Respiratory System (Med/surg) Hesi

Front 1

What is Pneumonia?

Back 1

Inflammation of the LOWER respiratory tract

Front 2

How is Pneumonia caused?
How is it classified?

Back 2

3 methods: Aspiration, Inhalation Hematogenous spread. It's classified by the causative agent: bacterial, fugal, viral, or chemical.

Front 3

What are the high risk groups of Pneumonia?

Back 3

Debilitated by lung secretions, Cigarette smokers, Immobile, Immunosuppressed, depressed gag reflex, Sedated, Experiencing neuromuscular disorders.

Front 4

Nursing Assessment of Pneumonia

Back 4

-Tachypnea, shallow resp w/ accessory muscle use. WBC ^
-fever and chills, productive cough w/ pleuritic pain
- Rapid bounding pulse
- pain and dullness over affected lung area w/ crackles

Front 5

Assessment of Pneumonia in elderly

Back 5

Confusion, Lethargy, Anorexia, Rapid respiratory rate. Abrupt onset of fever and chills not reliable with the elderly.

Front 6

Hesi Hint: Fevers

Back 6

Fever can cause dehydration because of excessive fluid loss from diaphoresis. Increased temp = increased metabolism = increased demand for O2

Front 7

Hesi Hit: High risk Pneumonia

Back 7

Any: ALOC, depressed or absent gag & cough reflex, or is susceptible to aspirating oropharyngeal secretions including alcoholics, anesthetized, brain injury, state of OD and stroke victims.

Front 8

What are the nursing diagnoses related to pneumonia?

Back 8

>Impaired gas exchange related to...
>Ineffective airway related to...

>activity intolerance related to....

>Risk for deficient fluid volume related to...

Front 9

Nursing Plan and Interventions with a pneumonia patient

Back 9

Assess sputum volume, color, consistency and clarity.
Assist to cough productively:
-Deep breathe q2 use icsp
-humidity to loosen secretions
-suction airway
3L qdaily unless contraindicated
Assess: lung sounds b4 and after coughing, rate, depth, pattern 16-12rr, skin color, mental status
monitor: abg Po2>80 Pco2 <45, O2 sat 95% temp. Provide rest periods and uninterrupted sleep. abx, family teaching about risk factors, encourage annual pneumonia and flu exam.

Front 10

HESI hint: Bronchial breath sounds

Back 10

Bronchial breath sounds are heard over areas of density or consolidation. Sound waves are easily transmitted over consolidated tissue

Front 11

Hesi Hint: Hydration

Back 11

-Enables liquefication of mucous trapped in the bronchioles and alveoli, facilitating expectoration
-300 to 400 ml lost daily by lungs thru evaporation.

Front 12

Hesi Hint: Early signs of hypoxia

Back 12

Irritability and restlessness are early signs of cerebral hypoxia

Front 13

Hesi Hint:Pneumonia Preventives

Back 13

-Elderly: flu shots; pneumonia immunizations; avoiding dust smoke, aerosols.
-Immunosuppressed and debilitated persons: infection aviodance, sensible nutrition, adequate intake, balance of rest activity

- Comatose and immobile persons: elevation of head of bed to feet; frequent turns

Front 14

Chronic airflow limitation includes : Chronic lung disease, chronic bronchitis, pulmonary emphysema, and asthma

Back 14

COPD: Bronchospasm and dyspnea damage not reversible, Asthma bronchospasm but reversible and intermittent

Front 15

Nurse assessment of chronic air flow limitation

Back 15

-change in breathing pattern ie: ^rr and ^depth, long term use of accessory muscles cause "barrel chest". Blue Bloater: cyanosis of lips, mucous membranes, face and nail beds, cough dry or productive, high CO2 average, low CO2 determined by pulse oximetry, decreased breath sounds. Coarse crackling tend to disappear after cough, wheezing. Dyspnea, orthopnea, poor nutrition, activity intolerance and Anxiety concerning brathing; manifested by Anger, Fear of being alone and not catch breath

Front 16

Hesi hint: Fowler and semi Fowler positions

Back 16

Productive cough and comfort can be facilitated by semifowler or high fowler position and lessen the pressure on diaphragm by abdominal organs. Gastric distention becomes a priority in these clients because it elevates the diaphragm and inhibits full lung expansion.

