Nursing 3Rd Medsurg: Lower Respiratory Problems

Front 1

Acute bronchitis is usually ____. It often occurs after a ___ or ____. If sputum can be produced (productive cough) may get a _____ to select _______ if it's bacterial. The air passages become clogged with dust, debris etc and some bug gets in there.

Back 1

Acute bronchitis is usually viral. It often occurs after a cold (common cold) or a URI. If sputum can be produced (productive cough) may get a culture to select antibiotic if it's bacterial.

Front 2

The most common bacteria that cause bronchitis include what 2?

Back 2

Streptococcus pneumoniae
Haemophilus influenzae

Front 3

Clinical manifestations of bronchitis include (5)

Back 3

cough
sputum (clear or purulent)
fever
headache
malaise

Front 4

Bronchitis has a characteristic cough that starts out nonproductive and then becomes productive. We don't want to give a cough _______ because we want to get the secretions out. Only give this if it's a dry, hacky cough or if it's keeping them up at night. Viral bronchitis can become bacterial if secretions aren't gotten out which could then lead to ______ this is especially important for _____ and who should get treatment for bronchitis. What's special about elderly and COPD patients and bronchitis?

Back 4

Bronchitis has a characteristic cough that starts out nonproductive and then becomes productive. We don't want to give a cough suppressants because we want to get the secretions out. Only give this if it's a dry, hacky cough or if it's keeping them up at night. Viral bronchitis can become bacterial if secretions aren't gotten out which could then lead to pneumonia this is especially important for elderly/geriatric who should get treatment for bronchitis. Elderly and COPD patients may get antibiotics prophylactically for bronchitis.

Front 5

Management for acute bronchitis includes supportive care. Encourage plenty of fluids and rest. _______ may be taken.

Back 5

antiinflammatories

Front 6

PNA is an acute/chronic ______ of the lung caused by microbial organism
It is likely to result when ____ ________ become incompetent or overwhelmed
Decreased cough & epiglottal _____ may allow aspiration.
Mucocilliary mechanisms can be impaired and contribute to facilitating PNA (give some examples).

Back 6

PNA is an acute inflammation of the lung caused by microbial organism.
It is likely to result when defense mechanisms become incompetent or overwhelmed
Decreased cough & epiglottal reflexes may allow aspiration.
Mucocilliary mechanisms can be impaired and contribute to facilitating PNA such as in smokers, smoke inhalation, COPD, air pollution, URI can also impair mechanism.

Front 7

People at risk for PNA include...

Back 7

COPD
HIV/ AIDS
on chemo
elderly
immobile
autoimmune disorders
(immunocompromised)

Front 8

People with decreased cough & epiglottal reflexes (that may be at risk of getting PNA) include...

Back 8

decreased cough and epiglottal reflexes- stroke patients, elderly, unconscious
patients in recovery room etc don't have reflexes back up to get secretions out,
may vomit and aspirate
people intubated or severly drunk under influence of drug
conscious sedation

Front 9

Alterations of _____ due to malnutrition can contribute to PNA.

Back 9

leukocytes

Front 10

There is an increased frequency of gram-_____ bacilli from _____, ____, and ____ ___.

Back 10

Increased frequency of gram-negative bacilli from leukemia, alcoholism, and diabetes mellitus

Front 11

3 ways organisms reach lungs (causing PNA)

Back 11

Aspiration
Inhalation
Hematogenous spread from primary infection elsewhere in the body

Front 12

True or False: Prognosis for PNA is good for healthy people, but needs to be treated. It's the leading cause of death in US from infectious disease esp. in immunocompromised and elderly.

Back 12

true

Front 13

What are some risk factors for getting PNA?(14!)


see table 28-

Back 13

age
poor air quality
altered consciousness
bed rest
chronic diseases
HIV
immunosuppressive Rx
inhalation noxious substances
NG or NI tube feedings
malnutrition
Residence at LTC
smoking
tracheal intubation
URI

Front 14

It takes ___ to ___ days from time infectious bacteria etc gets in to the time of onset of s/s. You can tell where someone hospitalized got their PNA infection based on when the s/s of infection show up. If they show s/s of PNA after being hospitalized one day, then they got it before coming in. If s/s after 48 h hospitalized, they got it in hospital.

Back 14

It takes ___ to ___ days from time infectious bacteria etc gets in to the time of onset of s/s. You can tell where someone hospitalized got their PNA infection based on when the s/s of infection show up. If they show s/s of PNA after being hospitalized one day, then they got it before coming in. If s/s after 48 h hospitalized, they got it in hospital.

Front 15

Dr's try to treat PNA at home (if stable, no comorbidities). A sicker person will be hospitalized for treatment, especially if bacterial PNA. Patients are usually on antibiotics for ___ to ___ days at home. They should see improvement within ___ to ___ h. If not, call the dr (may try to get sputum sample, see if it's bacterial, may adjust antibiotic etc).

Back 15

Dr's try to treat PNA at home (if stable, no comorbidities). A sicker person will be hospitalized for treatment, especially if bacterial PNA. Patients are usually on antibiotics for 10- 14 days at home. They should see improvement within 48 to 72 h. If not, call the dr (may try to get sputum sample, see if it's bacterial, may adjust antibiotic etc).

Front 16

Common drugs to treat PNA at home (community acquired) include ______ such as ______ and anti-pseduomonals like ___-and ____.

Back 16

Common drugs to treat PNA at home (community acquired) include macrolides such as Zithromax and anti-pseduomonals like Zosyn and primaxin.

Front 17

Community acquired PNA involves 3 step approach to tx---

Back 17

Assess ability to tx at home
Calculate PORT (PNA patient outcomes research team) severity index
Clinician decision for inpatient or outpatient tx

Front 18

Commonly used meds to treat community acquired PNA at home and in hospital?

