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70 Cards in this Set
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- 3rd side (hint)
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optimal positioning for unilateral lung disease?
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good side down
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describe pneumonia
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Inflammation of the lung parenchyma caused by 1) bacteria, 2) mycoplasm, 3) fungi or 4) viruses
Exudate accumulates in the alveoli and interferes with gas exchange |
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s/s pneumonia
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Cough, fever, chills*
Headache, malaise Myalgias (muscle pain), fatigue Pleuritic chest pain Tachypnea, dyspnea Tachycardia Use of accessory muscles Purulent sputum Rusty, yellow, green, red Abnormal breath sounds Crackles, rhonchi, wheezing Pleuritic friction rub side 3 diagnosis of pneumonia |
History and physical exam
CXR or CT scan Blood and sputum cultures (C&S) Elevated WBC with bands Arterial blood gas |
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nursing/medical treatment of pneumonia
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Antibiotics
Oxygen High calorie and high protein diet Semi-Fowler’s position Bronchodilators Antipyretics Encourage oral fluids Bed rest with passive range of motion |
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possible complications of pneumonia
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Shock and respiratory failure (dehydration, sepsis)
Pleural effusion (collection of fluid in pleural area. Thoracentesis.) Confusion or change in mental status (low O2 to brain) |
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describe CPOD
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Emphysema, chronic bronchitis or combination
Progressive disease Narrowing of airways Thickening of alveolar capillary membrane side 3: treatment |
Requires supplemental oxygen
IV antibiotics Bronchodilators Mechanical ventilation |
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describe acute respiratory failure
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Sudden, life-threatening deterioration of gas exchange
PaO2 < 50 mm Hg and PaCO2 > 50 with pH < 7.35 Caution, if PaCO2 chronically > 50 mm Hg then low PaO2 becomes primary drive for respiration ≤ 90–92% O2 saturation Patients with acute respiratory failure are always hypoxemic Administer oxygen with extreme caution ABG analysis is used to evaluate and diagnose respiratory failure (Allen’s test before) |
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the 2 "failures" of acute respiratory failure
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a) Ventilatory failure – inability to blow-off CO2
Mechanical abnormality of the lungs or chest wall Defect in the respiratory control center in the brain Respiratory muscle weakness b) Oxygenation failure – inability to exchange gas at the alveolar capillary membrane (COPD) Breathing air with reduced oxygen content Abnormal Hgb which can not transport oxygen Thickening or destruction of alveolar capillary membrane Combination of these two mechanisms |
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causes of acute respiratory failure
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Pneumonia
Fat embolism (long bone fracture) Gastric aspiration Inhalation of noxious gases Trauma Chronic lung disease Sepsis Multiple blood transfusions Burns Drug overdose Near drowning |
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s/s acute resp. failure
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hallmark: dyspnea
Restlessness (early: brain knows because the body does) Hypotension (blood goes to brain rather than systemic circulation) Altered level of consciousness Decreased breath sounds Motor dysfunction |
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what is the most important thing to remember about arterial lines?
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you have to check circulation regularly or else the pt. could lose fingers.
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guidelines for emergent intubation in ARF
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Emergent intubation,"40-40-40"
PaO2, 40 PaCO2, 40 Respiratory rate, 40 |
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ARF ABGs? (diagnosis)
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ABGs
PaO2 < 50 – 60 mm Hg PaCO2 > 50 pH < 7.35 |
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treatment of ARF (resp)
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Cautious oxygen therapy
Maintain PaO2 ≥ 60 mm Hg or O2 sat 90–92% Position for comfort High Fowler’s Pursed lip breathing (gets rid of CO2, keeps expirations longer) Medications Nutrition (high calorie, high protein) Bronchodilator nebulizers Avoid mechanical ventilation if possible (increased risk for infection) Non-rebreathing mask Non-invasive positive pressure ventilation |
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oxygen concentrations for
nasal cannula simple mask venturi mask nonrebreather mask |
Nasal cannula: < 40 – 50%
2 – 6 liters/minute (low flow system) Simple mask: 40 – 60% Venturi mask: up to 40% Air entrained with oxygen to specific FiO2 Non-rebreathing mask: 80 – 100% Highest oxygen concentration without mechanical ventilation |
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contraindications for positive pressure ventilation
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contraindications for positive pressure ventilation:
respiratory arrest, serious dysrhythmias, cognitive impairment, head, neck or facial trauma |
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what's the 3 step process of weaning from ventilation?