Front 17

Normal ABG Values!!

Back 17

Adult: 7.35-7.45 Child: 7.36-7.44

Pco2 35-45, Po2 80-100, HCO3 22-26

Front 18

Hesi Hint: Pink Puffer vs. Blue bloater

Back 18

Pink Puffer: Barrel chest indicative of emphysema caused by use of accessory muscles to breathe. The person works harder to breathe, but O2 taken up is adequate for life

Blue Bloater: Insufficient O2 indicative of chronic bronchitis and leads to generalized cyanosis and often right-sided heart failure (Cor Pulmonale)

Front 19

Chronic air flow limitation nursing diagnosis

Back 19

Ineffective airway clearance related to...
Ineffective breathing pattern related to...
Impaired gas exchange related to...
Activity intolerance related to...

Front 20

Oral Penicillin G

Back 20

use caution allergic to cephalosporins, monitor allergic reactions, observe clients at least 30 mins, TAKE ON EMPTY STOMACH, PROBENECID increases blood level of drug dt decreased renal excretion. Alters contraceptive effectiveness

Front 21

Semisynthetics: Oxacillin sodium, nafcillin sodium, Cloxacillin sodium, and Dicloxacillin sodium

Back 21

Dont use with pt allergic to penicillin, caution if allergic to sephlasporins, monitor for superinfections: sore mouth, vaginal discharge, diarrhea, cough

Front 22

Tetracycline, Doxycycline hyclate

Back 22

Decrease effectiveness of oral contraceptive, Aviod MILK and ANTACIDS, exposure to sunlight, pregnant women, children <8 years: causes yellow-brown teeth, growth retardation. Monitor IV, superinfections

Front 23

Aminoglycosides: Gentamycin, Tobramycin, Amikacin

Back 23

used with G-,
Monitor: BUN, Creatnine rt to nephrotoxicity. HA, hearing loss, tinnitus rt to ototxicity. superinfection

Front 24

Azactam

Back 24

used with Pseud. aeruginosa + resistant organisms, effective against G-. Adverse rxn: Phlebitis, colitis,

Diarrhea is excessive fluid loss which changes electrolytes leading to CNS and EEG changes, hypotension

Front 25

For a respiratory diseased client what diet should they have (pneumonia, COPD, Emphysema, Asthmatic)

Back 25

Mechanical soft diet, hydrate well

Front 26

Hesi Hint: Health promotion Respiratory

Back 26

Eating consumes energy needed for breathing. Assist feeding mechanical soft diet. Prevent secondary infection by avoiding crowds, contact with persons with infectious disease, tobacco smoke. Report changes in sputum. Hydrate well,obtain immunizations needed (flu and pneumonia)

Front 27

Hesi Hint: humidification

Back 27

use humidification at 4> L, dont use if <4.

Front 28

Suctioning

Back 28

Suction when adventitious breath sounds are heard, secretions present in endotracheal tube, and when gurgling is noted. Aseptic/Sterile procedure, mask, goggles. Advance until resistance is felt. Suction only when withdrawing while rotating gently, 10-15 secs less than 3x. Oxygenate 1-2 mins before and after suctioning to prevent hypoxia

Front 29

Ventilator setting maintenance

Back 29

Verify alarms are on, maintain settings and check often to ensure specific settings prescribed by doctor, q4hrs.

Front 30

Oxygen administration

Back 30

Nasal cannula: low oxygen flow for low oxygen concentrations good for COPD.
Simple face mask: low flow, high O2 concentration, cant deliver <40%

Nonrebreather: low flow, high oxygen con, 60-80%

Partial rebreather: low flow reservoir, delivers high oxygen

Venturi mask: high flow, delivers exact oxygen concentration