Back 18

azithromycin ( Zithromax), clariathromycin (Biaxin), or doxycycline (Vibramycin)

If hospitalized with IV – Combination of floroquinolone, macrolide, Beta-lactam, & antipseudomonal
agent if indicated

Front 19

True or False: PNA develops in 9-27% of patients on ventilator

Back 19

true

Front 20

Which requires heavier-duty antibiotics, community acquired or hospital acquired?

Back 20

hospital

Front 21

For hospital acquired PNA (HAP) the hospital usually knows what bacteria is prevalent at their institution. How to treat is basically a "best guess." Should see improvement in ___ to ___ days. If not, may add or change antibiotic.

Back 21

3 to 5

Front 22

______ is the best non medical intervention for treating pneumonia. What's best?

Back 22

positioning
elevate HOB (gravity)
if not possible, put on side
turn q 2h
(moves fluid around so it's not staying in one area)

Front 23

Predisposing factors to becoming infected with a hospital acquired PNA (HAP)

Back 23

Immunosuppressive Therapy
(especially chemo)
Endotracheal Intubation
Mechanical Ventilation
Immobility
Aspiration (head injuries, immobility, stroke, anything with loss of gag reflex)
Altered Oropharyngeal Flora

Front 24

People who are immunocompromised such as transplant patients, HIV, corticosteroids, chemo etc. are especially at risk of ______ PNA

Back 24

opportunistic

Front 25

What are the clinical manifestations of PNA?

Back 25

Fever, chills, SOB, productive cough, pleuritic chest pain
Confusion or stupor
Atypical – dry cough, HA, myalgias, fatigue, N&V, diarrhea, sore throat
Crackles, bronchial breath sounds (usually fine crackles, sometimes bronchial breath sounds in periphery instead of bronchiovesicular-- hearing more high pitched sound not the finer sound...?)

Front 26

Complications of PNA(9)
Which is most common?

Back 26

Pleurisy
Pleural Effusion (#1)
Atelectasis
Bacteremia
Lung abscess (rare)
Empyema (rare)
Pericarditis (after spread)
Meningitis(after spread)
Endocarditis(after spread)

Front 27

Diagnostic Studies for PNA

Back 27

H & P- risk factors, s/s
CXR- signs of consolidation
Gram stain of sputum
Sputum C&S (if possible)
CBC with differential (WBC's)
Pulse oximetry , ABGs (hypoxia)
Blood cultures (if indicated- usually pretty much a given)

Don't stress on getting a sputum sample, if you can get it- get to lab ASAP

Front 28

What is nursing management for PNA in addition to antibiotics?

Back 28

Oxygen (humidified )
Antipyretics
Analgesics (may be painful)
Increased fluids (to at least 3 L per day combined IV and oral -- if not contraindicated)
Limited activity and rest - activity is individualized according to patient's tolerance, want to encourage activity to encourage oxygenation.
Nutrition- very important to improve, will likely have poor appetite- small frequent feedings

Front 29

True or False: Prevention is key-- pneumococcal vaccine and influenza.

Back 29

true

Front 30

See nursing assessment table 28-7

Goals for treating PNA:
clear breath sounds
normal breathing pattern
no sign of hypoxia
normal chest x-ray
no complications r/t PNA

Back 30

...

breath sounds as clear as possible- never totally clear COPD

Front 31

In the National Patient Safety Goals for the PN-2 Pneumococcal Vaccine: All patients ___ years and older with pneumonia diagnosis must be screened for eligibility to receive pneumovax.
Must be current within last __ y
If eligible, ensure that order is written and signed by physician.
Give vaccine when....

Back 31

In the National Patient Safety Goals for the PN-2 Pneumococcal Vaccine: All patients 65 years and older with pneumonia diagnosis must be screened for eligibility to receive pneumovax.
Must be current within last 5 y
If eligible, ensure that order is written and signed by physician.
Give vaccine when stable and afebrile x 4 h

Front 32

Review page 7 of powerpoint (adult pneumococcal vaccine-- assessment decision tree)
Inclusion criteria....

Back 32

Inclusion criteria (must meet one)
All persons 65 years or older
Patient is a resident of a nursing home or chronic care facility
Persons with chronic heart, lung, renal, metabolic or liver disease, cancer, anemia,
alcoholism, HIV/AIDS
Persons without a spleen.
Immunocompromised persons
Vaccine recipient >/= 5 years since most recent vaccine
Patients meets any of the above criteria but is uncertain about prior vaccination

Front 33

Review page 7 of powerpoint (adult pneumococcal vaccine-- assessment decision tree)
exclusion criteria....

Back 33

Patient has received vaccine < 5 years
Previous allergic and/or neurologic reaction to vaccine
Pregnancy
Platelets <50,000
Fever (38 degrees C/100.4degrees F or above) at time of vaccine. May administer after
patient afebrile for four hours.
Patient refuses

Front 34

Is it ok for a patient to get pneumovax twice?

Back 34

yes.

Front 35

Blood cultures are done in 1st ___ h before/after antibiotics started (when admitted) these are hospital ____ _____.

Back 35

Blood cultures are done in 1st 24 h before antibiotics started (when admitted) these are hospital core measures.

(In the National Patient Safety Goals for the PN-3
Blood cultures must be drawn within 24 h of admit and before dirst dose of antibiotic )

Front 36

In the National Patient Safety Goals for the PN-4
All patients must be counseled about ___ _____. Must _____ counseling in _____ notes.

Back 36

In the National Patient Safety Goals for the PN-4
All patients must be counseled about smoking cessation. Must document counseling in discharge notes.

Front 37

In the National Patient Safety Goals for the PN-5 Antibiotic Timing
First dose of antibiotic received within ___ h of hospital arrival

Back 37

6

Front 38

In the National Patient Safety Goals for the PN-6 Antibiotic Selection
Appropriate antibiotics should be selected by physician based on ______ and ____ status.
Appropriate antibiotics are associated with improved _____ rates and reduces risk of ___ _______.

Back 38

In the National Patient Safety Goals for the PN-6 Antibiotic Selection
Appropriate antibiotics should be selected by physician based on immunocompetent and allergy status.
Appropriate antibiotics are associated with improved survival rates and reduces risk of drug resistance.