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3 step process
1. Ventilator free 2. Endotracheal or tracheostomy tube free 3. Oxygen free |
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how long can you use a ventilator without a trach?
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2 weeks. any longer risks necrosis.
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3 basic types of dialysis
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Intermittent hemodialysis (2-3 x/ wk)
Peritoneal dialysis (2-3 x/ wk) Continuous hemofiltration / dialysis (ICU floors) – controversial |
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what kind of dialysis uses osmosis?
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peritoneal
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indications for dialysis
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Acute RF
CRF until transplant becomes available Accidental or intentional poisonings (suicide attempts, kids) to clear drugs or toxins from body |
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what are the goals of dialysis (BUN, serum creat)?
what GFR necessitates dialysis |
when GFR < 5-10ml/min dialysis is necessary.
To keep BUN <80-100mg/dL & serum creat < 8-10mg/dL To control: pulmonary edema, hyperkalemia, or other life-threatening problems of renal failure |
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what's the most efficient form of dialysis?
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hemodialysis because of the rapidity and pressure gradient.
(but higher chance of hemorrhage) |
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what are 2 potential additives to hemodialysis blood in the machine?
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heparin, to prevent clotting in the machine.
pt. prone to bleeds may have protamine sulfate added before it's returned to vein. |
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3 types of vascular access for hemodialysis
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Cannulation of a large vessel (femoral or subclavian) & insertion of 2 single-lumen catheters or 1 large double lumen cath. (short-term only)
Surgical creation of an internal arteriovenous fistula or graft Surgical creation of an external arteriovenous shunt (if they want to get the dialysis started ASAP) |
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what do HD pts often experience on "off" days?
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fatigue, malaise, sleep disturbances, edema, SOB
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nursing actions for hemoD
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Monitor vitals (BP drops alarming)
Check site for s/sx infection Monitor blood work: lytes, CBC No BPs or venipunctures on extremity w/ access Palpate for a thrill or auscultate for a bruit at access site; notify M.D. if changepossible clotting of access site (protection of this access is a priority) Hypertension: monitor blood pressure, antihypertensive agents must be held on dialysis days to avoid hypotension. |
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what's the pruritis due to in HD patients?
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buildup of calcium deposits and urea in skin
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HD: avoid meds containing these elytes
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K and Mg
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who would want peritoneal dialysis?
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Unable or unwilling for HD
Timing, access to 3x week care those with higher risk for fluid and elyte changes -CVD, elders, DM, heparin intolerance Doesn’t hurt as much. |
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3 different regimens for peritoneal dialysis
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1. Intermittent P.D.—dialysis 3-5x/wk for 8-12hrs/tx; usu while sleeping; use automatic cycling equipment.
2. Continuous Ambulatory P.D. – manually infuses & drains dialysate 4-5x/qd for 4-8hrs/time; requires no special equip. The continuous process most closely approximates normal renal function. Because of thisfewer fluid/dietary restrictions; homeostasis maintained more easily 3. Cyclic Continuous P.D. – combination of intermittent P.D. at night & continuous ambulatory P.D. during day 3-4x/night using auto cycling machine |
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7 complications of peritoneal dialysis
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Peritonitis
Obstruction of flow Abdominal hernias Bleeding Dysrhythmias Respiratory distress Infection at catheter site Lyte disorders hypertriglycerides |
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what are 4 different kinds of pulmonary function tests?
