2L) -antibiotics, bronchodilators, suctioning |
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Respiratory Acidosis |
-pH DOWN (<7.35), PaCo2 UP (>45), HCO3 [compensated]UP (>26), [uncompensated] NORMAL
-hypoventilation, respiratory failure |
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Respiratory Alkalosis |
-pH UP (>7.45), PaCo2 DOWN (<35), HCO3 [compensated] DOWN (<22), [uncompensated] NORMAL
-hyperventilation |
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Metabolic Acidosis |
-pH DOWN (<7.35), HCO3 DOWN (<22), PaCo2 [compensated] DOWN (<35), [uncompensated] normal
-DKA, shock, renal failure, prolonged diarrhea |
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Metabolic Alkalosis |
-pH UP (>7.45), HCO3 UP (>26), PaCo2 [compensated] UP (>45), [uncompensated] normal
-excess vomiting, long-term NG tube |
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Diagnostic Tests- Serum blood tests |
-RBC&Hgb- O2 carrying capacity (decreased RBC, dyspnea) -WBC >10,000 indicates infection |
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Diagnostic Tests- Cultures |
-Sputum C&S- identify pathogen, obtain before starting antibiotics, cough and deep breathe before collecting -Throat- identify infections of pharynx, don't culture child at risk for laryngeal spasm (croup), aim for red/open lesions, squeeze culture media vial and send to lab immediately |
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Diagnostic Tests- ABGs |
-measures gas exchange from arterial blood sample (radial artery, painful, hold pressure for 5 min) -PaO2 (how much O2 in blood) -pH (level of acid-base balance in body) -PaCo2 (how well lungs are eliminating CO2) -HCO3 (kidney's ability to remove bicarbonate from body)
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Diagnostic Test- O2 Sats |
-tells percent of hemoglobin saturated with O2 -Normal is >95, emergency is <75 -Possibly inaccurate: nail polish, anemia, low blood flow/perfusion, movement, smoke inhalation, carbon monoxide poisoning |
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Diagnostic Tests- CXR |
-help diagnose pulmonary disorders -can be done at bedside |
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Diagnostic Tests- Ventilation-Perfusion Scan |
-radioactive substance injected IV and scan done to show blood flow (perfusion) to lungs -radioactive substance inhaled and shows how well O2 is distributed to lungs (ventilation) -good ventilation, poor perfusion could be PE -poor vent/perfusion- chronic lung disease |
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Diagnostic Tests- Pulmonary Function Studies |
-series of tests to determine lung volume, capacity, flow rates; diagnose/monitor obstructive disease; use peak flow monitor |
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Diagnostic Tests- Pulmonary Angiogram |
-IV of radioactive dye (catheter in vein, dye inserted into pulmonary artery), then x-ray of pulmonary vessels -diagnose PE/other pulm vessel disorders
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Pulmonary Angiogram Nursing Interventions |
-NPO 4-8hr before -Ask about allergies to dye -Tell pt may cause warm feeling -Consent form signed -Meds for comfort before/after -Post- flat in bed 3-8hr to prevent bleeding from injection site, monitor vitals, observe for bleeding, sandbag for pressure on site, increase fluids to excrete dye |
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Diagnostic Tests- Bronchoscopy |
-flexible endoscope to examine larynx, trachea, bronchial tree -diagnostic for visualization or obtain biopsy, therapeutic to remove obstruction |
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Bronchoscopy Nursing Interventions |
-Tell pt they can breathe thru nose and O2 can be administered -NPO 6-8 hr before -Consent form -Administer sedative, atropine (dry secretions), anesthetic spray -Post- monitor vitals, watch for laryngeal edema, sputum may be blood-tinged, NPO until gag reflex returns |
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Smoking Cessation |
-most important intervention for preventing/treating resp disorders -behavior modification, counseling, setting quit date, nicotine replacement therapy, drug therapy, acupuncture |
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Deep Breathing/Coughing |
-effective coughing=secretions, ineffective= exhausting, fails to bring up secretions -2-3 deep breaths with diaphragm and hold for a couple seconds then cough forcefully -every 1-2hr prn -good hydration |
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Huff Coughing |
-COPD -exhale deeply -keep glottis/mouth open and use abdominal muscles to create series of forced expirations, moving air and mucous up bronchial tree ("huff" sounds) -one more controlled inhalation and final huff cough to expel mucous |
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Breathing Exercises |
-Diaphragmatic (relax/conserve energy)- push out abdomen on inhale, relax abdomen on exhale -Pursed lip (when feeling SOB, promotes CO2 excretion)- done with diaphragmatic breathing, inhale slowly thru nose to count of 2, exhale thru pursed lips to count of 4 |
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Positioning |
-SOB- position to conserve energy/allow max lung expansion (Fowlers or Semi-Fowlers) -Sit in chair while leaning forward and elbows on knees or table (tripod position) -Unilateral lung disease ("good lung down")- side lying with good lung in dependent position, allows greater blood flow to dependent/good lung and raises O2 Sats |
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Incentive Spirometry |
-encourage deep breathing in pts at risk for collapse of lung tissue (atelectasis) -10x/hr when awake |
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Chest Physiotherapy |
-postural drainage, percussion, vibration -pts with weak/ineffective cough who are at risk for retaining secretions -head down, turned periodically, cupped hands to strike chest -give neb before to humidify secretions, cough and deep breathe during and after |
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Flutter Clearance Device |
-pt blows into mouthpiece, steel ball sends vibrations to loosen mucous -creates (+) pressure which opens airways |
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Thoracentesis |
-insertion of needle into pleural space -aspirate fluids in pts with pleural effusion (fluid trapped in pleural space), aspirate blood or air or inject meds -diagnostic to determine source of fluid -decrease resp distress |
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Thoracentesis Nursing Interventions |
-consent form if needed -void before -sensation of pressure, severe pain is rare -may administer analgesic -pt sitting, bending over table, or side-lying -sterile equipment -physician uses local anesthetic, can remove up to 2L fluid -usually immediate decrease in dyspnea -after: petroleum jelly dressing to prevent air leaking into wound, bedrest 1hr, vitals, may have xray to ensure lung not punctured |