Front 39

Review page 9 of powerpoint-- influenza vaccine (Oct 1 - mar 1)
assessment decision tree
inclusion criteria

Back 39

Inclusion criteria (must meet one)
All persons 50 years of age and older
Patient is a resident of a nursing home or chronic care facility
Persons with chronic heart, lung, renal, metabolic, or liver disease, cancer, anemia,
alcoholism, HIV/AIDS
Women who will be in 2nd-3rd trimester during flu season (if approved by MD providing
obstetrical care)
Health care providers
Patient meets any of the above criteria but is uncertain about prior vaccination.

Front 40

Review page 9 of PowerPoint-- influenza vaccine (Oct 1 - Mar 1)
assessment decision tree
exclusion criteria

Back 40

Already immunized this flu season
Serious allergy to eggs or thimersol mercury derivative or other components of the
influenza vaccine
Women in the 1st trimester of pregnancy
Serious reaction to prior influenza vaccine
Platelets < 50,000
Fever (38 degrees C/100.4 degrees F or above) at time of vaccination. May administer
after patient afebrile for four hours.
History of Guillian-Barre Syndrome
Patient refuses

Front 41

Look at nursing dx page 11 -12

Back 41

..

Front 42

Use caution giving _____ if allergic to pneicillin (cross sensitivity 10%) Call Dr and see if he really wants to give this med. Assess allergy always! Assess if it's a true allergy, ask what happens etc

Back 42

rocephin

(may use a fluoroquinolone instead)

Front 43

Nursing responsibilities for administering antibiotics- obtain a thorough _____ hx from patient, consider possibility of ____ _____, administer at prescribed i_____ and maintain therapeutic ____ levels.

Back 43

Nursing responsibilities for administering antibiotics- obtain a thorough drug hx from patient, consider possibility of cross sensitivity, administer at prescribed intervals and maintain therapeutic blood levels.
monitor patient closely for adverse effects
monitor trough levels to determine effectiveness

Front 44

__________ and ______ are 2 examples of meds that need trough levels.

Back 44

aminoglycosides & vanco

Front 45

________ is nephrotoxic and ototoxic.

Back 45

gentamycin

We try not to use this.

Front 46

Second time exposure or after is when you will see _____ reaction.

Back 46

allergic

Front 47

Teaching for home care for PNA includes encouraging plenty of _____ and ____, avoiding ____ and ___, and to report in changes in health status such as... (4) Stress the need to come back for care if any of these changes or new s/s PNA could be back, recurring, or a stronger bug need different antibiotics etc.

Back 47

Teaching for home care for PNA includes encouraging plenty of fluids and rest, avoiding smoke and fumes, and to report in changes in health status such as sputum characteristics, fever despite antibiotics, decreased activity tolerance, and increasing chest pain.

Front 48

Goals to be evaluated during and after treatment of pna include:
no _____, spO2 greater than or equal to ___, free of ______ breath sounds, clears _____ from airway, reports ____ control, adequate ____ and ____ intake, verbalizes ____ factors, and is able to perform _____ of ____ _____.

Back 48

Goals to be evaluated during and after treatment of pna include:
no dyspnea, spO2 greater than or equal to 95, free of adventitious breath sounds, clears sputum from airway, reports pain control, adequate fluid and calorie intake, verbalizes causal factors, and is able to perform activity of daily living.

Front 49

Tuberculosis is a disease caused by _____ ______. It is the lead killer of people with ____. It involves the ____ most of the time but can also involve what 6 areas? (If these other organs or areas are effected, it has spread before the immune system has got it under control. It usually does NOT spread to other organs with treatment. Full coarse of treatment is very important.

Back 49

Tuberculosis is a disease caused by Mycobacterium tuberculosis. It is the lead killer of people with HIV. It involves the lungs most of the time but can also involve the meninges, kidneys, bones, adrenal glands, lymph nodes, and larynx. MK BALL (If these other organs or areas are effected, it has spread before the immune system has got it under control. It usually does NOT spread to other organs with treatment. Full coarse of treatment is very important.

Front 50

Who is at risk for getting TB?

Back 50

HAD FIRES
H- Homeless
A- Access (poor access to health care)
D- Drug Users (IVDA)
F- Foreign-Born
I- Institutionalized
R- Residents of inner city neighborhoods
E- Elderly
S- Suppressed (Immunosuppression)

Front 51

People from southeast ____ or ____ are at risk of getting TB (foreign born)

Back 51

southeast Asia and Africa

Front 52

TB is spread via ____ ____. Transmission requires ____, _____, or _______ exposure such as within a household. The chance of getting becoming infected with TB from casual exposure, such as going into and out of a patient's room is poor.

Back 52

TB is spread via airborne droplets Transmission requires close, frequent, or prolonged exposure such as within a household. The chance of getting becoming infected with TB from casual exposure, such as going into and out of a patient's room is poor.

Front 53

Inhaling the TB _____ causes them to be passed down into the _____ system and they implant themselves on the ______ or ______. They multiple with no ____ _______. The bacteria usually settles in the ____ lobes and usually _____ here.

Back 53

Inhaling the TB bacilli causes them to be passed down into the bronchial system and they implant themselves on the bronchioles or the alveoli. They multiply with no initial resistance. The bacteria usually settles in the upper lobes and usually infiltrates here.

Front 54

True or False: Tuberculosis is highly infectious unless you are immunocompromised.

Back 54

False, NOT highly infectious unless you are immunocompromised.

Front 55

Latent TB stays ________. The person is infected but not _______. Basically the bacteria is _______ , forming a _____. The bacteria is contained, which prevents replication and spread of the disease. Without sufficient immune response, the organism is maintained and active primary disease results, known as _____ TB.

Back 55

Latent TB stays dormant. The person is infected but not infectious. Basically the bacteria is encapsulated, forming a granuloma. The bacteria is contained, which prevents replication and spread of the disease. Without sufficient immune response, the organism is maintained and active primary disease results, known as infectious TB.

