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172 Cards in this Set
- Front
- Back
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Acute Pain
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pain that occurs immediately and lasts up to 6 months
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Chronic pain
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Pain that lasts 6 months or longer
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Pain is also referred to as...
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"The fifth vital sign"
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opioid tolerance
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drug builds up in system...need higher and higher doses.
NOT ADDICTION |
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How does oral administration dose of a drug differ from IV or IM administration doses?
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Oral concentration is 3x higher than IV or IM, to compensate for first pass effect, and metabolization
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Which statement would be an expected outcome for a client experiencing acute pain?
a. decreased use of medication b. will participate in self care c. will use relaxation techniques d. will repeat instructions about medications |
b. will participate in self care.
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Preoperative Nursing
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Begins with the decision to have surgery
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intraoperative nursing
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everything having to do with the surgery in the or
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postoperative
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Begins when the patient is transferred to PACU
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When do most Surgical complications occur?
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POst op
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Pre-op Instructions
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-NPO
-Patient Medications -Post-op instructions -Family Instructions -Discharge Instructions -Pain Management |
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What factors can increase risk of surgical complications?
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Obesity and elderly
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Epistaxis
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Hemorrhage from the nose
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Most common site of bleeding with epistaxis
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Anterior Septum
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Causes of Epistaxis
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Dry air
dehydration extreme sinusitis/rhinitis Drugs (cocaine) |
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Care of pts with upper resp. infections ~ #1 planning consideration...
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Maintenance of a patent airway!!
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Treatment of epistaxis
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-Topical vasoconstrictors
(topical cocaine) -packing of the nasal cavity -positioning |
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Proper positioning of a patient with epistaxis
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Sitting up
lean forward to prevent aspiration |
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True or false:
Topical adrenaline is used to reduce blood flow in patients with epstaxis. |
True
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Nursing care of pt with epstaxis
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~assessment of bleeding
~monitor airway and breathing ~Vital signs ~Reduce anxiety ~teaching |
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what kind of teaching for epistaxis?
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~proper positioning
~fluids ~humidifier ~pinch bridge of nose ~seek medical help if bleeding doesn't stop within 15 minutes |
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Rhinitis
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Infection of mucous membrane of the nose
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Sinusitis
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Congestion of the sinuses
~ usually folows an upper resp infection Can be acute of Chronic |
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Pharyngitis
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Sore Throat
Can be acute or chronic |
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what percentage of pharyngitis cases are viral?
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90%
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Treatment of bacterial pharyngitis
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Penicillin is still drug of choice
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Treatment of viral pharyngitis
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-saline gargle
-rest -fluids |
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true or false:
Viral rhinitis is the most frequent viral infection in the general population |
True
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Potential complications of Strep throat
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~Sepsis
~Meningitis ~peritonsillar abscess ~Otitis media ~sinusitis |
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Assessment of upper respiratory disorders
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-thorough health history
-signs and symptoms -allergies -inspection of nose, neck and throat |
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Nursing diagnoses for upper respiratory disorders
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~ineffective airway clearance
~Acute pain ~impaired verbal communication ~deficient fluid volume ~knowledge deficit |
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pneumonia
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Inflammation of the lung, fluid in the alveoli
~can be bacterial or viral |
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hospital acquired pneumonia
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after first 48-hours of hospitalization
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community acquired pneumonia
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acquired prior to or within 1st 48 hours of hospitalization
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aspiration pneumonia
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aspirate fluids, tube feedings, etc, into the lungs
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what are some things nurses can do to foster the prevention of lower respiratory disorders?
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~frequent turning
~Deep breathing ~mobility ~stop smoking (teaching) |
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Diagnostic tests for lower respiratory infections
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-Chest x-ray
-sputum exam |
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Early signs of Hypoxia
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R-Restlessness
A-Anxiety T-Tachycardia/Tachypnes |
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Later signs of Hypoxia
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B-bradycardia
E-extreme restlessness D-Dyspnea (Severe) |
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What is pneumonia?
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bacterial, viral or fungal infection that causes inflammation of the alveolar spaces
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Causes of pneumonia
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-strep
-e. coli -influenza -aspiration of food or gastric contents -chemical irritants |
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key assessment findings in pneumonia
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~cough
~chills ~dyspnea ~elevated temp ~crackles ~rhonchi ~pleural friction rub ~sputum production |
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key facts about pneumonia
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~inflammation of alveolar spaces
~alveolar fluid increases ~Ventilation decreases |
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How is pneumonia diagnosed?
