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83 Cards in this Set

  • Front
  • Back
respatory acidosis
risk factors
pneumonia,COPD, narcotic analgesics, airway obstruction or neuromuscular disease
respatory acidosis S/S (acute)
headach,warm, flushed, blurred vision, cardiac arrest, irritability
respatory acidosis S/S (chronic)
weakness, dull headache, personality changes, sleep disturbances, impaired memory
Respatory acidosis NSG diagnoses
impaired gas exchange
ineffective airway clearance
respatory acidosis alerts (nsg assessments)
assess LOC, a decline in LOC may indiacate increasing hypercapnia & need for increasing ventilatory support
respatory acidosis alerts immediately report
decreasing level of conscoiusness or depressed resp
respatory acidosis nsg interventions
frequently reposition, increase fluid intake 3000ml/day, adm meds, provide percussion
resp alkalosis S/S
dizziness, palptations, tetany, tremors, chest tightness, tingling, dyspnea
resp alkalosis meds
sedative, antianiety (paper bag or rebreather mask)(hyperventilation)
resp alkalosis nsg diagnosis
ineffective breathing pattern, risk for injury, anxiety
metabolic acidosis S/S
nausea, vomiting, adb pain, weakness, fatigue, dysrythmias, bradycardia, kussmauls, anorexia
metabolic acidosis causes
diabetes, hypoxia, renal failure, diarrhea, intestinal sucting or adb fistulas
metabolic acidosis nsg diagnosis
decreased cardiac output
risk for excess fluid volume
risk for injury
metbolic acidosis nsg intervention
acid-base management, fluid management, environmetal safety
metbolic acidosis outcomes
v/s, safety, electrolyte &acid base b alanc, cardiac pump effectiveness
metaboic acidosis alerts as condition corrected monitor
serum potassium levels because potassium shifts
metabolic alkalosis risk factors
metabolic alkalosis S/S
confusin, decreasing LOC,, hyperreflexia, tetany, hypotension, resp failure
metabolic alkalosis nsg diagnosis
risk for impaired gas exchange
deficient fluid volume (assess I&O accurately less than 30ml/hr indicates inadequate tissue perfusion, inadequate renal perfusion)
Laryngeal obstruction common cause
ingested meat (cafe' coronary)
laryngeal obstruction risk factors
large boluses of food, chewing insufficiently, onsuming excess alcohol, wearing dentures
laryngeal obstruction S/S
pain, laryngospasm, sypnea, inspiratory stridor (goal maintain open airway)
laryngeal cancer S/S
hoarseness, change in voice, painful swallowing, foul breath,palpable lump in neck earache
laryngeal cancer risk factors
smoking, alcohol, poor nutrition, hpv, asbestos
laryngeal cancer nsg diagnosis
risk for impaired airway clearance,impaired verbal communicatin, impaired swallowing, anticipatory grieving
laryngeal cancer after total larngectomy
monitor for signs of airway obstruction,surgery can further restrict airway, interfering with lung ventilation & gas exchange
lung abscess causes
pneumonia & aspriration two weeks later becomes lung abscess
lung abscess S/S
fever, chills, chest pain (blood streaked sputum, dimished breath sounds crackles if ruptured)
lung abscess treatment
chest tube, postural drainage, adbt-pcn, augmentin, cleomein
lung abscess nsg diagnosis
impaired gas exchange
ineffective airway clearance
valley fever
fungus in dirt
ARDS develops
24-48 hrs
dyspnea, tachypnea, anxiety, increased resp rate, use incostal muscles, cyanotic, develops crakles=mental confusion
ARDS treatment
intubation & ventilation, semi-fowlers, treat underlying conditions
ARDS nsg diagnosis
ineffective breathing pattern, impaired gas exchange, decreased cardiac output (must wean from vent)
Asthma-resp alkalosis
risk factors
allergies, exercise, genetics, emotional stresses, virusis
asthma late phase
+mucus production
limit mucus clearance
prolonging bronchoconstriction
asthma nsg diagnosis
ineffective airway clearance, ineffective breathing pattern, anxiety, therapeutic regimen management
PE risk factors
prolonged immobility, trauma, MI, obesity, advanced age
dyspnea, chest pain, anxiety, cough, diahoresis, decreased fever, hemophysis (if large syncope & cyannosis)
PE nsg diagnosis
impaired gas exchange, decreased cardiac output, ineffective protection:risk for anticoagulant threrapy, anxiety
pulmonary hypertension causes
COPD, emphysema, sleep apnea, hypoventilation, large or multi PE
pulmonary hypertension S/S
dyspnea, back pain, fatigue, syncope, peripheral edema, distended neck veins, productive cough
pulmonary hypertension ngs diagnosis
decreased cardiac output, impaired gas exchange, anticipatory grieving, hopelesness
pulmonary hypertension restrictions
salt & o2, diretic therapy, procaria, cardizem
lung cancer 2 types
small cell, non small cell
lung cancer nsg diagnosis
ineffective breathing pattern, activity intolerance, risk for injury, pain, anticipatory grieving
pleuritis causes
pneumonia, rib injury, viral resp
pleuritis S/S
abrup, localized pain, friction rub heard over area
pleuritis treatment
indocin, codeine, splint chest, positining
pleuritis when call dr
increased fever, dyspea, productive cough, SOB
pus in pleural cavity
blood in cavity
hemorrhagic pleural effusion
blood & pleural fluid mixture
pleural effusion S/S
dyspnea, pain, diminished or absent breath sounds
air/fluid removed from pleura space (put on unifected side)
pleural effusion potential complication
pneumothorax primary cause
pneumothorax secondary affects persons with
COPD,ARDS, TB (more serious)
pneumothorax S/S
chest pain, Sob at rest, increased resp & heart rate,absent lung sounds
traumatic pneumothorax results from
fractured ribs,MVA, fall, CPR
(closed) stab, gunshot, chest trauma (open)
tension pneumothorax is
injury to chest wall or lungs that allows air to enter pleural space but prevents it from escaping (med emergency)
pneumothorax nsg diagnosis
impaired gas exchange, risk for injury maintenance of chest tube
blood in pleural space from chest trauma, surgery (liver or spleen injuries)
hemothorax treatment
chest tube, blood replacemnt if needed,
flail chest s/s
pain, dyspnea on inspiration, palpable crepitus, diminished breath sounds
pulmonary contusion appears
12-24hrs after injury
pulmonary contusion treatment
often requires intubation & mechanical ventilation
chest tube nsg diagnosis
ineffective airway clearance, impaired gas exchange, acute pain, risk for injury
fresh water drowning is
fresh water drowning leads to
hypervolemia, hemodilution=acute renal failure, and dysrhythmias
salt water drowning is
salt water drowning leads to
hypervolemia & hemoconcentration
drowning nsg diagnosis
ineffective airway clearance, ineffective breathing pattern, impaired gas exchange, ineffective tissue perfusin:cerebral
chest tubes after firsst 2 hrs worry if more than_____ml/hr
notify dr when? (chest tube)
abruptly stops draining, frank blood flowing, clear to cloudy drainage
what happens if chest tube disconnects
perodic bubbling means
air is comming out
what controls neg suction in tube system
water level on machine
ventalation is
gases moving in and out of lungs
gas exchangs
occurs in the cellual level (alveoli)
(PEEP) on vent
keeps alveoli open
tital volume
amount of gas delivered with each ventilator breath