Front 56

It takes ___ to ___ weeks before TB test comes back positive after exposure if a person is infected. One exposure does not mean that one will become infected, the immune system should work on it and prevent from becoming infected (hopefully immune system is intact).

Back 56

2 to 10

Front 57

Latent TB will have ___ symptoms, is infectious/non infectious, will show a positive/negative skin test, will be positive/negative for sputum, and will have a positive/negative chest x-ray.

Back 57

Latent TB will have no symptoms, is non infectious, will show a positive skin test, will be negative for sputum, and will have a negative chest x-ray.

Front 58

TB Disease develops _____, is infectious/non-infectious, will show a positive/negative skin test, a positive/negative sputum test, and the chest xray may be normal/abnormal showing infiltrates, cavities, and/or lymph node involvement.

Back 58

TB Disease develops symptoms, is infectious, will show a positive skin test, a positive sputum test, and the chest x-ray may be abnormal showing infiltrates, cavities, and/or lymph node involvement.

Front 59

If you are ______ with TB you're not sick, if you are ________ you're sick.

Back 59

infected, infectious

Front 60

True or False: If you are at risk of being infected with TB, a baseline TB test will be done now and again in 2-3 months

Back 60

True

Front 61

True or False:
We do a 2 step TB because of the chance of a false positive test.

Back 61

false
because there may be a false negative

Front 62

If positive chest x-ray, the sputum sample is done for ___ consecutive days in testing for TB to test for what classification of bacteria?

Back 62

3
acid fast

Front 63

True or False: If you test positive on a TB test once, you're always going to test positive. (at least on the 2nd test of a 2 step)

Back 63

true

Front 64

Most clients with active TB have negative cultures after ___ months of treatment.

Back 64

3

Front 65

What are the clinical manifestations of active, infectious TB (when you're sick).

Back 65

PC FLAWS
Productive Cough
Chest pain
Fatigue
Low grade fever
Anorexia
Weight loss
Sweats at night (night sweats)

Front 66

____ against TB are available in areas of high infectious rates (not in the US). A person who gets this vaccine will always test _____ on a TB skin test.

Back 66

Vaccines against TB are available in areas of high infectious rates (not in the US). A person who gets this vaccine will always test positive on a TB skin test.

Front 67

How is TB classified (0-5)?

Back 67

0- no TB exposure
1- TB exposure, no infection
2- Latent TB infection, no disease
3- TB clinically active
4- TB but not clinically active
5- TB suspect (until tests have been ruled out)

don't get "hung up" on this...

Front 68

Complications of TB (3)

Back 68

Miliary TB- getting to other organs before immune system gets going against it
TB PNA- acute PNA may result when large amounts of tubercle bacilli are discharged from granulomas into the lung or lymph nodes
Pleural Effusion or Empyema- caused by bacteria in the pleural space, which trigger an inflammatory reaction and a pleural exudate of protein-rich fluid. Empyema is less common but may occur from large numbers of TB organisms in the pleural space.

Front 69

Drugs that treat TB are usually taken for a range of ___ to ___ months depending on total number of doses per day or week. Usually 3 or 4 drugs are taken at a time to decrease chance of TB being resistant to one of the drugs. _______ is a major issue with people infected with TB due to the lengthy medication regimen, poor access, and costs.

Back 69

6-9 months

noncompliance

Front 70

Sputum samples for TB are obtained _____ then ____ until sputum converts to negative status. The patient is no longer infective after ___ consecutive negative tests. Patients are usually not infective after ___ to ___ weeks of therapy but still need to take medication (no longer infective).

Back 70

Sputum samples for TB are obtained weekly then monthly until sputum converts to negative status. The patient is no longer infective after 3 consecutive negative tests. Patients are usually not infective after 2 to 3 weeks of therapy but still need to take medication (no longer infective).

Front 71

Family members of patients being treated for TB are often started on ___ just to be safe even before skin test is positive because....

Back 71

INH
it can take so long for TB skin test to show up positive

Front 72

Latent TB infection usually get ____ for ___ to ____ months. If HIV positive, may take this for ___ months. Or, they can take _____ for ____ months.

Back 72

Latent TB infection usually get INH for 6 to 9 months. If HIV positive, may take this for 9 months. Or, they can take Rifampin for 4 months.

Front 73

Nursing dx relative to TB include...

Back 73

noncompliance
ineffective breathing pattern
imbalanced nutrition <body req's
ineffective health maintenance
activity intolerance.

Front 74

True or False- Most patients with TB are treated on an inpatient basis.

Back 74

False, outpatient unless there are critical coexisting conditions

Front 75

True or False: Fungal infections do not require any isolation because they are not transmitted person to person.

Back 75

true

Front 76

_____ pulmonary infections include...
Coccidiodomycosis
Histoplasmosis
Aspergillosis
Cryptococcosis
Blastomycosis
Actinomycosis
Candidiasis
Norcardiosis
Pneumocystis Pneumonia (PCP)

Back 76

fungal

Front 77

Coccidiodomycosis is commonly known as..

Back 77

valley fever
spores are inhaled from soil

Front 78

Amphotericin B is used to treat more serious _____ infections and is administered in what route? What are some side effects?

Back 78

Amphotericin B is used to treat more serious fungal infections. It is administered IV.
SE: hypersensitivity reactions, fever, chills, N & V, thromboplebitis at IV site

Front 79

More/less serious fungal infections can be treated with _____ (what route) medications like:
fluconazole (Diflucan)
ketoconazole (Nizoral)
voriconazole (Vfend)
itraconazole (Sporanox)

Back 79

Less serious fungal infections can be treated with oral medications like:
fluconazole (Diflucan)
ketoconazole (Nizoral)
voriconazole (Vfend)
itraconazole (Sporanox)

Front 80

Environmental or occupational lung diseases result from inhaled dust or chemicals. The _____ of exposure and the amount of inhalant have a major influence on lung damage. Pneumoconiosis is a general term for a group of lung diseases caused by inhalation and retention of ___ particles.