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~Sputum culture
~Chest X-ray ~Hematology |
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Patient teaching for pneumonia
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~smoking cessation
~self-monitoring for infection ~medication therapy ~dietary and exercise recommendation ~Follow-up care |
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Treating Pneumonia
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~oxygen therapy
~antibiotics ~antipyretics ~bronchodilators |
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Key nursing interventions for patient with pneumonia
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~admin O2
~Assess resp. status ~Monitor VS, I&O, labs and pulse ox ~monitor and record color, consistency, and amount of sputum ~Encourage fluids |
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complications with pneumonia
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~heart failure
~pulmonary edema ~respiratory failure ~death |
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What is COPD?
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group of diseases (emphysema, asthma, bronchitis) that result in persistent obstruction of bronchial airflow
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Causes of COPD
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~cigarette smoking
~irritants ~infection ~Genetic |
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Key signs and symptoms of COPD
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~cough
~dyspnea ~sputum production ~clubbing of fingers ~use of accessory muscles ~barrel chest ~weight loss ~diaphoresis |
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Diagnostic tests used for COPD
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~Chest X-ray
~ABG analysis ~PFT - pulmonary function tests |
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treating COPD
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-oxygen therapy
-high-calorie diet -increased fluids -antibiotics -bronchodilators -corticosteroids -beta-andrenergic mediation -mast cell stabilizers |
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Key nursing interventions in patient with COPD
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~assess resp. status
~admin. low-flow O2 ~high fowlers, semi-fowlers ~reinforce pursed-lip breathing ~small, frequent feedings ~push fluids ~positioning, percussion, deep breathing |
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key complications of COPD
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~Acute resp. failure
~Pneumonia |
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Normal Blood Values:
pH |
7.35 - 7.45
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Normal Blood Values:
PCO2 |
35 - 45
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Normal Blood Values:
HCO3 |
22 - 26
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Normal Blood Values:
PO2 |
80-100
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Normal Blood Values:
SaO2 |
Above 90%
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Acid Base Mnemonic:
R O M E |
Respiratory Opposite
pH up and PCO2 down - Alk pH down and PCO2 up - Acid Metabolic Equal pH up and HCO3 up - Alk pH down and HCO3 down - acid |
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Normal Values:
Sodium |
135 - 145 mEq/L
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Normal Values:
calcium |
4.5 - 5.5 mEq/L
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Normal Values:
Potassium |
3.5 - 5.0 mEq/L
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Normal Values:
Magnesium |
1.5 - 2.5 mEq/L
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What is the Mantoux test?
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skin test used to diagnose TB (PPD test)
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Corticosteroids
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Minimize inflammation
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Bronchoscopy
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Diagnostic test of the bronchial tree
tube through nose and mouth, into the bronchi to look at the airways |
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Pleurisy
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inflammation of both layers of the pleura
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Symptoms of pleurisy
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knife like pain that intensifies on inspiration
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Pleural effusion
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a collection of fluid (>than 5-15mL) in the pleural space, usually secondary to another disease process
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Most common causative factors for pulmonary disease?
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Air pollution and cigarrette smoke
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Important things to consider in a patient with upper resp. infections
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~positioning
~hydration ~pain relief ~Oxygen ~effective communication |
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nursing interventions or a pt with upper resp infection
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~maintain patent airway
~promote comfort -analgesics -soft diet -positioning ~rest ~encourage fluids |
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Educating a patient with upper respiratory infection
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-prevention
-frequent hand washing -contact provider with complications, colored secretions, on going symptoms -influenza vaccine |
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Why is it important to cmplete antibiotic regimen
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to prevent resistance and recurrence
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Sleep apnea risk factors
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~male gender
~smoking ~obesity |
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True or False:
Cigarette smoking and obesity are potential risk factors for obstructive sleep apnea |
True
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Signs and symptoms of sleep apnea
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~irritability
~snoring ~fatigue |
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what is Tuberculosis?
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An infection of the lung perinchyma
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Signs and symptoms of Tuberculosis
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-cough
-sweats -chest pain -low grade fever -weight loss |
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Difference between TB infection and active TB?
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infection means you are infected with the disease and will show a positive PPD
Active disease means you are showing signs and symptoms |
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How is TB spread?