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1. Spirometry: to evaluate functional lung capacity in comparison to what is expected of someone your age, height and sex.
2. Lung Volume Measurement: to determine your total lung size, which helps distinguish between lung disease types. 3. Diffusion Study: to evaluate the lungs' ability to move oxygen and carbon dioxide to and from your blood. 4. Methacholine Challenge: to aid in the diagnosis of reactive airway disease. |
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PFT: what is the FVC?
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FVC – Forced vital capacity. After the deepest breath, the most exhaled
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PFT:
what is the FEV1? what is the FEV1/FVC? |
FEV1 – Forced expiratory volume in 1 second
FEV1/FVC - indicates the percentage exhaled in first second |
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PFT:
What is the PEFR? What is the RV? |
PEFR – Peak Expiratory Flow Rate
RV – Residual volume – amt left after a full expiration |
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disease states as % of PFT:
normal mild disease moderate severe |
Normal PFT – 85% of predicted value
Mild disease - > 65% and < 85% Moderate disease - > 50% and < 65% predicted values Severe disease - < 50% predicted values |
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normal PaO2
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75-100
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4 "false" pulse ox reading causes
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Carboxyhemoglobin – false high
Hi bilirubin – false low Melanotic skin – variable results Poor tissue perfusion – low signal and unreliable results |
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what does a v/q scan do?
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V/Q scan- measure blood perfusion to lungs by injecting radioisotope
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criterion for candidacy for tonsillectomy?
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>3 strep throats in a year: candidate for tonsillectomy.
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treatment of tonsillitis
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Encourage fluids
Analgesics, Salt-water gargles Antibiotics (bacterial) Tonsillectomy (w/repeated infections) |
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treatment of peritonsillar abscess
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Corticosteroids
Antibiotics Aspiration Incision and drainage tonsillectomy |
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treatment of epistaxis
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Lean forward, hold pressure 5-10 min
Silver nitrate, eletrocautery Topical vasoconstrictors - adrenaline, phenylephrine Nasal packing |
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sx of laryngeal cancer
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Hoarseness >2 weeks; Persistent cough; sore throat; Lump felt in neck (early)
Dysphasia; dyspnea, persistent hoarseness; foul breath (late) |
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2 types of laryngectomies
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Partial laryngectomy – excision of a lesion on one vocal cord
Total Laryngectomy – removal of larynx, hyoid bone, & tracheal rings; closure of pharynx (can’t talk, trach.); formation of permanent tracheotomy |
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postop nursing of laryngectomy
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Admin. O2 via high-humidity tracheostomy mask
VS, I&O, lab studies, pulse ox. Assess dressings & drainage tubes Provide oral hygiene Establish method of communication Assess gag reflex & ability to swallow Reinforce speech therapy |
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assessment and nursing strategies for aspiration pneumonia
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Assess for risk
NPO if in doubt – contact speech therapist Head of the bed up 30 degrees during all tube feeding and/or by mouth feedings Thickened liquids or pureed consistency of foods Supervised feeding as needed with suction available. Slow feeding and assess for pocketing of food or pills |
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s/s pleural effusion
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S&S
Underlying disease If large→SOB Absent breath sounds Dull to percussion Cough Pleuritic pain (sharp, worse on inspiration) DOE Mediastinal shift |
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describe pleural effusion
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Collection of fluid in pleural space
Usually secondary to other disease Heart failure, TB, pna, nephrotic syndrome, malignancies Fluid may be clear, bloody, or purulent depending on cause |
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nursing care of pleural effusion
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Identify & treat underlying cause
Monitor VS Monitor breath sounds Position pt. in High Fowlers Encourage C & DB Prep. pt. for thoracentesis Pleural catheters for recurring effusions Pleurodesis Chemical agent used to obliterate the pleural space |
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describe empyema
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Thick, purulent fluid within the pleural space
Complication of bacterial pneumonia or lung abscess side 3 s/s |
Fever; Night sweats; pleural pain, cough, dyspnea, weight loss
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tx of empyema
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Treatment:
Antibiotics Needle aspiration Tube thoracostomy Chest drainage via thoracotomy |
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describe pulmonary edema
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Accumulation of fluid in the lung tissue
Fluid builds up in the pulmonary vessels, forces its way into the alveoli Caused by left sided heart failure; fluid overload or “flash” pulmonary edema a post operative complication |
Cardiac measures (vasodilators, inotropic medications, afterload or preload agents, or contractility medications, balloon pump if no response
) Diuretics, restrict fluids Oxygen- intubation may be required |
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how long can death occur following onset of PE sxs?