Back 80

Environmental or occupational lung diseases result from inhaled dust or chemicals. The duration of exposure and the amount of inhalant have a major influence on lung damage. Pneumoconiosis is a general term for a group of lung diseases caused by inhalation and retention of dust particles.

Front 81

Examples of pneumoconiosis include silicosis, asbestosis, and beryliosis. The classic response to the inhaled substance is diffuse parenchymal _______ with ________ cells. This eventually results in diffuse ____ _____ (excessive connective tissue).

Back 81

Examples of pneumoconiosis include silicosis, asbestosis, and beryliosis. The classic response to the inhaled substance is diffuse parenchymal infiltration with phagocytotic cells. This eventually results in diffuse parenchymal infiltration (excessive connective tissue).

Front 82

Chemical pneumonitis results from exposures to _____ chemical fumes. Acutely, there is diffuse lung injury characterized as pulmonary _____. Chronically, the clinical picture is that of bronchiolitis obliterans (obstruction of the bronchioles due to inflammation and fibrosis) which is usually associated with a normal chest x-ray or one that shows ________. An example is ___ filler's disease.

Back 82

Chemical pneumonitis results from exposures to toxic chemical fumes. Acutely, there is diffuse lung injury characterized as pulmonary edema. Chronically, the clinical picture is that of bronchiolitis obliterans (obstruction of the bronchioles due to inflammation and fibrosis) which is usually associated with a normal chest x-ray or one that shows hyperinflation. An example is ___ filler's disease.

Front 83

Hypersensitivity pneumonitis or extrinsic allergic alveolitis is a form of parenchymal lung disease seen when an individual inhales antigens to which he or she is ____. Examples include _____ ____ lung and ____ lung.

Back 83

Hypersensitivity pneumonitis or extrinsic allergic alveolitis is a form of parenchymal lung disease seen when an individual inhales antigens to which he or she is allergic, usually moldy hay or bird droppings etc. Examples include bird fancier's lung and farmer's lung.

Front 84

_____ is caused by inhalation of inert substances more risk of cancer.

Back 84

silicosis

Front 85

Fibrotic tissue is non _______ lung tissue.

Back 85

non functioning

Front 86

Clinical manifestations of environmental lung diseases include ____ and ____ (early signs) and ____ _____ (late signs).

Back 86

Clinical manifestations of environmental lung diseases include cough and dypsnea (early signs) and chest pain (late signs).

Front 87

For environmental lung diseases, the collaborative care includes education about prevention such as about asbestos, relief of ____. There is no cure. _____ and ______ are given as needed. Treatment of comorbidities is included such as for COPD, PNA, asthma etc.

Back 87

For environmental lung diseases, the collaborative care includes education about prevention, relief of symptoms. There is no cure. Bronchodilators and oxygen are given as needed. Treatment of comorbidities is included such as for COPD, PNA, asthma etc.

Front 88

Lung cancer is the leading cause of cancer-related deaths. Risk factors include the total ___ of cigarettes smoked, ____ of smoking onset, ______ of inhalation, ____ and _____ content, use of ______ cigarettes, exposure to ___ hand smoke, and other inhaled _______ such as uranium, iron oxides, radon, nickel, polycylic aromatic hydrocarbons, arsenic, chromates, air pollution, and asbestos. The more exposure makes the risk greater-- such as a miner who smokes is at higher risk of lung cancer than a miner who does not smoke.

Back 88

Lung cancer is the leading cause of cancer-related deaths. Risk factors include the total # of cigarettes smoked, age of smoking onset, depth of inhalation, tar and nicotine content, use of unfiltered cigarettes, exposure to second hand smoke, and other inhaled carcinogens such as uranium, iron oxides, radon, nickel, polycylic aromatic hydrocarbons, arsenic, chromates, air pollution, and asbestos. The more exposure makes the risk greater-- such as a miner who smokes is at higher risk of lung cancer than a miner who does not smoke.

Front 89

80% of lung cancers are the ____ type, which include what 3? 20 % of cases are the ___ type.

Back 89

NSLC include:
(Non-small cell lung cancer)
adenocarcinoma
squamous cell
large cell

20 % of cases are the SCLC (small cell lung cancer) type.

Front 90

The NSCLC types are more on the ______ and may be _____. The SCLC types are mostly from _____, often spreads, and causes airway ______. These are very ____ and have a ____ prognosis. The care for these is more ______, not for ____. Chemo and radiation, surgery may be done for any of these depending on where cancer is, and how healthy the patient is to begin with.

Back 90

The NSCLC types are more on the periphery and may be removed.The NSCLC types are more on the periphery and may be removed. The SCLC types are mostly from smoking, often spreads, and causes airway obstruction. These are very deadly and have a poor prognosis. The care for these is more palliative, not for cure. (May do radiation to shrink). Chemo and radiation, surgery may be done for any of these depending on where cancer is, and how healthy the patient is to begin with.

Front 91

Lung cancer metastasizes by direct ______, ______ circulation, and the _____ system. The most common sites for metastasizing are what 5 areas?

Back 91

Lung cancer metastasizes by direct extension, blood circulation, and the lymph system. The most common sites for metastasizing are the liver, bone, brain, lymph nodes, and adrenal glands.

Front 92

What are the early signs of lung cancer?

Back 92

pneumonitis (inflammation of lungs causing fever, chills, cough)
persistent cough w/ sputum
blood tinged sputum
chest pain (localized/unilateral)
dyspnea & wheezes (due to bronchial obstruction)

Front 93

What are the late signs of lung cancer? It has often already

Back 93

anorexia
nausea & vomiting
bone pain
cardiax s/s i.e. dysrhythmias
hoarse voice (involvement of laryngeal nerve)
hemoptysis
pleural effusion
unilateral paralysis of diaphragm, dysphagia, and superior vena cava obstruction may occur because of intrathoracic spread of malignancy

Front 94

Diagnostic tests for lung cancer include..