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Airborne
Droplet |
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Who is most at risk for developing TB?
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Elderly
immuno-compromised health care workers |
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medication plan for TB
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medications for 6-12 months
family members also treated |
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importance or completing medication regimen for TB
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to prevent superinfection
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test card
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test card
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patient teaching with TB
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~hand washing
~cover mouth when coughing ~complete medications |
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best time to collect sputum samples?
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in the morning
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arterial blood gasses
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gasses dissolved in the blood that help blood maintain normal pH
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How are ABG's obtained?
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from arteries, rather than veins
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Computed tomography
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Cross-sectional view of the chest that distinguishes fine tissues, density and nodules
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MRI - Magnetic Resonance Imaging
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*most detailed*
visualizes soft tissue |
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Bronchoscopy
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diagnostic test of the bronchial tree
used to remove foreing obstructions and tissue |
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complications of bronchoscopy
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aspiration, infection, perforation, ataxia, pneumothorax
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what interventions are important prior to a patient procedure (bronchoscopy)?
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~NPO for 6-8 hours prior
~informed consent ~Vital signs |
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what is important after a patient procedure (bronchoscopy)?
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~NPO until return of gag reflex
~respiratory status ~assess sputum |
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what is thoracentesis?
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aspiration of air or fluid from the pleural space
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why is a thoracentesis done?
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can be done for diagnostic or comfort reasons
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complications of thoracentesis
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pneumothorax, infection, pulmonary edema
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nursing care for thoracentesis
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-patient must be immobile
-upright position -assess fluid aspirated |
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what are normal aging changes in the lungs?
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-decreased elasticity
-decreased # of alveoli -more prone to infections, r/t decrease in function |
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why is a COPD patient still short of breath, even with oxygen?
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decreased respiratory drive
if O2 is increased, can send patient into respiratory arrest. |
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purpose of diaphragmatic and pursed-lip breathing
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to strengthen muscles and eliminate O2 to maintain adequate ventilation
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medications used for COPD
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Bronchodilators
Corticosteroids magnesium sulfate anticholinergics |
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pneumothorax
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collection of air and/or fluid arounf the lungs, causing increased pressure and possible collapse.
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Asthma
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A chronic inflammatory disease of the airways
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Should corticosteroids be discontinued abruptly?
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no...need to be weaned off
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Strongest predisposing factor for asthma
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~allergies
~chronic exposure to airway irritants and allergens |
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Clinical manifestations of asthma
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inflammation leads to:
cough chest tightness wheezing dyspnea |
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how is asthma diagnosed?
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allergy testing
family history lung function test |
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who is at risk for developing asthma?
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children
female gender |
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status asthmaticus
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severe and persistent asthma that does not respond to conventional therapy
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with asthma, what does a decrease in lung sounds signify?
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possible sign of impending respiratory failure
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Asthma Medications:
short acting |
beta2 andrenergic agonists
(albuterol, Proventil) anticholinergics (atrovent) |
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Asthma Medications:
long acting |
corticosteroids
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patient teaching for asthma
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~know your triggers!!
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Are increased O2 sats a good sign in a patient with COPD?
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NO
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Barrel chest
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caused by overinflation
Increased compliance leads to air pockets which expand the chest cavity |
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Pulmonary Embolism
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Section of a DVT that breaks off, travels in circulation, gets trapped in the lung, cuts off oxygen.
can cause heart failure |
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Symptoms of Pulmonary Embolism
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dyspnea
anxiety increased pulse rate diaphoresis tachypnea sharp chest pain |
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signs and symptoms of pulmonary embolism are...
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frequently non-specific and can MIMIC other cardiopulmonary events.
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risk factors for pulmonary emboli
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venous stasis
hypercoagulability venous endothelial disease previous hx or thrombophlebitis |
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Is a pulmonary embolism fatal?
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if left untreated, pt can die within
1 HOUR! |
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Treatment for Pneumothorax?
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Chest tube insertion
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prevention of pulmonary emboli
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exercises (to prevent venous stasis)
early ambulation anticoagulant therapy sequential compression devices (SCD) TED hose |
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Treatment for Pulmonary Emboli
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Streptokinase
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three types of pneumothorax
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Spontaneous
Open Tension |
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pulmonary Embolism is...
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...always treated as an emergency!