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1 hour from onset of sx
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sx of PE
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Dyspnea
Chest Pain Anxiety Fever Tachycardia Cough Diaphoresis Hemoptysis Syncope |
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nursing treatment of PE
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Monitoring thrombolytic therapy
VS q 2hrs INR or PTT q 4 hrs Manage O2 therapy Cough, Deep breathing, IS Pulse ox Monitor for complications Cardiogenic Shock Bleeding Hypoxia |
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describe sarcoidosis
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Multisystem, granulomatous disease of unknown etiology
Fibrosis in low lung compliance, impaired diffusing capacity and reduced lung volumes Sx: dyspnea, cough, hemoptysis, and congestion Dx: Chest x-ray CT Biopsy side 3: tx |
corticosteroids
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immediate nursing care following intubation
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Immediately after intubation:
Auscultate Breath sounds Obtain order for chest x-ray Secure tube to patient’s face with tape Use sterile suction technique and airway care Reposition tubing q 2hrs (prevent breakdown) Provide Frequent oral Hygiene |
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numerical def of systolic HF
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LVEF < 40% (Normal LVEF 60-75%)
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difference b/w systolic and diastolic HF?
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Systolic dysfunction: symptoms of HF occur because of reduced cardiac contractility
LVEF < 40% (Normal LVEF 60-75%) Diastolic dysfunction: symptoms of HF occur because of resistance to ventricular filling |
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what does an echocardiogram measure?
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Echocardiogram gives an EF, diagnoses systolic dysfunction.
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life-prolonging treatment for HF
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ACE-inhibitors (intereferes w/ RAAS)
β-blockers Aldosterone inhibitors Automatic implantable cardioverter-defibrillator side 3: meds for sx relief of HF |
Digoxin
Diuretics Bi-ventricular pacing < 2 Gm sodium and < 2 quarts fluids** Daily weights |
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diagnostic procedures for ADHF
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pulmonary artery catheter
BNP >100 pg/ml ECG echo CBC, chem7, thyroid CXR |
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what can lasix IV push result in?
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deafness
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HF poor tissue perfusion treatment
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Vasodilators
NTG/SNP Inotropic therapy Dobutamine Vasopressin antagonist Bi-ventricular pacing IABP/LVAD/Transplant |
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treatment of HF pulmonary edema
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Place patient in sitting position
Give supplemental oxygen – O2 sat ≥ 90% Morphine 2 to 5 mg IV every 10 to 20 minutes if needed IV loop diuretic IV nitroglycerine infusion Inotropic agents IABP (intra-arterial BP monitoring) |
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what are backward failure and forward failure?
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backward failure - pulmonary edema
forward failure - cardiogenic shock - poor circulation due to pump failure |
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treatment of cardiogenic shock
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Treatment
Fluid bolus (250 cc) with continuous reassessment Inotropic drugs Dopamine 2.5 – 5 mcg/kg/min Dobutamine 2-20 mcg/kg/min Norepinephrine 0.5 -30 mcg/min |
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complications from CABG
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Decreased cardiac output
Hypovolemia Reduced contractility Persistent bleeding Cardiac tamponade Dysrhythmias Decreased tissue perfusion Impaired gas exchange Fluid and electrolyte imbalance (potassium, magnesium – dysrhythmias) Sensory impairment related to environment Acute pain Hypothermia and shivering |
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