Back 94

Chest xray
CT scan
MRI
PET
sputum studies
diagnosis of malignant cells from biopsy via bronchoscopy, mediastinoscopy, VAT, or thoracentesis
TNM staging
screening

Front 95

Tx for lung cancer include surgery, which is contraindicated for ____. Surgeries include pneumonectomy, lomectomy, segmental or wedge resections.
Radiation can be used for both types of lung cancer. It is used in combination with chemo and may be given as curative therapy, as palliative (lower doses), or as adjuvant therapy in combo with surgery.
Chemotherapy is the treatment of _____ tumors or adjuvent treatment in NSCLC with distant metastases. There are improved survival rates for NSCLC and SCLC when going through chemo.

Back 95

Tx for lung cancer include surgery, which is contraindicated for SCLC. Surgeries include pneumonectomy, lobectomy, segmental or wedge resections.
Radiation can be used for both types of lung cancer. It is used in combination with chemo and may be given as curative therapy, as palliative (lower doses), or as adjuvant therapy in combo with surgery.
Chemotherapy is often the treatment of nonresectable tumors or adjuvent treatment in NSCLC with distant metastases. There are improved survival rates for NSCLC and SCLC when going through chemo.

Front 96

What is the difference between a blunt trauma and a penetrating wound?

Back 96

Blunt trauma- such as a MVA

Penetrating- stab wound, gunshot wound

Front 97

What are some common findings in a chest injury?

Back 97

surface findings- assymetric chest expansion, could be pneumothorax, fractured ribs
also
subcutaneous emphezema- air escaping into tissues also called crepitus, feels like rice crispies

Front 98

What is the management of a pt with a chest injury?

Back 98

initial - ABCs! Airway airway airway
O2 for anyone with chest trauma- not gonna hurt them.
If they have a knife in- leave it in! Elevate HOB
Ongoing monitoring of VS, resp pattern, LOC
esp- difficulty breathing, may not initially have this difficulty , continue to assess
CV s/s if bleeding internally
decreased BP (late) HR goes up (first
Remember they can
decompensate quickly. have
RT ready in case they need
to intubate

Front 99

In an open chest wound, a flap may act as a __-___ valve,, thus air can enter on inspiration but cannot escape. This involves a ____ pneumothorax. S/S include dyspnea, chest pain radiating to the shoulder, tracheal deviation, decreased or absent breath sounds on the effected side, neck vein distention, and cyanosis

Back 99

In an open chest wound, a flap may act as a one-way valve,, thus air can enter on inspiration but cannot escape. This involves a tension pneumothorax. S/S include dyspnea, chest pain radiating to the shoulder, tracheal deviation, decreased or absent breath sounds on the effected side, neck vein distention, and cyanosis

Front 100

A pneumothorax can be open or closed. The treatment is a ___ ___. Tension pneumothorax involve a one way valve. Treatment includes either a ____ _____ or needle ______. A hemothorax involves _______. Treatment includes a chest tube as well as treatment for h________ if needed.

Back 100

A pneumothorax can be open or closed. The treatment is a chest tube. Tension pneumothorax involve a one way valve. Treatment includes either a chest tube or needle decompression. A hemothorax involves bleeding. Treatment includes a chest tube as well as treatment for hypotension if needed.

Front 101

In a tension pneumothorax, there is more air in, no air can come out. The heart, trachea etc is all pushed over resulting in a _____ shift. There's only so much space the chest cavity has, so pressure is going to effect the _____. There will be signs of ____ hunger, may be tracheal _______ which is an early/late classic sign. Positive/negative pressure needs to be relieved so the lung can reexpand.

Back 101

In a tension pneumothorax, there is more air in, no air can come out. The heart, trachea etc is all pushed over resulting in a mediastinal shift. There's only so much space the chest cavity has, so pressure is going to effect the heart There will be signs of air hunger, may be tracheal deviation which is an late classic sign. Positive pressure needs to be relieved so the lung can reexpand.

Front 102

Too much v________ pressure or even a _____ line catheter can puncture a lung and cause a pneumothorax.

Back 102

ventilator
central

Front 103

What needs to be done to confirm placement of a chest tube?

Back 103

chest xray

Front 104

True or False: Air rises with pneumothorax and fluid falls.

Which intercostal space is chest tube inserted for either air or fluid drainage?

Back 104

true

air- 2nd intercostal space
fluid 8th or 9th

Front 105

A chest tube is placed between the ____ pleura and the ______ pleura. Placement depends on what needs to be removed. A ______ valve is a portable chest tube.

Back 105

A chest tube is placed between the parietal pleura and the visceral pleura. Placement depends on what needs to be removed. A Heimlich valve is a portable chest tube.

Front 106

The Heimlich valve has a one or two way valve?

Back 106

one way- air out not in

Front 107

Can an RN put in a chest tube?

Back 107

no

Front 108

Make sure tape is "_____" on a chest tube. During assessment of the chest tube use the "_____" method.
Site- dressing, bleeding, subcutaneous emphyzema
Tube taping, looping
Output- checking, marking, documentation
Patient- fluctuation, water seal level

Back 108

Loopy
S.T.O.P.

Front 109

Generally, _____ is discontinued and chest drain is on gravity drainage for ___ hours before the tube is removed when the lungs appear to be reexpanded and fluid drainage has ceased.

Back 109

suction
24

Front 110

The Heimlich valve has a one or two way valve?

Back 110

one way- air out not in

Front 111

Can an RN put in a chest tube?

Back 111

no

Front 112

Make sure tape is "_____" on a chest tube. During assessment of the chest tube use the "_____" method.
Site- dressing, bleeding, subcutaneous emphyzema
Tube taping, looping
Output- checking, marking, documentation
Patient- fluctuation, water seal level

Back 112

Loopy
S.T.O.P.