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Interoperative
Complications |
Nausea/Vomiting
Anaphylaxis Hypoxia & resp complications Hypothermia DIC Malignant Hyoerthermia (weight lifters) |
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Indicators of
Hypovolemic Shock |
decreased urine
decreased BP weak, thready pulse cool, clammy skin increased bleeding increased thirst concentrated urine restlessness |
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Types of Chest Trauma
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Blunt Trauma
Sternal and rib fractures Flail chest pulmonary contusion penetrating trauma pneumothorax |
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What is Flail Chest
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When the chest wall is unstable due to multiple broken bones
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Asepsis
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Freedom from organisms
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Medical asepsis
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Clean technique
Goal for external procedures |
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Surgical asepsis
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Sterile Technique
Goal for internal cavities |
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infectious process
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Chain of infection required
Treatment breaks the chain |
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6 links in the infectious process chain
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reservoir
infectious agent (causative microbe) mode of transmission portal of entry susceptible host portal of exit |
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Chain of Transmission:
#1 Reservoir |
Environmental home for infectious agents
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Chain of Transmission:
Examples of Animate reservoir |
People, insects, animals, plants
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Chain of Transmission:
Examples of Inanimate reservoir |
water, soil, medical devices and instruments
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Chain of Transmission:
#2 Infectious agent |
Bacteria
Virus (may not have increased temp) Protozoa Helminth Prion |
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Chain of Transmission:
#3 Mode of transmission |
Direct contact (kissing, dirty cath, etc)
Indirect contact Airborne |
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Chain of Transmission:
#4 Portal of Entry (definition) |
Entry into susceptible host
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Chain of Transmission:
Portals of entry |
Respiratory tract
skin mucous membranes gastrointestinal tract genitourinary tract placenta |
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Chain of Transmission:
#5 Susceptible Host |
From breakdown in natural defenses:
-elderly -young children -malnourishment -immunocomprimised -chronic disease -stress -invasive procedures |
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Chain of Transmission:
#6 Portal of exit |
Rout used by infectious agent to leave host who has become reservoir for infection
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Septicemia
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Bacteria in the blood
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Symptoms of septicemia
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fever
increased temp (>100 degrees) chills rash abdominal distention pain headache nausea diarrhea prostration |
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Treatment for septicemia
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blood work for Culture & Sensitivity
antibiotics |
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Nursing interventions for septicemia
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Monitor vitals and LOC for signs of septic shock
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Body's defense mechanisms
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skin and mucous membranes
mucociliary membranes gastric juices immunoglobulins leukocytes and macrophages lysozomes interferon inflammatory response |
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Where are macrophages found?
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lungs, lymph nodes, intestinal walls
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what are immunoglobulins?
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antibodies
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What is the Immune System?
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the body's final defense against infection
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What is the immune system comprised of?
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immune cells and lymphoid tissue
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When does disease result?
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when immune system protection fails
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What is a localized infection?
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microbes are confined to one area
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Signs and symptoms of localized infection
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pain, redness, swelling, warmth at the site
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what is a generalized infection?
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an infection with systemic involvement
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signs and symptoms of generalized infection
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headache, muscle aches, fever, anorexia
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end result of a generalized infection
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sepsis
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diagnostic tests used for infection
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gram's staining (bacteria)
Culture & Sensitivity Test (bacteria) Antibody test (Virus) CBC w/Diff (types of WBCs) Erythrocyte Sedimentation rate |
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Common nosocomial pathogens
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E. coli - fecal organism
S. aureus - we all have P. aeruginosa - URI mainly (green nasal drainage) (viral cold) enterococcus - (70% have) C. Difficile - carried in GI Tract |
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#1 way to prevent infection and the spread of disease?!?!?!
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WASH YOUR HANDS!!!
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Antibiotic resistant infections
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type/strain of organism determines drug selection and isolation procedures.
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MRSA
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Methicillin resistant Saphylococcus aureus
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VRE
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Vancomycin resistant enterococcus
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Early signs
of shock |
normal BP
increased pulse normal skin color cool/moist skin anxious increased resp rate and depth |
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Late signs
of shock |
systolic below 90 mmHg
increased pulse (weak) pale skin color cold skin temp coma increased resp rate shallow breathing |
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Characteristics of Tuberculosis
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Airborne, infectious, communicable disease that can occur acutely or chronically
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intrinsic asthma
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caused by sensitivity to specific all
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