Front 113

If you are assessing a drain system with a hemothorax, ask how much drainage you should see. Usually more than ____ ml per hour is excesssive and you should call the Dr

Back 113

100

Front 114

Generally, _____ is discontinued and chest drain is on gravity drainage for ___ hours before the tube is removed when the lungs appear to be reexpanded and fluid drainage has ceased.

Back 114

suction
24

Front 115

To determine the source of an air leak in a chest tube, momentarily ___ the tubing starting at the insertion site to the drainage set, observing for the bubbling to cease. When bubbling ceases, the leak is ____ the clamp.

Back 115

clamp
above

Front 116

With chest tubes, assess for manifestations of reaccumulation of air and fluid in chest. If this is happening, you might see _____ or ____ breath sounds, significant ____ (>___ ml/h), and chest drainage site ____, r poor wound healing. Notify dr and evaluate for subcutaneous emphyzema.

Back 116

With chest tubes, assess for manifestations of reaccumulation of air and fluid in chest. If this is happening, you might see decreased or absence breath sounds, significant 100 (>100 ml/h), and chest drainage site infection, and poor wound healing. Notify dr and evaluate for subcutaneous emphyzema.

Front 117

Leanne says.... only clamp the tubing if you're collecting ____ and you're changing out the fluids. We need a dr's order to clamp...?

Back 117

fluid

Front 118

After chest surgery, it's good to elevate ____, administer lots of ___ meds, a ____ is good for these patients. Encourage use of ____ and administer O2 as needed.

Back 118

After chest surgery, it's good to elevate HOB, administer lots of pain meds, a PCA is good for these patients. Encourage use of IS and administer O2 as needed.

Front 119

Pleural space usually contains about ____ ml of fluid, usually doesn't become a problem until around ____ mls, then it's real painful

Back 119

10
250

Front 120

With pleural effusion, you will hear decreased breath sounds where?

Back 120

lower lobes (fluid is gravity dependent)

Front 121

Thoracentesis is done where? What's the best position? What does the RN do?

Back 121

patient's room
sitting up head over overbed table
RN can assist, obtain consent

Front 122

____ _____ is an abnormal collecitonof air in the pleural space. It is not a disease but an indication of disease. It can be caused by increased production of fluid due to decreased oncotic pressure, increased production of fluid due to increased capillary permeability, bleeding into the space, decreased lymphatic clearance of pleural fluid, and infection.

Back 122

pleural effusion

Front 123

The 2 main signs of pleural effusion is ____ and ___ ____. Treat the _______ cause. Remove fluid via _____, ______, and chest tubes. _____ is seen more with malignancies.

Back 123

The 2 main signs of pleural effusion isdyspnea & chest pain. Treat the underlying cause. Remove fluid via thoracentesis,pleurodesis, and chest tubes. Pleurodesis is seen more with malignancies.

Front 124

_______ is pleural effusion except with pus not fluid. Symptoms are the same with the addition of ____ loss, ____ing, ____, and ____ ____. Tx includes a chest tube and _________s.

Back 124

_______ is pleural effusion except with pus not fluid. Symptoms are the same with the addition of wt loss, coughing, fever, and night sweats. Tx includes a chest tube and anitbiotics.

Front 125

Pleurisy is an ______ of the ____. The most common causes are PNA, TB, chest trauma, pulmonary infarctions, viruses, and neoplasms.

Back 125

Pleurisy is an inflammation of the pleura. The most common causes are PNA, TB, chest trauma, pulmonary infarctions, viruses, and neoplasms.

Front 126

The pain of pleurisy is typically ____ and ____ in onset and aggravated by ____. Every breath is stretching the lining. What might you hear when you listen to the lungs?

Back 126

The pain of pleurisy is typically abrupt and sharp in onset and aggravated by inspiration. Every breath is stretching the lining.
Pleural friction rub- very distinct, grating sound like sandpaper

Front 127

Treatment of pleurisy is aimed at treating the underlying cause and providing pain relief. Administer _____ and encourage the patient to do what 2 things? Intercostal ____ blocks may be done if the pain is severe.

Back 127

Treatment of pleurisy is aimed at treating the underlying cause and providing pain relief. Administer analgesics and encourage the patient to lay on the effected side or splint it to provide some relief. Teach patient to splint rib cage when coughing. Intercostal nerve blocks may be done if the pain is severe.

Front 128

Atelectasis is a lung condition characterized by ____, __less, alveoli. The most common cause is _____ of the small airways with _____. This is common in bedridden patients such as post surgery (especially of chest). Normall the pores of Kohn provide collateral passage of air from one alveolus to another. Deep inspiration is necessary to open the pores effectively. For this reason, deep breathing exercises and coughing are important to prevent atelectasis and treat the patient at risk.

Back 128

Atelectasis is a lung condition characterized by collapsed, airless, alveoli. The most common cause is obstruction of the small airways with secretions. This is common in bedridden patients such as post surgery (especially of chest). Normall the pores of Kohn provide collateral passage of air from one alveolus to another. Deep inspiration is necessary to open the pores effectively. For this reason, deep breathing exercises and coughing are important to prevent atelectasis and treat the patient at risk.

Front 129

With atelectasis, you will probably see an increase in ____ and ____, dyspnea, and decreased ___ ____, the chest is symmetrical/unsymmetrical. You might hear ___ ____ _too. What should you do?

Back 129

With atelectasis, you will probably see an increase in RR and temperature, dyspnea, and decreased breath sounds, the chest is symmetrical. You might hear fine crackles too. Act fast- get them up and moving, encourage deep breaths. (TCDB). Can cause pulmonary fibrosis (permanently nonfunctioning lung tissue) if not corrected.

Front 130

If not corrected, what can happen with atelectasis?

Back 130

continued resp. distress &
Can cause pulmonary fibrosis (permanently nonfunctioning lung tissue) if not corrected.

Front 131

A Pulmonary Embolism is usually due to a dislodged thrombi that causes obstruction of pulmonary arteries.. What are some risk factors?

Back 131

immobilization
surgery w/i last 3 mo
Hx of DVT, stroke, malignancy
Women- obesity, smoking, HTN

Front 132

Clinical manifestations of PE (small, medium, massive)

Back 132

small- undetected or vague s/s
medium- pleuritic chest pain, dyspnea, slight fever, cough with blood tinged sputum
massive- shock, pallor, severe dyspnea, hypoxemia, and crushing chest pain
(More severe the clot, more severe the s/s)

Front 133

Complications of a PE include pulmonary _____ and pulmonary _____.

Back 133

Complications of a PE include pulmonary infraction and pulmonary hypertension.

Front 134

Diagnostic studies for PE

Back 134

D dimer
ventilation-perfusion lung scan (VQ scan)
pulmonary angiography
CT, ABGs, chest xray, ECG, troponin, BNP (used to detect severity of disease-- also used to detect heart stuff like MI and CHF--- higher number grades severity)

Front 135

What is the tx for PE

Back 135

O2
TCDB
treatment for shock or HF if indicated
pain management
emotional support- very anxious
"impending sense of doom"
limited activity
Anticoagulant therapy
heparin/lovenox- short term
Coumadin- long term
If severe-
thrombolytic therapy
Surgical therapy- emboletomy (go into pulmonary vasculature and pull clot out, poor survival rates) , Inferior vena cava filter such as greenfield filter- catches clots before they get to heart, pulmonary circulation

Front 136

_____ of ___ is key to preventing a PE

Back 136

prevention of DVT is key to preventing PE

Front 137

Primary pulmonary hypertension (PPH) is a severe and progressive disease. It is characterized by mean pulmonary arterial pressure greater than 25 mm Hg at rest (normal 12 - 16 ) or greater than 40 with exercise in the absence of a demonstrable cause. It is a rare and potentially fatal disease of unknown cause. _____, vessel wall ______, and _____ increase vascular _____.

Back 137

Primary pulmonary hypertension (PPH) is a severe and progressive disease. It is characterized by mean pulmonary arterial pressure greater than 25 mm Hg at rest (normal 12 - 16 ) or greater than 40 with exercise in the absence of a demonstrable cause. It is a rare and potentially fatal disease of unknown cause. Vasoconstriction, vessel wall thickening, and thrombosis increase vascular resistance.

Front 138

There may be a ____ component to PPH and it is most common in men/women between 30-40 y old. Also a risk if they took ___ ___. Basically, non oxygenated blood goes to right side of heart, which is where the pulmonary HTN is. It increases the workload of the right ventricle and causes right ventricular hypertrophy ( a condition called ___ _____) and eventually causes ___ ___.

Back 138

There may be a genetic component to PPH and it is most common in /women between 30-40 y old. Also a risk if they took phen phen. Basically, non oxygenated blood goes to right side of heart, which is where the pulmonary HTN is. It increases the workload of the right ventricle and causes right ventricular hypertrophy ( a condition called cor pulmonale) and eventually causes heart failure.

Front 139

Diagnostic studies related to PPH include a chest xray, pulmonary function testes, echocardiogram, spiral CT, and cardiac catheterization. It is diagnosed by exclusion- after all other dx's are ruled out.
Clinical manifestations of PPH include...

Back 139

FEED
fatigue
exertional dyspnea & chest pain
exertional syncopy
Dizziness

Front 140

Management of PPH includes lots of vasodilator therapy and diuretics. Review page 30 of powerpoint for specific drugs. Surgical interventions include ____ septostomy, _____ thromboendarterectomy, and ___ transplant.

Back 140

Management of PPH includes lots of vasodilator therapy and diuretics. Review page 30 of powerpoint for specific drugs. Surgical interventions include atrial septostomy, pulmonary thromboendarterectomy, and lung transplant.

Front 141

Secondary pulmonary HTN is a result of primary disease that cause chronic increase in ___ ____ pressure. Causes include COPD, pulmonary fibrosis, chronic emboli, and conditions that create chronic hypoxia.

Back 141

Secondary pulmonary HTN is a result of primary disease that cause chronic increase in pulnonary artery pressure.

Front 142

Clinical manifestations of secondary pulmonary HTN include

Back 142

dyspnea, fatigue, chest pain

S & S r/t underling cause such as
right ventricular hypertrophy or right ventricular failure.

Front 143

How do you treat secondary pulmonary HTN?

Back 143

treat underlying cause

Front 144

Cor Pulmonale involves the ______ of right ventricle secondary to disease of the lung. What is the most common disease of the lung? Cor Pulmonale may be present with or without ____ ____.. Usually chronic due to _____ _____.

Back 144

Cor Pulmonale involves the enlargement of right ventricle secondary to disease of the lung. What is the most common disease of the lung? Cor Pulmonale may be present with or without heart failure. Usually chronic due to alveolar hypoxia.

Front 145

Clinical manifestations of Cor Pulmonale include _____ on exertion, a chronic and _____ cough, ______ respirations, retrosternal or substernal ___, and l____. If HF accompaines, there may be ____ gain, peripheral _____, distended ___ ____, a _____ pulse, and an enlarged ___.

Back 145

Clinical manifestations of Cor Pulmonale include dyspnea on exertion, a chronic and productive cough, wheezing respirations, retrosternal or substernal pain, and lethargy. If HF accompaines, there may be weight gain, peripheral edema, distended neck veins, a bounding pulse, and an enlarged liver.

Front 146

Collaborative Care for Cor Pulmonale

Back 146

Collaborative Care
Long term low-flow O2
Bronchodilators (easier to get O2 down bigger pipe)
Diuretics & low sodium diet (get rid of excess fluid volume)
Possibly vasodilators or calcium channel blockers
Anticoagulants (risk for thrombosis)
Treat underlying cause (COPD, pulmonary hypertension)
Lung transplantation may be an option

Front 147

Bottom line of cor pulmonale is-- how well is the ____ being controlled?

Back 147

hypoxia